cyclist - burning pain inner thighs & hamstrings

[saunaboy]

Hi all,

I have a desk job & am a road cyclist. Was in good shape until I scaled up the miles this year.

Basic story...

1) pain in right medial knee. told to stretch hamstrings by physio.
2) stretching resulted in burning pain in BOTH medial knees, and in backs of knees & hamstrings
3) 3-4 weeks of rest & no bike
4) pain eased, leaving hotspots where hamstrings attach to inner shin
5) had antother assessment that identified tight satrorius. Had release therapy into sartorius with instant results. was cleared to go back on bike as long as I went easy.
6) burning in groin & hamstring recurrs few hours after finishing small bike ride 3 days after release therapy.

I have been given exercises to strengthen pelvic floor area. I have read on the internet about the contribution the iliopsas can have to leg pain. I can add the following...

1) for about 3 years I couldn't run more than a mile without back cramp around base of spine
2) stomach sticks out a bit
3) if i stand for long periods I feel the need to bend over. When I do it feels great.
4) during a bike fit, the right leg (that got injured in frst place) was commented to be shorter than the left. not identified by physio.

Is this all related? The sartorius release was great buy hasn't helped get me back on the bike. At the moment I'm walking but with a sort of stinging/itching/burning down both groins & hamstrings. I've read that cycling can worsen already tight iliopsoas.

Is there anything I can be doing at home to help???

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[alleex]

Hi

Have you had your posture and lumbar spine assessed? As you are experiencing bilateral symptoms this is something I think needs looking at.

Some of what you have said certainly points to a postural issue. If your leg lengths are different then I would expect that your pelvic alignment will be off and this could effect your back and cause some of the symptoms you have described. So this will also need to be corrected. You mention your stomach sticks out so this could again point to posture.

[Musculoman]

Hey Saunaboy,

Cyclists commonly have tight hip flexors due to the nature of cycling (won't go into detail). Office workers also commonly have tight hip flexors due to the hip being constantly flexed to 90 degrees for ~ 50 hours per week. Tight hip flexors will cause an anterior pelvic tilt (stomach pushed forward) which will further shorten your hip flexors and actually put your hamstrings slightly in a lengthened position. When you have such muscle imbalances you throw off your length/tension relationship (http://www.public.iastate.edu/~zool.255/Nov08_02.pdf) and the muscles become less efficient, which can also lead to injury / overuse or symptoms as you have described (aggravation of the insertion / tendonitis).

As previous physio suggested, a postural assessment is definately in order. Hamstring stretching (light, you do not want to further overtension the insertion, leading the some isolated hamstring strengthening (low grade) if symptom free), hip flexor stretching (more important!!!), and some pilates focusing on posterior pelvic tilt w/ core activation would be where I would start.

This could also explain your cramping in your back, as altered pelvic position can also cause problems with your quadratus lumborum etc. (other lumbar spine muscles) and increased Lx. lordosis due to anterior pelvic tilt will reduce the effeciency of impact loads through the lumbar spine and likely cause protective local muscle activation...? I could go on and on, but correcting the relationship between your hip flexors + extensors will likely help, get out of the chair regularly and stretch hip flexors (i.e. reduce the CAUSE of the imbalance), stretch regularly outside of work, strengthen gluts + abdominals (help bring the pelvis back to an anterior tilt)...

Does this make sense? just typing it all out quickly during lunch.

Let me know if you want more info!

[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.

[physiobob]

Thanks all for your input to this post. Please keep it friendly. I remember when I was a super zealous student. Sometimes a discussion via a personal Message (PM) is useful to have a dig at one another as it often doesn't add to the information on the thread. You are both making me smile though I hope saunaboy is smiling also!

[Musculoman]

Awesome thread Let the hilarity ensue. I guess I should add something constructive so this doesn't get deleted huh?

Piriformis release and glut med / abductor exercises should be a no brainer for most athletes. You will want to focus on isolated and dynamic exercises. Here are a few more good ones! You may also want to throw some glut max exercises in, occ. poor glut max firing overloads piriformis (gluts can be inhibited due to tight / over active hip flexors)

Crab walk: Theraband around both ankles, feet pointing forward and wide enough to have quite a lot of tension on the band. Keeping the feet pointing forward (very important) slowly step one foot to the side, then bring the other towards it until you are back to your starting stance. Ensure constant tension on the band. Don't rotate your feet out (you will want to) 10 metres 3 sets (each step should take 5-7 seconds).

Hip hitching single leg squats: Single leg squats exaggerating hitching your opposite hip up. Do this in a mirror until you can maintain good control. You can start with one foot back on a bench to give you stability, and as you improve do an unsupported single leg squat. (great for cycling as it simulates quads / hamstring contraction w/ glut med control). Watch the bony point at the front of your hip (put a sticker on each if you want) so you can see how much you are hitching etc.

Leg Circles (side lye, don't roll forward or back too far as you will take the bias off glut med / abductors) performing shapes / drawing in the air with your feet is important as it turns it more into a dynamic control exercise (keep the circles / dodecahedrons ) as accurate as possible, especially when you fatigue.

Side Planks w/ hip raises (side lye on elbow)

Wall on ball: lying on back pushing one leg hard into a fitball on the wall (hip bent ~ 30-40 degrees to make it functional towards cycling) turn on core / quads + roll ball up and down trying not to shake as much as possible (push HARRRDDD!)

Throw some ITB rolling in there as well / self release piriformis and glut med, hip flexor stretches (as previously advised) etc. (to prevent it tightening in response to increase load of HEP and cycling) .... Some pilates classes may also go a long way in helping if you have any postural / core imbalances (check out this thread: http://forum.slowtwitch.com/gforum.cgi?post=3320766;) for some more advice.

[saunaboy]

thanks for the awesome advice. Here's where I am at the moment...

1) went to a pilates one-on-one session & got a series of basic hip/core strength moves.
2) started glute exercises - kneeling squat, back bridge, clam
3) a specific stretch where I stand one foot on a table, leaving the stretched leg being stood on. This was a real stretch to begin with, right down inside of thigh, but it's become easier.
4) hip flexor stretch. creates very tight feeling down front of thigh

they have helped a great deal. I now have greater flexibility in the hips, especially the troublesome right one. No great pain when walking as everything seems looser.

BUT...even a short session on the bike flares up the inner thigh (right about where the gracilis is) and the attachment spots of the medial knee tendons. No screaming pain, they just get very hot & bothered. I take cold baths post cycling but that doesn't really solve it. It's still keeping me off the bike as even a 20 min session leves me with very tight hamstrings & inner thigh afterwards. I can feel them tugging at the inside of the knee until thye're rolled out.

I saw the physio again who commented 1) that the legs were looser but that 2) there wasn't a great deal else they could do. I still have sports massages booked.

[abishek.pt]

do u have any back ache? or u felling tight ness in back region (low back pain)?

[saunaboy]

I have a long history of it. No great pain, but a lot of tightness, especially when standing for long periods.

Relieved almost instantly by bending over at waist.

[Ironmike]

I'm wondering if maybe you have torn the Sartorius? It seems you have been attacking it quite fervently with the stretching and physio/sports massage, but it isn't letting go completely. Giving you pain 20 mins into a bike ride seems to me too soon for tightness. If anything, I would suspect that the tightness would disappear as your legs got warm and you would present with a painful at the start and the end of the session, but nothing inbetween sort of thing. Have you had any imaging such as an MRI done to look into the physical condition of the muscle. Could possibly be a grade 1 or 2 tear and that is giving you issues.

[saunaboy]

thanks for all the help. I'm after a little reassurance here...

legs are much looser & constant pulling into medial knee has lessened enormously. Pilates in particular seems great. However, I still have a lot of dull,achy soreness where the pes anserine area is, into top of medial calves & hamstring stiffness. I have been back onto the bike a couple of times & knees (especially right) don't mind it until about 3-4 hours later when they're very sore. Hamstrings are very tight afterwards.

Went to doc yesterday & have a referral to knee specialist. The thing that is freaking me out the most is the potential for Tendinosis in this region. There's no real swelling there & bearing in mind the length of time I've had it (>2 months) I could be at risk I guess. Given the area it's in, I'm not sure how much the conventional treatments for this would help. How on earth would you eccentrically exercise a sartorius??

I have a holiday booked in Spain on the bike in August & that's looking decidedly shaky now.

[dio567]

Hi,

I seem to have a lot of similar issues: burning inner thighs, a clicking knee due to something pulling on it, stomach sticking out, ultratight hamstrings....

Just a question: can you sit 'indian style'?

From october 2010 till 2 weeks ago I could not do this because my left leg wouldn't lower without severe pain somewhere in groin if I pushed through. After a few days of mountain-hiking during holiday, suddenly this was possible again?!

I'm still getting this burning feeling though, and I think there's a muscle imbalance or something. (Already did 9 sessions of PT without any help.. )

[violablue]

You may also want to do a quick check for trigger points in the Pectineus, Vastus medialis, Gracilis, Adductor magnus, and Sartorius (you've already had that worked on), as they all have referral patterns in various parts of that area. Could be your previous muscle imbalance issues left you with lingering trigger point issues. If so, very easy to release. See TriggerPoints.net for more info at Hip, Thigh, and Knee Pain A great book for the layperson on the topic is Clair Davies Trigger Point Therapy Workbook.

And just checking for red flags: are you having any numbness in your pelvic floor area? Any trouble with bowel and bladder?

Questions about your bike, are you using "clipless" pedals? If so, can you get refitted to take into account the angle your foot is held in? Sometimes an adjustment can make all the difference. What about your seat? Sounds like you may be getting some compression issues going on in the sit bone area. Checking with your bike shop on seat options may also help in this area.

[dio567]

And just checking for red flags: are you having any numbness in your pelvic floor area? Any trouble with bowel and bladder?

Hi, could you tell me why you mention bladder trouble as a red flag? (And in which way)

Thanks

[violablue]

Well, if there's any damage to the spinal cord/cauda equina lower down due to injury, degeneration, that sort of thing, then pressure can be put on certain nerves that allow proper functioning of bowel and bladder. So say, someone falls of a horse, injures their spine, and then has a bladder that overdoes it, then switches and doesn't allow urination at all. That is a red flag that those nerves are in trouble and it could become a life threatening issue quite quickly.

So the red flags always need to be checked on to determine if there's an issue or not.