A 61-year-old competitive male cyclist presented to these authors' clinic with a history of insidious onset pain in the left perineal area which occurred during cycling. Shortly prior to seeking medical attention, he noted a tender mass in his perineum.
No visible abnormality was detected. On palpation, a nodule of approximately 1 cm in transverse and 4 cm in longitude was noted adjacent to the left ischial tuberosity. It was firm and rubbery in consistency, mildly tender on palpation, and not fixed to the underlying muscle or bone.
The patient was referred for diagnostic high-resolution ultrasound.
High-resolution greyscale ultrasound demonstrated a well-defined, heterogeneous, predominately cystic mass inferior to the left scrotum. It measured 5.0 x 2.4 x 4.0 cm and contained hypoechogenic material within it, with no increased vascularity.
Based on the imaging and clinical findings, it was diagnosed as an ischial hygroma.
The patient was reluctant to undergo surgery and specifically requested conservative management.
A comprehensive assessment of his cycling biomechanics and saddle contact point was performed.
Pre-fitting and static kinematics were performed using ErgoFiTTM (http://www.sciencetosport.com/ergofit) software and kinematic tools. Saddle pressure mapping was performed using Gebiomized  dynamic saddle pressure mapping systems (http://www.gebiomized.de).
Salient findings were that underwear was being worn under the cycling-specific garment and that the cycling-specific garments were of relatively low quality, with chronic wear demonstrated on the padding material. The kinematic assessment demonstrated excessive saddle height (static knee flexion angle (KFA) of 22  using the Holmes10 method) and excessive saddle setback (10.5 cm). This was confirmed on initial saddle pressure mapping by a front: rear pressure balance ratio of 62:38.
After correction of the kinematics (KFA of 31  and saddle setback of 6.8 cm) a series of minor adjustments were made and numerous different saddle types were tested to achieve the most favourable saddle pressure mapping possible (pre- and post-pressure mapping are shown in Fig.4).
Pre- and post-changes (Table 1) improved overall pressure distribution by:
Improving front: rear pressure balance ratio from 62:38 to 46:54
Increasing loaded area in left ischial area from 4300 mm2 to 5325 mm2
Reducing peak pressure from 923 mbar to 724 mbar
The patient returned to cycling activity and has subsequently not experienced any recurrence of symptoms at two-year follow-up.