36-year-old male, 5’9” 180 pounds. Normally fit and well, significant past medical history: Road traffic accident (RTA) 5 years ago resulting in right hip pain and reduced movement. Long standing lower back pain that was evident prior to the RTA. Unlike the lower back pain, he thinks right hip pain directly relates to his road traffic accident as he feels the right hip is weaker.
History of lower back pain: Right side lower back back pain. Also gets referred pain into right foot with numbness but no actual weakness or loss of sensation and no bladder/bowl disturbance. Prior to this bike fit his GP requested an MRI which found a disc bulge between L5 and S1. He was advised to manage it conservatively with physiotherapy treatment for now unless his symptoms worsened.
Lower back aggravating factors: riding for distances over 5 miles and in any hand position. Pain isn’t so extreme it stops his cycling but certainly feels stiff at the end of the ride.
History of right hip pain: He also reports getting pain into right hip when cycling or squatting. After the RTA the hip was x-rayed which found a bony spur in the hip joint. Advised by his surgeon to manage conservatively with physiotherapy but in the future will likely need a total hip replacement. Therefore, advised to stop running to avoid having a hip replacement even earlier.
Hip aggravating factors: He reported deep squats caused right hip pain. This translates as cycling on the drops when the hip again goes into extreme flexion. More dynamic movements like hip adduction also causes pain. Loading of the hip as when running again causes pain. All these movements cause right IT band pain and pain into the groin coming round from the hip bone (Greater Trochanter).
Physiotherapy Observations: Left leg longer than right by 1cm this has results in a standing posture where the left iliac crest of the pelvis appears higher than the right . This in-turn closes down the right-side lumbar area.
Movement Analysis: When squatting there is over pronation of the left foot when compared with the right – this is exaggerated when lunging or a single leg squat. He isn’t able to achieve a full squat or lunge with right leg due to pain.
Physiotherapy Assessment and Tests
Lumbar Spine: full range of movement through flexion, extension left and right-side flexion. No pain with over pressure. As he reported numbness into the right foot a neurological assessment was carried out which found myotomes, dermatomes and reflexes were intact for L1,2,3,4,5 and S1.
Muscle strength and flexibility tests found the right quadratus lumborum was tighter than the left. Deep abdominal strength test was weak and couldn’t hold posture for more than 1 minute. Also, his hip flexors and quads were tight bilaterally.
Hip Special Tests: including quadrant test of the right hip he reported pain into the hip joint, Also FADDIR’s test again reported pain in the ball and socket joint but also pain into the groin. This all fits with the x-ray showing a bony spur in the hip joint. Despite pain at the end of hip flexion and adduction the hip felt smooth in other movements with no pain reported. This was a good sign that he could tolerate a position on the bike that didn’t go beyond 120 degrees of hip flexion.
Physiotherapy Treatment: I prescribed a strength and flexibility programme for the above symptoms which I will review in 6 weeks time to see if on testing they are helping both his muscle function but also avoiding his lower back and right hip pain. I also advised on how to avoid the aggravating positions for both his lower back and hip when off the bike. Of course, in some situations hip flexion can’t be avoided but instead controlled with improved awareness of how he is performing the movement and what muscle groups he is using.
The Bike Fit: Found his saddle was too high by 1cm and angled up both of which was closing up the hip joint and further aggravating his hip pain when he tries to reach for the bars. This was also excessive lumbar rotation (side to side movement) confirming the saddle was too high and the weakness in his core muscles.
The Leomo Pre Fit Test found there was also asymmetry when comparing the left to right foot angular ranges. This presented as the right foot plantar flexing more to compensate for the left leg being longer.
Changes To Bike Set up: saddle down 1cm to open up his hips and allow his hamstrings to innovate as they were working out of range. The saddle was angled down to op up the hips. I also shortened and raised the handlebar stem to both open up his hips and take the strain off his lower back trying to hold a low front end. Last but not least I fitted a shim under the right cleat which improved the symmetry between his left and right foot angular ranges as found on the Leomo post fit test.
Follow-up Appointment: He reported the hip pain had resolved with the new bike setup. Also, he felt more power through the right leg as he can drive his heal through the bottom of the pedal stroke. He also reports the lower back pain is improving and doesn’t come on until much later in the ride. Importantly the numbness in his right foot had resolved. He can use his core muscles to hold a more neutral spine and because of that he is less reliant on his leg muscles which previously were always sore after a ride.
Reviewing his exercise programme, I found he had improved in holding a neutral spine with a core strength test and the range of his muscles like the hip flexors had improved his flexibility. This showed the targeted exercises were working both by what he was reporting and on testing. However as always with a strength and conditioning programme and when considering postural lower back pain there is definitely room for improvement which we would follow up on again in 3 months time.
It will be interesting to see if he can avoid hip pain in the long term with what sounds like early osteoarthritis but by avoiding the above aggravating factors, he can avoid a total hip replacement as suggested by his surgeon.
The long-term plan is to continue to optimise his bike position and physiotherapy treatment plan. It is likely that the hip will become more limited in its range of movement if the osteoarthritis worsens and, in that case, a more elevated position could be offered, if not on his road bike, then a mountain bike could be the alternative.
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