August 5th, 2005
Most massage therapists see clients suffering with low back pain that continues down the leg. Learn how to accurately identify piriformis muscle syndrome, how to locate this external rotator and which massage techniques can release the piriformis.
Sciatica refers to pain that begins in the hip and buttocks and continues all the way down the leg. This condition is often accompanied by low back pain, which can be more or less severe than the leg pain. In addition to pain, other sensations include spasms, tingling or numbness along the sciatic nerve that can travel down the hamstrings, legs and feet. These symptoms can be bilateral or can occur on one side.
The cause of sciatica can range from a misaligned vertebra or disc, to tightened muscles surrounding these structures, to tightened muscles anywhere along the length of the sciatic nerve. It is called true sciatica when a herniated lumbar disc compresses one of the contributing roots of the sciatic nerve. It is called false sciatica when contracted musculature in the buttocks or lower extremity compresses the sciatic nerve. The symptoms are the same for true or false sciatica.
The sciatic nerve passes through a mass of the hip’s external rotator muscles. The sciatic nerve exits the greater sciatic foramen and can run superficial to, deep to or even through the pirformis muscle. Spasm in the piriformis muscle can cause compression on the sciatic nerve sending pain, tingling and numbness down the posterior leg. This description falls into the category of false sciatica and is referred to as piriformis muscle syndrome.
Piriformis syndrome is sometimes referred to as “back pocket” sciatica. People that keep a wallet in their back pocket and sit on it throughout the day often develop symptoms of pain in the rear and down the leg. The extra pressure on the buttocks can cause tightening of the buttock muscles which can compress the sciatic nerve. In “back pocket” sciatica, the removal of the offending wallet usually brings relief.
Thanks to the Institute for Integrative Healthcare Studies’ Neuromuscular Therapy and Advanced Deep Tissue Manual, massage therapists have a guide for determining piriformis muscle involvement. If the following three tests are positive, there is a strong indication of piriformis muscle involvement in a client’s sciatica symptoms.
Three Piriformis Syndrome Tests:
- In the supine position, the affected side’s foot lays out in external rotation (at least 45-degrees), indicating tight external rotators.
- In the prone position, there is restriction or pain when doing this range of motion (ROM) test for the external hip rotators. Grasp the ankle and bend the knee to 90-degrees. Stabilize the pelvis with one hand on the sacrum and pull the leg toward you (internally rotate the femur). Normal ROM of the leg is about 30-degrees; less than this indicates a restriction. Test both sides and compare.
- Palpation of the piriformis muscle elicits pain and tenderness.
Important Considerations for Piriformis Work:
- During ischemic compression, it is normal for there to be some soreness. The pain and any referral of pain should diminish slowly within 30 seconds. If the pain or referral intensifies, this may indicate pressure on a nerve instead of a muscle. If this is the case, release the pressure.
- Be careful not to go in too aggressively in an attempt to work through the gluteus maximus to contact the external rotators. Instead, visualize sinking through the gluteus and direct your attention to the piriformis. Myofascial release can be used here to access the piriformis.
- Repeatedly check in with your client, as you do not want to further irritate an already inflamed sciatic nerve.
Locating the Piriformis:
The piriformis is deep to the gluteus maximus. It laterally rotates the hip and adducts the thigh, when the hip is flexed. Its origin is the anterior surface of the sacrum and it inserts on the greater trochanter of the femur.
Art Riggs, Certified Advanced Rolfer, CMT, gives us help in finding this muscle in his book, Deep Tissue Massage:
- Locate the top of the greater trochanter.
- Palpate for the piriformis tendon about half of an inch medial to the trochanter.
- Locate the midpoint of the sacrum’s lateral border.
- Draw a line between the top of the trochanter and the midpoint of the sacrum’s lateral border – the piriformis follows this line beneath the gluteus maximus.
Massage techniques for Piriformis Syndrome:
According to Whitney Lowe in Issue 106 of Massage Magazine, the following massage techniques are highly effective in releasing the piriformis muscle:
- Use static compression on piriformis myofascial trigger points.
- Do longitudinal stripping along the length of the piriformis muscle.
- Have the client prone with the knee flexed to 90-degrees. Ask the client to hold the hip in that position as the therapist tries to medially rotate the hip by pulling the leg into medial rotation. With a moderate degree of contraction, the client is to slowly release the contraction. With this release of tension, the practitioner applies longitudinal stripping to the pirifomis. Compressing and stripping the muscle while it is under contraction magnifies the effect of force and allows the therapist to go deeper into the muscle.
According to Sean Riehl in the The Institute for Integrative Healthcare Studies’ Neuromuscular Therapy and Advanced Deep Tissue Manual, the following techniques are also highly effective in initiating piriformis release:
- Either skin roll or pull out and hold the gluteal fascia with no oil.
- Elbow strip from the iliac crest, inferiorly between the sacrum and to the greater trochanter. Add internal and external rotation of the hip with the leg bent at 90-degrees to increase range of motion.
- Thumb friction medial to the greater trochanter, superior to inferior over the attachments of the external rotator muscles.
- Friction the quadratus femoris at the femur attachment, then apply static elbow point pressure.
- Apply static thumb pressure to the piriformis where it attaches to the sacrum. Should the piriformis spasm, bend the knee to 90-degrees and internally rotate the leg while applying pressure to the piriformis; then have the client attempt to externally rotate his/her leg against your resistance to activate the internal rotators. This will engage the piriformis and calm it down.
- After releasing the external rotators, place the client in supine position and stretch by bringing his/her knee up and across his/her body. Stabilize the torso with your other hand. Ask him/her where he/she feels the stretch and move the leg around to get the stretch in the appropriate place.
Riggs cautions massage therapists to maintain a global view of a muscular imbalance. He encourages us to remember that the piriformis may be tight because motor nerves from the spine are making it contract. He advises to include massage on all of the hip rotators and muscles in the low back for sciatica pain.
For those massage therapists addressing sciatica, one final reminder remains stressed by every author of piriformis massage — continually communicate with your client. Ask to be informed of any nerve sensations that travel down the leg as you work. This will be the therapist’s gauge to alter his/her pressure, adjust the direction of force or focus on a different location. Further irritation of the sciatic nerve will deliver results contrary to that which is desired. The practitioner’s goal of alleviating piriformis muscle syndrome can be achieved by inquiring and respecting the directions given by the client.
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