Greetings, humans. I have been chasing a hip issue for three years and think I’ve gotten to the bottom of it, but could use a gut check. Does anyone have advice on the right kind of exercises, bike fit mitigations, or a good PT to help with the below problem? If it matters, I live in Chicago, USA. The problem:
After I ride (or sit too much, or run), my left piriformis muscle BURNS at the top of the glute area, and pretty often I get sciatic nerve pain radiating all the way down the same leg. I have done three years of medical FAFO — America — and am confident (1) it’s the piriformis clamping down on the sciatic nerve, which is now irritated and (2) the proximate problem IS in the hip, NOT the spine. This persists across multiple bicycles of different fit (including crank length and saddle shape) and has kept me off the bike. It’s worst on my lowest-stack bike.
The obvious first step here is strength training, and I have done that religiously for all three years. While I do not regret that one iota, having strong glutes and a strong core has not magically solved the problem. What it did, is gave me enough body awareness to diagnose the problem. Here are the most obvious symptoms I have keyed in to:
There is a dead spot at the bottom of my left pedal stroke where I barely control my foot / leg. It’s most obvious in a single-leg drill.
My right leg is doing a lot more work on the bike than my left leg, and when I consciously override that, the piriformis issue gets worse.
I do not roll off of my left foot while walking.
My left knee locks out while walking.
My single leg balance is bad, worse on left, and… immediately becomes very, very good with the faintest touch of a pinky finger against a wall or some other object.
Eccentric contraction is difficult for me to control in all of the muscles on the back of my left leg (won’t go into more specifics here, to avoid writing a novel)
I can consciously contract glute med on either leg and leave it contracted (like one does for weightlifting)… but the left one doesn’t seem to fire automatically at the bottom of the pedal stroke while riding, and burns out after a few pedal strokes when I contract it consciously.
And here is how I think it happened.
Multiple ingrown big toenails ~30 years ago as a kid → I learned to lock out my knee and avoid pushing off my forefoot when walking → I unlearned how to use my glute med automatically to stabilize my leg (instead, piriformis clamps down hard to compensate). Nails were worse on the left.
Because of the weird gait , I sprained my ankles a lot → proprioception at the ankle (and probably the knee) is shot.
The problem became loud enough to notice a few years ago when I started working full-time remote (way more sitting) and entered middle age.
So I am pretty sure I need a lot of neuromuscular work to regain proprioception and teach the muscles to fire in the right sequence. But I am not at all sure where to start — least of all finding (probably) a physical therapist who takes all that ^ seriously rather than prescribing more clamshells.
If anyone has advice on the right kind of exercises that might help, any bike fit mitigations that might help for now, or how to find a good PT, I would be much obliged.
I’m also dealing with a hip issue that was diagnosed as glute tendinitis and IT band syndrome by a sports orthopedist/hip specialist. He prescribed PT and my usual therapist (at a local hospital) was unavailable for several weeks, so I decided to try another place that focuses on athletes and is co-located with a gym rather than a medical facility. It’s unlike any PT I’ve ever had, has me working harder and takes a more whole-body approach than typical PT. So you might see if there’s a place like that in Chicago.
For reference, the place I’m going to in the Boston area is:
Dead spot at the bottom of the pedal stroke: I’ve been using oval chainrings(Absolute Black) for several years, and my perception is that they are smoother across the bottom of the pedal stroke than round rings.
I think I’ve got a 34T for Shimano 4-arm 11-speed that I could send you if that’d be useful. My first try at ovals was to replace just the inner ring on a 50/34.
nothing to add Aryeh other than thanks for the detail and your year on year monitoring. Was told by a doctor about a decade ago when the symptoms first arose (similar to yours) that it was piriformis and/or psoas. I can’t work my hip ache/pain out other than (1) x-ray showed nothing (2) CT scan shows mild osteoarthritis (3) MRI not allowed because I have metal in that hip from an accident a decade ago. I feel that if I lay off the bike and exercise, I’ll just go backwards, so just doing the shit eating smile, taking paracetanol and looking for a physio who can help. The two I have seen so far have sort of shrugged their shoulders. I also get what can only be described as agonising yet periodical hip flexor issues, and my gait is now weird because I cant push my knee back beyond the zero axis when walking. Other than that, its great! Cycling doesn’t make it worse, and I have taken up weights this year which also does not make it worse. Nor does it make it better. I am going to go out right now and try all those tests that you have inflicted upon yourself, because self-experimentation is a great way to advance things. Like Prof Barry Marshall getting the Nobel Prize for working out that stomach ulcers are not due to stress but are bacterial, and proving it by swallowing a beaker full of said bacteria and fixing it with plain old antibiotics.
Obligatory I am not a doctor so this is only my own experience/advice:
Last year I developed this real bad in my left leg. It had always been the problem leg, but last year a botched fit made it explode in discomfort. Things I did that seemed to help:
Standing more at work. Sometimes upwards of 3-4 hours and while doing it kind of engaging my glute
Doing some pre-bike glute engaging movements (crab walks, hip bridges, bird dogs)
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Basically before every ride now I will do the pre-ride movements, and then after the myrtle routine and then my modified combo of the yoga video + old PT movements (kneeling lunge, hamstring, pigeon pose, cross legged yoga, cobra press ups, dead bugs). Twice a week I also do some weights (reverse lunge, squats, single leg Romanian dead lifts). Ive noticed if my left leg flares up BAD, just doing the myrtle routine will completely unlock it.
Ive also been wearing minimal drop (0-1mm), wide toebox shoes for a few years now. Ive noticed this has helped with gait and arch strength but it may not be for everyone.
Anthony helped with me a frozen shoulder a number of years ago after a collarbone break. Great therapist, super strong and built so no tendon or tightness issue stands a chance. Located in the West Loop.
My partner and I have similar problems, with different causes.
My piriformis problem was solved with kinesitherapy (is that a word in English?), and with a chiropractor (dry needling etc.), plus keeping a basic weekly level of yoga/pilates/etc. It tends to flare up when I do more running training (I have wonky ankles and am probably running a bit wonky as well).
My partner’s problem is a chronic issue which can only be controlled with anti-inflammatory medication. It took 6 years to get the diagnosis. Core strength training and pain medication never helped. CT scans of the spine (seemed like sciatic nerve issues) never showed anything. After a bad episode, we ended up at a reumatologist (correct word?) and they finally did a scan of the hip (area) and found a chronic infection, which is now being treated with anti-inflammatory drugs.
Why am I mentioning all this? Hopefully you recognize something that can help guide you to the right diagnosis. It can take time to find the root cause and the right treatment for issues in that area.
Have you seen a physiotherapist? If you mean you’ve been seeing doctors, they aren’t really qualified and experienced in this sort of stuff.
Strength work alone isn’t enough. I’d suggest you try pilates. It is highly effective in resolving these types of issues.
Short story: my wife had chronic back pain for years. Saw doctors, chiropractors. Many consultations. Chiropractors were just inflaming it. Doctors eventually resolved that she needed fusion surgery. She took up pilates, trained to become an instructor and taught for years. That resolved it very effectively. It wasn’t easy - she took it seriously. Regular pilates, changing her body. Not stuff a doctor can resolve with simple wisdom, drugs or surgery.
Smart. The gym I go to is somewhere between that and “normal” (former PT started a gym, and does most of the programming for members). So I Get It for sure and see the value.
+1000 on wide toebox. I really ought to replace my old road shoes. You found it made a hip difference riding? I’m already there for walking (old man new balance life).
I’m glad you (plural) found something that worked. I had sort of the opposite trajectory and started with rheumatology / NSAIDS but they just masked the problem. No two of us are alike, but they sure want you to be at patient intake.
Have not tried Pilates! No gym close enough for it. Have tried PT. I learned some biomechanics and body awareness that proved useful in getting me to the current hypothesis, but ultimately spent a lot of time not getting to the bottom of the issue. I do have an email thread going with a local PT who has a weapons-grade biomechanics background and a bike fitting practice — and is a competitive cyclist herself. That’s my next best shot for someone who might have the right skillset to break the bad biomechanics down and teach me how to build back up.
I know everyone has their own theory on this stuff, but I find many medical professionals specialise in diagnosing the cause. Once they’ve done that they congratulate themselves as job done.
In my experience, your body rewards consistent conditioning that rehabilitates the problem. Pilates is great for that. It fixes the source of many of these problems, without even requiring you to pinpoint it.
When my hip issue finally started disrupting my sleep, I had an MRI which found a small labral tear. The general consensus was to ‘go until it hurts’ and treat with Tylenol and ibuprofen, since it was unlikely to get much worse. I avoid trail runs due to a potential loss of balance, but it’s not bad on the bike.
Yikes. Yeah, I think some of this stuff is probably relatively diagnose-able… if someone is paying a lot of attention to you… which is unobtanium, unless or maybe even if you’re a pro. Or have crazy money.
Im dealing with something similar. Its on the side of a shorter leg and i dont think ive ever gotten cleat spacers / stance width quite right to match the longer leg. Working on stretching the front side of my hips, (hip flexor?)helped alot. I get in a lunge position and reach up feeling for a stretch deep in my front hip
PT here. Dude, that’s complicated. I wish you were in Richmond, VA so I could give it a shot, this sounds like a fun, interesting problem.
To find a good PT in Chicago, looking at board certified ones is a great place to start. An OCS is an orthopedic clinical specialist and that should be the right thing for you. This link should take you directly to the Chicago search for them, I found 92 so you should be able to find one close by who has availability.
If that doesn’t work correctly, just search for board certified PT directory and look for orthopedic specialists.
When you do see the PT, don’t be surprised if there’s some disagreement with your self diagnosis. I’m not saying you’re wrong, just that a PT may have different eyes than you. If they listen and respect your thoughts, that’s what matters even if they take a different tack.
From reading your description, I have a slightly different idea of source, for example. If they do try a new direction, go with it for a few weeks, maybe a month, religiously, before disagreeing. Very often I see people not fully commit to my plan when they have a different idea about the path. It’s partially on me to sell it and partially on the patient to trust. If you don’t wholeheartedly follow, a plan won’t work. So give it a shot and best of luck! Feel free to ask me questions if you’d like.
You haven’t mentioned leg length discrepancy. The dead spot at the bottom of the left pedal stroke and locking out of the left knee while walking suggest a short left leg. It’s possible that you’re rocking or reaching with your hip at the bottom of the left pedal stroke as well. This can cause all sorts of issues. I suspect that you have checked this line of thought, given your thorough description and insights, but I thought I’d throw it out there just in case.
Ive personally found that moving to more “naturally shaped” shoes for everyday use is helping me. I don’t have super low arches, but my feet do flatten out some. So it’s all helped in some ways, but this is for me.
In terms of the bike, moving to Lakes has helped allowed my feet to breathe more in the toe box. I used to feel squished in Giros, and Fizik and Shimano never worked for me.