Question: I am a 55-year-old cyclist who rides about 7,500 miles per year and for the last 2 years I have been experiencing bilateral hip pain during rides that limit my efforts. I think I have trochanteric bursitis. Is this an overuse problem and what can I do about it? — B. Noah
Dr. Dennis Devito Responds: You certainly may have trochanteric bursitis, and it sounds as if you have earned it with all that mileage. But to be a bit more precise, we will call this greater trochanteric or lateral hip pain syndrome (and “bursitis” is one of the causes). The normal bursa lies between the lateral gluteal muscles and the greater trochanter bone (the bony prominence you feel at the outside of your hip area), and it serves as a shock absorber and as a lubricant for these muscles as they move over the bone.
Any repetitive abnormal strain in this area can produce inflammation of the bursa, resulting in lateral hip pain. This can occur after local trauma, i.e., a fall off the bike often bruises this area; as a result of overuse, especially with any repetitive twisting motion of the hips; it could be an early symptom of rheumatoid arthritis; or it can just happen without any apparent cause.
The most common age for this affliction is the 4th – 6th decade, and is sometimes associated with being overweight. 20-35% of people with greater trochanteric pain syndrome (GTPS) also suffer from low back pain – one could speculate that their back discomfort and stiffness alters the way they walk, or ride a bike, producing abnormal mechanics about the hip area.
Occasionally, degenerative disc disease masquerades as GTPS, since it can produce lateral thigh pain as well as soreness in the gluteal region. Finally, tendonitis of the gluteal muscle insertion onto the greater trochanteric can occur as a result of repeated micro-trauma, and this may be indistinguishable from true bursitis.
Most people that have GTPS pain on the lateral side of the hip area when they stand up after a prolonged period of sitting, and possibly when they lay down on that side. Single leg stance may also be uncomfortable especially when active resistance is applied to the leg during abduction (moving the lower extremity out to the side as in spreading the legs apart). Most of the time weakness of the abductor muscles is seen in GTPS, and it may be difficult to determine which came first, the pain that produces weakness or vice versa.
With specific regard to cycling issues, one of the more common causes of GTPS would be a difference in the length of your lower limbs, although this generally produces a unilateral problem. Tightness of the iliotibial tract with lateral knee pain can also alter motion about the hip and is associated with GTPS; of course, this condition is also aggravated by gluteal weakness on the same side.
Some have implicated excessive foot pronation during the pedal stroke as a way to generate a twisting force of the limb, contributing to both abnormal strain on the knee or the hip, or both. Cyclists should also be sure that their seat is not too high or too far back, since both can cause a slight rocking motion with each pedal cycle and result in overuse micro-trauma, which would certainly be magnified over 7,500 miles.
Treatment always starts with a good exam by someone familiar with the various causes of lateral hip discomfort, and this should include a measurement of limb lengths in addition to an assessment for excessive foot pronation. If leg-length discrepancy or excessive pronation is a problem, a small lift can be placed in the cycling shoe, along with rigid arch support as needed. Alternatively, wedges can be placed under the cleat and the degree of pedal float adjusted.
A period of rest might be needed during acute pain episodes, followed by icing the lateral hip area after rides. Adding a non-steroidal anti-inflammatory (NSAID) such as Motrin or Aleve would be recommended, although I have found this condition often to be resistant to such medications. Stronger NSAIDs such as Indocin can be more effective but have more side effects like gastritis, so usage should be monitored and administered under a physician’s care.
Physical therapy can be helpful for stretching of the iliotibial tract and the gluteal muscles on the affected side, as well as a strengthening program once the soreness has abated. Occasionally, steroid injection is indicated and is helpful 75% of the time if delivered to the proper area. Resistant cases can ultimately benefit from arthroscopic bursectomy, but only after ensuring the proper diagnosis after considering the other diagnoses discussed.
Finally, and perhaps the most challenging solution, is less doughnut consumption. Consider some weight loss through proper diet, if indicated!