cyclist - burning pain inner thighs & hamstrings

[saunaboy]

Thanks very much to both of you for your help.

I tried an psoas stretch, quad stretch plus a hip flexor stretch last night & this morning and I am walking pretty much pain free today - in the sense that the usual 'tug' on my medial knee is much reduced & there's less inflammation. Thighs are a bit warm from the stretches but I guess that'll ease. I went pretty easy.

More info...

When I was fitted for my bike I was assessed for hip flex. Was on my back on a physio bench with knees bent, feet flat. I was then asked one leg at a time to straighten & lower leg over edge of bench. Left (uninjured) leg went to about 180 degrees from body with no sensation of pull but right leg was nowhere near. In fact the pull on the right hip was very uncomfortable & I must have had a deficiency of about 20 degrees compared to left. If I pulled my bent left leg further towards me I was actually raising the right leg just by the tension of the front thigh/hip.

Musculoman - it would be a great help if you could go into a little detail of the steps you would recommend to relieve the tightness & eventually correct the tilt. As mentioned, the psoas stretch has had what seem to be immediate results. I'm finding I need to do these 3-4 times per day, holding stretches for 30 sec.

Also, should I lay off the bike or would you say I should stay away until I see some real & long-term significant benefit from the posture work? I am thinking about reducing the 'lean over angle' on the bike by dropping the seat a few mm, moving it forward & fitting a shorter stem to give the hamstrings an easier ride. I was riding long distances last year on a mountain bike with none of these issues so I'm thinking a move to a less bent posture might help?

Thanks again, much appreciated !!!!

[Ironmike]

Ok, as a caveat, I am currently a physio student, not qualified.

With cycling, there is a tendency for people to let their knees come across the front of them so that they are not pedalling in a biomechanically sound position. I see this on the club rides that I do week in week out. I would actually look at the strength of your gluteus medialis alongside the pelvic tilt issue. If psoas was going to refer pain, it wouldn't be referring it to the inside of the leg, it would refer it down the front (femoral nerve route). The femoral nerve passes through this muscle, and therefore if this was going to be problematic I would expect a different pattern of pain than to the medial knee.

With the right leg being shorter than the left, could it be that the adductors and sartorius are being chronically shortened even when off the bike? Do you get pain relief when performing a stretch for the groin? Related to this, I would be suspecting an involvement of the piriformis muscle due to sciatica type symptoms of burning pain down both legs when performing a stretch - could either have neurological shortening of the sciatic nerve which when put under a stretch gives symptoms (slump test) or the movement is causing the potentially inflamed and overworked piriformis muscle to compress the sciatic nerve. Cycling frequently with an adducted leg would stress and inflame piriformis?

So, what would I do? I would want to strength test your ABductors (glute med particularly) and work on building strength there. I would also want you stretching the groin area as much as possible, alongside psoas. The test you describe from your last post sounds like the Thomas test, and it sounds like you were definitely positive on the right side. I would also want to do some manual therapy on what I suspect will be a very tight and angry piriformis that is giving you burning pain from time to time. Have a look at this:

YouTube - ‪DeFrancosTraining.com - Piriformis myofascial release‬‏

I would advise a medicine ball would be best to start on as a cricket ball (or whatever he is using) may well be too much. For glute medius strengthening exercises (very important to you as a cyclist) I would perform:

1) Hip sinks - standing sideways on a stair keep your supporting leg straight. Then let your hips sink down on the side of the leg that is off the ground (without bending your supporting leg's knee) and concentrate on bringing your hips level again by squeezing in from the side of the buttocks. Imagine you are trying to hitch your hip up as high as you can before letting it drop back down again in a controlled manner.

2) Sideways leg kicks - as you are looking for functional stability in cycling. Kneel down and then support one side by putting your hand on a raised surface (about a foot off the ground). Straighten the top leg and then lift this off the ground. You should know be on one knee, leaning on a surface with one hand and with the top leg straightened and just off the ground. As you bring the leg back breath in and focus on not letting your hips fall forwards (what yours do currently) by tucking your stomach underneath you. Then, bring the top leg slowly forward breathing out before returning to the middle. Do this very slowly - you should notice that both sides of your hips are really working hard, especially as I suspect you are very weak there.

3) Hip ABduction - With a theraband or stretch chord, wrap around both ankles. Stand tall and aligned and then push one leg out as far as you can before slowly returning to the middle. I can't find anything on youtube, but basically this YouTube - ‪Joyband but stood up and with the band around your ankles not thighs.

With all these, perform a maximum of 10 very slow controlled repetitions, 3 times every other day. If you can't get to 10, stop when you fatigue. You could try every day if you don't feel tired, or simply use a heavier resistance on the band. I hope the explanations are ok - it's really hard to find any videos of these exercises on the net, and describing them is tough.

[Diilan]

Hello,
Can I just say that the below statement is partially untrue..

If psoas was going to refer pain, it wouldn't be referring it to the inside of the leg, it would refer it down the front (femoral nerve route). The femoral nerve passes through this muscle, and therefore if this was going to be problematic I would expect a different pattern of pain than to the medial knee.

Well some of it is true but not all... eg I'm not going to go into much detail but I really think you should look closer at your anatomy and the 'innervation' of the BRANCHES of the femoral nerve. I then think your going to wish you never wrote that statement.

I know this is true as I have a medial knee issue caused by a pinching of the femoral nerve (look at branches of this nerve, and dermatomes), this in turn is causing a loss of 'full' innervation to the VMO, my VMO is a little atrophyed, hence medial knee pain...

Solution: TPT.com bought the kit, do the exercises for Psoas etc and things are much better.

May I suggest in future that you research better before making sweeping statements

Good thread though

[Ironmike]

Hello,
Can I just say that the below statement is partially untrue..

If psoas was going to refer pain, it wouldn't be referring it to the inside of the leg, it would refer it down the front (femoral nerve route). The femoral nerve passes through this muscle, and therefore if this was going to be problematic I would expect a different pattern of pain than to the medial knee.

Well some of it is true but not all... eg I'm not going to go into much detail but I really think you should look closer at your anatomy and the 'innervation' of the BRANCHES of the femoral nerve. I then think your going to wish you never wrote that statement.

I know this is true as I have a medial knee issue caused by a pinching of the femoral nerve (look at branches of this nerve, and dermatomes), this in turn is causing a loss of 'full' innervation to the VMO, my VMO is a little atrophyed, hence medial knee pain...

Solution: TPT.com bought the kit, do the exercises for Psoas etc and things are much better.

May I suggest in future that you research better before making sweeping statements

Good thread though

I'm not sure if you intended to come across as arrogant and condescending, but well done anyway.

I stand 100% by my statement that psoas will refer pain to the front of the thigh - go google it or look it up in the textbooks. The original poster's presenting complaint amongst others was that "stretching resulted in burning pain in BOTH medial knees, and in backs of knees & hamstrings." So, you're not thinking hang on a minute, this sounds like there is neurological involvement? Did the original poster complain that he had an atrophied VMO? NO. Did I at any point state that medial knee pain couldn't be caused by a weak VMO? NO. Would you suspect that someone who is a very keen cyclist would have weak quads? NO. You have chosen to completely ignore everything that the patient has presented with, and have just seen the words medial knee pain. Oh hang on a minute, I had that once and it was caused by a pinched femoral nerve - that must be what is going on with 100% of people who present with medial knee pain and burning sensations all over the posterior part of their leg. Oh and I'm not going to elaborate with any clinical reasoning or anything silly like that, just go to TPT.com and do psoas stretches etc. Tell you what, whilst we're on anatomy lessons, go look up the innervation of the hamstring muscles. When you have done that, look up where piriformis (muscle) sits and then something called piriformis syndrome. Apply this knowledge to THE PRESENTATION OF YOUR PATIENT, and then tell me why I am wrong to at least suspect that this could be a cause of his pain? Then come back and try to argue that a pinched femoral nerve will lead to burning in the groin, hamstring and all over the back of the knee. But then again, you know this is true because you had knee pain once, and psoas stretching solved it as prescribed by TPT.com who are a worldwide commodity and risk management company. Perhaps their city hedge fund managers frequently suffer from knee problems?

Your post is so badly put together that I am actually starting to think that it is a joke? Sweeping statements? You have grouped the root cause of all knee pain into a slightly de-innervated femoral nerve, and referred your patient to a corporate risk management company for a solution. Where as I have fully explained my thinking and have reached a hypothesis/alternate way of looking at things based on what the patient presented with, you have decided to say ah heck ignore all that nonsense, who cares about the history of presenting complaint, I'm going to get my speech about VMO out for the 101st time.

A final thing, if you are going to seek to patronise someone in order to gain academic high ground, might I suggest in future that your arguments will have more weight to them if you learn some basic grammar, such as the difference between your and you're. As suggested by yourself, I'm off to send the bankers an e-mail about where I can get hold of their infamous psoas stretching exercises - you have really made me smile, thanks.