Cycling Injury-partial tears glute medius, biceps femoris, & glute med tendinopathy

[williteverstop]

Hi

I’m a competitive recreational cyclist (although not a racer) and in Aug 06 as a result of several bike position modifications and possible fatigue and/or overtraining I suffered what I considered a hip injury on a ride that wasn’t diagnosed until Dec 07. The injury manifested itself as loss of power in my legs and pain in the general whole hip region (lining of my hips and in my iliac crests on both sides). One of the many doctors I have seen diagnosed me with a partial tear of my left glute medius and right biceps femoris both at their origins and tendinopathy of the right glute minimus; however, the MRI report (attached) indicates there may not be tears but rather varying levels of tendinopathy. To make a long story short I now have many other issues (muscle imbalances, low back pain, groin or psoas issues, you name it) that I just can’t seem to shake in spite of staying off of my bike for periods of time, seeing 2 physical therapists, several massage therapists, orthopedic doc, pain management docs, multiple recommendations from friends with similar issues and searching the internet relentlessly.

Here are some of the issues I’m dealing with.

When I ride my bike the main problem is a burning sensation in my butt and no power output what-so-ever. Most of the time the pain is on both sides but occasionally it resides on one side only (right or left). It usually occurs at around 5-7 miles into the ride but occasionally is there at the start. This is riding at very slow speeds (10-15 mph). If I ride faster the pain intensifies. If I stand up and peddle or stop the pain goes away. The discomfort however never goes away unless I am laying down or standing up straight.

I have no leg pain other than a left side groin issue. I feel as though something is not quite right in my left hip and often times when a practitioner has put pressure on my left SI joint I feel as though something needs to be popped back into place but everyone insists that there is nothing wrong mechanically. The initial cycling injury occurred on my right side and for some time only affected my right side but as time went by the pain and discomfort moved across my entire body.

I have pain in my back at L2-L3 due to a degenerated disk (I believe) and pain around L4-L5 facet joints which the MD says is due to osteoarthritic joints. If I lean to the left I feel like something is pinching at the top of my left hip (or back?). If I lean to the right the stretch I feel on the left is quite intense. When I’m sleeping at night and turn over to the right (only) I’m awoken by the pain in my back particularly when I lift my torso to turn. I have never in my entire life had back pain until this injury occurred. I had a radiofrequency procedure done January 08 as a result of a facet injection that seemed to have eliminated the pain for the 4 hours until the lydicane(sp?) wore off. I believe it helped slightly. I’ve also had 2 epidurals which helped enough to where I regained mobility and was able to start doing light weight training.

I’ve done every kind of stretching, strengthening, exercise, that anyone has ever suggested to no avail. I don’t know if I’m doing too much, not enough, the right stuff, the wrong stuff or if I should just give up and be a couch potato for the rest of my life! I feel like I’ve aged 10 years in the last 2! Frankly I’m hating life right now.

Sorry for the long read. I felt it was important to document my story as best I can because no one person has been able to take the time to (or can’t) digest the full picture which has been a major source of frustration for me and the practitioners. Time is also against me since the initial injury occurred almost 2 years ago now.

Do you think you can help? I look forward to a reply!!!

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[Canuck Physio]

Will reply once fully read.

[williteverstop]

Thank you! I'm looking forward to it!

[sharileedahl]

WOW! Ergonomics is definitely important but seeing someone like you (with this extent of difficulties) walk through the door would still baffle me.

Couple questions first...
1. What do you mean by "hip"? Can you describe exactly where you mean? (If I saw you in the clinic, I'd have you point at it!)
2. When you have burning in your buttock, where exactly is it? (is it the whole buttock / lower part toward the leg / higher toward back / outside along the iliac crest...)

Now, I'm sorry "williteverstop", but I'm going to talk about you like you're not here for a moment. Just because this is quite the history and I don't think there is a simple answer so I just want to get other physio's thoughts about a couple other things....
So to the physio's reading this... Some thoughts.....
1. tendonopathy resulting in adhesions around the inferior / superior gluteal nerves??
2. involvement of quadratus lumborum? (iliac crest pain; L2/3 pain)
3. psoas and adductors mentioned in post (groin pain; back pain; L4/5 facet involvement)
4. anyone deal with cyclists often and have seen variations of the same injury?

Looking forward to following up on this one. I think alot of discussion will come out of this and hopefully in the end some decent problem solving......

[williteverstop]

Hi sharileedahl!

I can't tell you how excited I am to see your reply. I'll answer your questions (in red below) and then wait to see what everyone has to say.

Couple questions first...
1. What do you mean by "hip"? Can you describe exactly where you mean? (If I saw you in the clinic, I'd have you point at it!)
[williteverstop] this is a hard one to be specific about because it happened so long ago and so many things have occured since then but I think I felt the pain at the top of the illiac crest just to the right of my right SIJ. When I ride my bike today I feel the burn in the same place.

2. When you have burning in your buttock, where exactly is it? (is it the whole buttock / lower part toward the leg / higher toward back / outside along the iliac crest...) [williteverstop] same answer as #1

The original injury occurred on a Sunday, I had to go out town the next day for the week and couldn't get to a doctor. For most of the week I could hardly function (lift my right leg, bend over, turn at the waist, get in or out of the car, etc) and because it seemed to have calmed down significantly by the time I got home I decided I didn't need to see a doctor.

Thank you so much for your quick response. I will anxiously await any feedback you and the others may have.

Cheers!

[alophysio]

i too will reply later - this entry is so that it keeps popping up in my email...

[linbin]

hi
since you are having problems which are multifactorial its difficult to come to a conclusion by the description.what i mean is a detailed assessment is needed.there may be muscle imbalances and altered muscle recruitment patterns.positional faults of the lumber,pelvis ,hip might be there.my suggestion is that you should consult a physio who is skilled in musculoskeletal conditions
cheers

[sharileedahl]

I agree with "linbin" in that it would be important for a full assessment by a physiotherapist as you're not just dealing with a "simple" injury here. Quite often with these type of injuries, you have the initial problem then gradually a whole lot of compensatory problems as your body tries to make due with it's limitations. By the sound of your story, the compensatory issues have become big.

However...still really interested in this progression.
You mentioned you have had physio in the past. What had you been told...how long ago did you go for assessment / treatment....how many sessions....what type of treatment / education / exercise were you given....are you still doing any of the exercises / treatment at this time....what effects did the treatment have...?

Thanks.

[williteverstop]

However...still really interested in this progression.
You mentioned you have had physio in the past. What had you been told...how long ago did you go for assessment / treatment....how many sessions....what type of treatment / education / exercise were you given....are you still doing any of the exercises / treatment at this time....what effects did the treatment have...?

Thanks.

Hi sharileedahl...

Unfortunately I wrote into the PhysioForum 'because' I have done all that to no avail and I'm still looking for answers.

I went for PT for 12 weeks 3x/wk Oct-Dec 07 and then again for 13 weeks 2x/wk Feb-Apr 08. The first 12 weeks was a referral from an orthopod who took xrays of my hips, said I have perfect hips and he couldn't see anything wrong (this was before learning about the muscle issues (tears & tendinopathy). The PT had me doing all kinds of stretching & strengthening for my hip rotators after determining that my left side pelvis was rotated anteriorly and on occasion my left leg was 1/4 inch shorter than the right for which I was able to do some techniques to correct but nothing permenant. I did (and still do many) clam shell, side steps, hip hitch, squats with the stability ball, hip flexes with the ball, hamstrings with the ball, back extensions, etc. This was basically a canned approach (imho). At times I felt things improve and at times things got worse. In 08 a different PT worked specifically on my glutes with massage and cycling specific exercises such as ad & abductors, hamstrings, and stretching. This guy was more focused on the fact that I'm a cyclist and felt that we needed to do cycling 'like' exercises. He too was perplexed and didn't know what else to do. He was well aware of the all the back issues and believes that there is nothing structurally wrong with me.

After the muscle tears diagnosis I requested that I have another mri to see if anything had changed with my back in the last year and more specifically to see if there was any change in the muscles since Dec 1, 07. Feb 10, 08 mri results returned all the back issues and still signs of the tears or tendinopathy. Prior lumbar mri dated Feb 19, 07 showed very few 'slight' disc bulges and normal degeneration for my age (50).

Twice I've stayed off my bike completely (once in Feb 07 (for 6 wks) & again in Dec 07 (for 4 months) at the doctor's recommendation. I believe things got worse as I became less active. I was very limited in what I could do because the docs were telling me don't do anything that involved 'those' muscles (the glutes). Unbelievable!! I am riding my bike again now albeit at a snails pace. I'm lifting weights, mostly upper body, and some legs (extensions, ab & ad ductors), quite a bit of core strenghtening (I have the book 'spinal stabilization) and walking.

My back has finally loosened up to the point that I can bend over and touch my toes without pain and that was after having cranial structural therapy a few weeks ago. I am now seeing a local therapist who is certified in Hoshino Therapy, OH MY, might I have Arthrosis? Are you familiar with?

What else can I tell you? Can you recommend (by name or by institute) anyone or anyplace that specializes in such issues? I have not seen a back doctor yet. Should I? I know it's a complex situation and of course it's best to see someone in person but what I really need now are names for those who are the absolute best in the business. Any suggestions?

Thanks for any recommendations or suggestions you care to provide.

[sharileedahl]

Hi "williteverstop". I read through your posts again to try to get a better understanding of the sequence of events etc.

Mechanism of Injury - If I understand correctly, the initial injury was related to over-use but also changes to ergonomics (bike set-up). As you noted, you thought it was getting better after some time off the bike so you initially didn't have the injury looked at. I think we all do that especially when we are physically active....we seem to be used to abusing our bodies and having it spring back and are surprised when it doesn't seem so "springy"!!
The issues you are having now are probably in part due to the initial injury but, as noted previously, there are likely alot of compensatory issues. This is not uncommon with tendonopathies and over-use type injuries. Unfortunately, it also makes treatment more difficult (rehab is not impossible it just takes a whole lot more work and patience).

Based on the findings of tendonopathy - I used to work in a clinic that dealt with chronic upper extremity over-use injuries. Clinically the clients were often diagnosed with "tendonopathy" however not always were there MRI findings. Therefore my thought is that the extent of your tendon injuries is significant if showing up on MRI. (However, I would be interested in other physios thoughts on this as judging from the posts on this forum, I get the feeling that MRI is used much more frequently in the US than in Canada so perhaps my opinion is based on not seeing enough MRIs of musculo-tendinous injuries.)
As a side note however, I would encourage you not to get to worried about the finding of "slight" disc bulges on you lumbar MRI as this is quite common and there has been quite a number of research articles that have noted these findings in asymptomatic clients (and your symptoms as reported would not make me suspicious of lumbar disc issues).
Tendinopathies can explain a few of your symptoms.... Total rest is not normally beneficial as increased feeling of tightness usually occurs (which you experienced). Pain like that which you report, could be due to "ischemic pain" (pain due to poor circulation due to scarring / poor fitness...) or could be due to entrapment of small peripheral nerves in adhesions in the muscle (as I noted before...perhaps superior gluteal nerve). Pain with tendinopathies is also thought to be due to the way the body tries to heal these injuries....in research there has been seen an infiltration of small nerves and capillaries in to the areas. The thought now is that exercise should be aimed at stretching out these areas and breaking down these new little vessels and nerves (eccentric exercise is used). (Again if other physios have read more recent research I would be interested in a response!)

Core Strength - Because alot of the injuries that you have are affecting muscles around the hip, low back and pelvis, your core strength will be affected. Some of the deeper stabilizing muscles quite often can not do their job efficiently when those larger more superficial muscles are injured / tight / sore. Again due to compensations, your body has likely learned new ways to function due to the pain. Although these compensations probably helped with pain short term, the end result is not normally beneficial. Regaining proper muscle balance will be necessary.

You noted a feeling that "something needs to popped back in to place". If the physios that you saw noted no need to mobilize the joints in the area then likely the sensations were related to the forces the tight muscles were putting on tight joints. Occasionally joint mobilizations / manipulations are used to decrease neural activity of the muscles in the area however without addressing the muscle imbalances, joint mobilization would not on its own "fix" the problem.

SO....what to do now??
The recommendations are limited by the fact that I haven't assessed you but based on what I'm reading and thinking...
-I really don't think you're going to be able to do this totally on your own. I do think that ongoing reassessment and progression of a rehab program is going to be necessary.
-In terms of physiotherapy, I would try to find a therapist who has a lot of tools to use. Someone who has advanced manual therapy skills to assess and mobilize / manipulate as necessary the pelvis / lumbar spine. Rarely do manual therapists NOT address muscle imbalances concurrent with manual treatment. Therefore, I'm fairly confident that if you find someone with advanced manual therapy skills they will progress an individualized exercise program for you as well. Another tool that may be of use is needling. Quite often it is easier / quicker to decrease tone in tight / overactive muscles with needling (acupuncture and/or intermuscular stimulation (IMS; aka dry needling)) prior to teaching the client how to recruit weak / underactive muscles.
-Ways you find someone...
--you could contact the American Physical Therapy Association as they would likely be able to offer contacts.
--Diane Lee and Linda-Joy Lee are two Canadian therapists (from British Columbia) who come to mind. Both of these therapists research and present on chronic pelvis / lumbar / thoracic injuries. They lecture world-wide and MAY have contacts for therapists in your area. You could try to search on them on the web to find a contact e-mail.
--If there is a cycling club in your area, they may have a contact for a therapist that has a lot of experience working with cyclists which would be beneficial.
--The docs in my area that do facet injections, work closely with physiotherapists to assist with assessment and follow-up treatment. That may be the same with the docs near you. Contact the office of the physician that did the injections for you...they may have a contact.


So...long, long reply without actually giving you an answer!!! But as noted before...there probably isn't a simple one. I think it's great that you are back doing very light cycling and weights. Keep it up and just try to stay patient with the rehab process.

[alophysio]

Hi Williteverstop,

I think Sharileedahl has covered a lot of the same ground i was thinking of.

Diane Lee & Associates - Consultants in Physiotherapy, Linda-Joy Lee Physiotherapist Corporation - Physiotherapy Education and Resource Company - Vancouver, BC and Discover Physio - Diane Lee and LJ Lee are the websites that you can get in contact with Diane Lee and LJ Lee.

Don't avoid the gluts but work them eccentrically as stated above.

And as Limbin said, find someone who is good at looking at you as a whole rather than just a hip problem.

Asking Diane or LJ Lee for good contacts is a good start.

Cheers

[bmc]

Hi Williteverstop,

I think from the above two posts you are certainly on the right track to a solution. I would like to ask however, what were the original bike position changes that you feel may have contributed to this problem starting. Gluteus medius tendinopathy is certainly not uncommon in competitive cyclists and is often related to sitting too high and too far back. This position also loads the biceps femoris more. In some riders it is associated with the typical excessive pelvic rocking motion from sitting too high, but I have seen it a number of times in riders who are otherwise very flexible, look really symmetrical and stable on the bike, and mask this problem very well.

I would reccomend a review of your bike position by someone who understands bike fit AND injuries. Hard to find I know. In the states I would start with the Boulder Sports Medicine Centre, or if that is too far for you, call them and see if they can reccommend someone closer to home.

I would also load the glut medius eccentrically. This means that you load the muscle and then let it stretch from a shortened to a lengthened position. This form of training has been shown to help with patellar and achilles tendinopathy but I think it is also useful for other tendinopathies in the body. To do it with glut medius you need to be a little creative (either using cables or lying on your side with exercising leg down) and probably need the help of a physio to perfect the exercise. Important to remember is that in the programs that have been doccumented to work, the exercises were somewhat painful (i.e. reproduced SOME of the tendon pain) and all other activity was stopped for the first 6 weeks. The typical loading was 12 repetitions, 2 sets, every morning and every evening for 12 weeks (the "Alfredson Protocol"). I have had good success when using this in combination with soft tissue work (massage, needles etc), core-control exercises and bike position modification in many cyclists.

Good luck!
BMC

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