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Lateral hip pain

Feb 25th, 2019

Hi,

 

Having a cycling related hip problem. Hope you can help. Feeling confused by advice offered by physios so far.

 

I get hip pain when cycling – well, maybe better described as irritation, nerviness, burning sensation. Feels like it presents right at the bony protrusions of both hips, maybe slightly behind. But sometimes feels like it spreads out from there. Relatively even on both hips, but more predominant on right leg. Where it can also travel down outside of leg. And then present in outside of right knee (although this is less frequent since some physio exercises) I can cycle very lightly and hip issue will stay away or be very low level, but higher cadence spinning to climb or high effort / load can bring it straight on. The one way it is less bad is out of saddle, at lower cadence with bit more load.

 

It originated about six months ago, when I was doing a lot of long distance rides, varying from 100 to max 250 miles. First symptom was a deep pain – tenderness, weakness – in the right glute. That spread down to outside of knee as described. I assumed muscular at time, but rest off bike did not clear it. Returned to cycling, very low mileage, low effort, but after a few weeks this hip pain started.

 

One physios diagnosed chronically tight IT band. Another thinks tendinitis / tendinopathy. My back was looked at and there seemed no disc issues, and sciatic issues were checked for, and also movement of hip checked. There also doesn’t seem to be any pain to touch, other than deep in right glute. One thing that can highlight any pain is when they bend one leg at knee, then push knee laterally across other leg. Easy to feel pain in the glute. But hips feel fine, and nothing when pushed on locally.

 

Physio I’m seeing has been doing hip and glute strengthening pilates type exercises with me, checking balance, and trying to open up lower back as I’m discovering I’m super inflexible in this and many areas! Very guilty of just cycling and nothing more. The rehab work hasn’t really improved hip things after 6 weeks although body in other areas feel vastly improved already. So last week we took out certain exercises – clam, side leg lifts and walking ones that stretch glutes / tendons (?) in that way, and refocused on the more load bearing ones – glute bridges, single leg balance and single leg squats etc. and keep in the back ones.

 

One of the main things I’m concerned with, is I’ve been encouraged to keep cycling, albeit inside myself, to keep those muscles ticking over. Stressed by this as it brings on the hip issue if I’m not super vigilant and concerned it is exacerbating it or causing long term damage. The cycling I’m doing is so low level, my instinct is to take it out of the equation.

 

Sorry for the very long question. Was very impressed by the other Q and As so wanted to try to describe as well as my limited understand is able… Any reply at all will be much appreciated!

 

Many thanks indeed,

 

Daniel

The Guru Responded:

Hi Daniel – I’ll try not to increase your confusion, but give clarity instead as you’ve described “stuff” well.

 

The key is you can do low level stuff well but can’t progress, and if you do you get an increase in pain and everything tightens up.

 

I don’t think you’ve got an issue with your lumbar spine- hence all scans appear normal, but I think it is to do with your thoracic spine being the cause of your issues.

 

Here goes…sitting on a bike for hours, then sitting at work and at home etc will cause your thoracic spine to naturally flex forwards and stiffen. You won’t notice the stiffness as the joints move less and so get less reception back to you. Having a stiff thoracic spine is fine (!) as your body will naturally compensate and allow your lumbar spine to move more. You push on one side of a seesaw and the other end moves.

 

As your lumbar spine becomes more mobile (in joint play, not necessarily range) your glutes and hip flexors stiffen to protect your mobile lumbar spine (hence no low back pain). Having a stiff thoracic spine also means that when your stand up (or get off your bike) straight you will extend (lean backwards) through your lumbar spine because your thoracic spine of flexed forwards – the compensation. When standing in this type of slight windswept or sway back posture you’ll loose your gluteal drive/initiative  (as they should extend your hip/lumbar spine) because you are already leading backwards (in your lumbar spine) because your thoracic spine is flexed forwards – and so it looks as if your standing straight, which you are but you’ve simply (over) extended some joints and (over) flexed others.

 

Sit on a bike and go real hard…your thoracic spine stiffens and flexes even further forwards, your poorly controlled lumbar spine doesn’t have enough control so calls up more protective tone from your glutes/hip flexors which gives your symptoms where you feel them….

 

So crack on with your stability based rehab BUT if you don’t have enough thoracic mobility OR you don’t recruit the muscles with your lumbar held in a neutral position, you won’t pick up the control and your symptoms will continue. When you’ve got this crack on with strength etc, but not before….

 

Sounds reasonable?

 

The Guru

 

Daniel’s been Googling!

Many thanks indeed for taking the time to write such a full and detailed reply.

 

I think that makes perfect sense (after Googling a bit to get up to speed on lumber and thoracic spine it does anyway!).

 

If I do understand correctly, my posture standing straight is very much as you describe. A bit like an ‘S’ shape if the top of that S was leaning forwards. My lower back (lumber?) like the bottom of the ‘S’ with a pronounced curve arching in/forwards, and my upper back the top of the ‘S’ hunching out then over to where my head and shoulders are positioned pretty far forward. Have I got it right?

 

I have been working on this alongside the strengthening, so hopefully I’m being taken through some of the right exercises to ‘open up’ already. Mix of rotational exercise to try to get some lateral movement, like ‘threading the needle’, simple spine flexing on all fours and against wall trying to engage and move each vertebrae one by one, and then some strength things like reverse plank bridging (although I can’t bring my shoulders together close enough to be able to put palms flat on floor, so have to elevate on fingers or with blocks until I get more flexible!) I was just checking out all your exercises for cycling after reading your reply and realised I was also shown the thoracic spine stretch this morning. Hadn’t realised the specific target of that exercise when doing it. So hopefully I’m being taken on the right track with my rehab and treatment?

 

Guess I’ve found it too easy to focus on the strength stuff as it seems more familiar. I’ll really take on board your advice and focus strongly on the back and spine work too.

 

Again, much appreciation for the time taken to supply such a generously detailed reply.

 

Daniel

 

Hi Daniel – yes sounds about right.

A very easy way to see if you are on the right track is get your Physio to only treat your thoracic spine for about 20 mins (not just a few minutes, you need to be given the ability to move better (quality) not just more (quantity))  – no release work, no stretching, not nothing else elsewhere. This will either confirm or deny the involvement of your thoracic spine with regards to your symptoms.

 

Easy on just getting stronger – you need more control not just strength. Control is tricky, a bit like juggling and needs to be learnt. It why things like a single knee squat is such an important measure and control based exercise….

 

Keep on going – slowly try to increase cadence and load.

 

The Guru

 

Thanks so much again for the advice.

I’ll ask them to do that regarding thoracic spine. See what kind of treatment they follow. Will it be an exercise? Or do you mean manipulation on their part in some way?

 

I see, I get you, I should have said control rather than strength. Control is what my physio has focused on. Single knee squats were introduced this week and last, but I overdid it practicing on my own on right side where I have had the initial glute and knee symptoms prior to hips. It flared up badly, pain in glute, back of leg and knee. Really hard for me to control on that side. So back to working semi supported on that side for that exercise, very small movements. Big big challenge for me to gain stability of pelvis on that side and in turn control tracking of knee. Knee either wants to dip in, or I need to lean into hip. As you say, keeping on going and going slowly is the order of the day. As for cadence, it’s all making me really notice my bad habits pedaling! I’ll stick at it all and  get there.

 

Thanks once more,

 

The Guru replies

Should be hands on stuff – give you the ability to move better, and then rehab to keep you and coach you to move better – should absolutely include

these thoracic mobility exercises

 

Sounds like you’ve got a good handle on the glutes stability work – lift your chest and concentrate on control and form.

 

Keep it simple!

 

The Guru

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