One day I’ll write something thorough on piriformis syndrome and sciatica. Til then, here’s some brief info from en email exchange. Edited for relevancy:
Hi Brian,
I recently took a trip driving to Arkansas from NJ with my family. After getting home (actually I knew while in Arkansas) my hips are out of sync, my right hip is higher than the left. I started going to the chiropractor. In the midst of getting treated, a few days later I got a excruciating pain from my right buttocks, behind the right knee and some numbing of my right big toe/foot. When I went back to the chiropractor that day the pain started, he checked me out and told me I have Piriformis Syndrome (then of course he said I have literally a ‘pain in my butt’ (well he didn’t say butt, but you get it.). I have been icing it continuously which helps. I have used anti-inflammatories Flexeril and Lidoderm patches (both limitedly as I truly do not like taking any medications but this pain was worse than having my twins). He has been treating me with ultrasound and electric stimulation (I don’t know what that thing is really called). Today I will be going to an acupuncturist (for the very first time, although I always wanted to go to one). I am hoping she can help too. The pain is not as bad as the first few days and I am only icing the buttocks area where the pain is. I do stretches – lifting my right knee to my chest and holding it, crossing my right leg over my left (where my foot is at my left knee), and some others. Is there anything else I can do to help this go away so I can start doing ‘normal’ things again (and get my butt back into some exercising)? Thanks for reading my rant.
Pain radiating down the leg like that is often (but not always) actually coming from the lower back. The sciatic nerve starts at the lower back, then travels all the way down the butt, knee, and into the foot. So, if that nerve is getting pinched / compressed at the lower back, it can send shooting pain way down the leg.
Next, a common issue at the lower back is the lower back is twisting too much. If you’ve noticed one hip is higher than the other, this is likely a problem you’re having.
This is an example:
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You’ll notice when he bends to the right side in particular -right shoulder comes closer to the right hip- his hips are getting pushed forward but his shoulders backward. That is, his shoulders are behind his hips. Basically, when he side bends his lower back is arching and twisting all over the place. (Potentially pinching that sciatic nerve.)
So, you then need to figure out, why is my right hip higher than my left? (When are you side bending?)
Common examples include: Sleeping, driving, leaning on a desk.
Here is a thorough example going over sleep positioning and the hips. This woman actually has the right hip higher than the left too:
Link- http://b-reddy.org/2013/04/16/an-example-of-how-important-your-sleep-positioning-can-be/
You can see the side bending present during how most people drive as well. Left hand on wheel; leaning on console:
At a desk, people often side bend / tilt / twist when reaching for something such as a phone, which they may always have set to one side.
Video here:
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Standing on one leg can cause asymmetry in hip height too.
In terms of exercise, a backward rocking / child’s pose stretch can often give some nice relief:
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That will even things a bit as well as stretch the back of the hip out. (Where the piriformis / sciatic nerve is located.)
Overall, you’d want to throw in something like the backward rocking stretch, then also look for instances where your lower back is twisting, or your side bending / tilting, and then get rid of those instances. Often, it’s during way more things than the person realizes.
Another way of thinking about this is, “I want to make sure my hips and shoulders always face the same direction.”
For example, when someone reaches while seated you can see their shoulders turn to the right, but their hips stay in place. The shoulders, relative to the hips, are turned to the right.
The hips, relative to the shoulders, are turned to the left. What the person should instead do is turn the hips and shoulders at the same time. This is where a swivel chair is better than a stationary one.
Top video view:
I tend to be verbose, so if you want a more thorough discussion of this stuff I’ve written these. Some are a bit more technical than others:
http://b-reddy.org/2012/06/23/assessing-the-hips-in-the-transverse-plane-why-your-lower-back-hurts/ -> More examples of the lower back twisting too much.
http://b-reddy.org/2012/12/27/thoughts-on-correcting-a-lateral-pelvic-tilt/
http://b-reddy.org/2013/02/06/example-of-a-postural-assessment-2/ -> This is an example of a postural assessment of a guy who also has one hip higher than the other.
I haven’t gotten around to writing a specific post on piriformis syndrome / issues with the sciatic nerve, but many parts of those posts above are related.
Hope that all helps. Let me know if you have other questions.
-Brian
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Here are some other common movements people fall into, and how to get rid of them.
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Philip
November 22, 2013
Hi Brian, I’d be really interested to hear your thoughts on how to exercise when you really do have a tight piriformis – it seems that whatever I do in terms of hip exercise, when I wake up the next day, low and behold the piriformis is aching. I’ve been trying for a while to work my glute meds but I have tight quads and weak hams – I cycle to work which I’m not sure helps – i think a slightly anterior hip carriage, tight and painful glute min which seems to be the cause of most of the sciatica-like pain (I don’t get all that much anymore, and the glute med pain seems to be slowly subsiding) and tight piriformis! I really can’t find an exercise which seems to help me – working my glute meds whilst not stressing anything that’s already tight. It seems my hips are at the root of my lower back problems, although my lower back may well be moving around too much as well. Can you suggest anything? Thanks
reddyb
November 24, 2013
Hey Philip,
I would worry much more about your lower back (probably moving too much) than I would your glute medius.
Also, you’re speaking too much in terms of tight this, weak that. You need to speak more in terms of how you’re moving. You could be doing all the glute medius exercises in the world, but if you’re doing them in the wrong manner -you’re not moving well- it won’t matter: http://b-reddy.org/2013/11/20/rethinking-how-and-why-youre-training-your-glutes/
(For example, if you’re legs are internally rotating like I go over in that glute post, you could be excessively using your piriformis.)
If you’re getting sciatic type symptoms the cycling probably isn’t helping. It’s common to flex the back (move the back) too much when cycling. Excessive flexion of the spine can cause the nerves to be pressed upon, one of which is the sciatic nerve. http://b-reddy.org/2013/10/18/reversing-an-arthritic-spine-degenerative-disc-disease-spinal-stenosis-how-to-decompress-your-spine/
Adam
July 10, 2014
Hey Brian,
Hate to resurrect an old thread but this article struck a chord with me as I believe I’m having similar problems. Long story short, I’ve been having left lower back problems for a few yrs now, and last year I went to an ortho who diagnosed me with (Quote-unquote) ‘potential’ spondylolysis and recommended PT. I was then put on a 6 week program that focused on strengthening the TA and other core stabilizers. The back pain subsided quite a bit but I still feel tightness all along the left side of my body, all from the left side of the rectus, through the left obliques, to the left erector spinae. In fact, just running my hand all over the left abdominal/oblique region, it seems like that side is much better developed than the right side. I’ve also found that side bending is the #1 movement that causes the back pain to return (I have since scratched the movement from my workout routine), and the side bending video that you posted in this article looks exactly like the issues I’ve been having with it. The best for for this in my experience is rolling over the piriformis on a lacrosse ball, but that only offers a temporary solution, and I know that you’re not a big fan of such tools.
So my question is pretty much how do you generally address this? Obviously trying to correct the issue from an ADL perspective is the first priority, but from a strengthening/stretching perspective, what do you look for? Do you see this as an issue of tight obliques and possibly QL? Does maybe the glute med play a role in this problem as well?
Sorry for the lengthy post but this is an issue that I’ve been having for a few yrs and this is the closest that I have come to a satisfying solution.
reddyb
July 13, 2014
This is a very good exercise to work on proper side bending:
From an ADL perspective you basically get the person to stop twisting / bending, period. “Hips and shoulders always face the same direction” is a common cue I use. (Hard to twist if this is adhered to.)
Note that the exercise I embedded has to be done properly. The bending has to occur at the thoracic spine and not the lumbar. If that exercise is too hard for a person I will have them place their hand under their arm pit and have them side bend over their hand to insure they cannot side bend from the lumbar spine.
In an assessment, this is what you do to figure out if moving the lower back too much is what’s causing pain. So, person side bends = pain. I place my hand at their ribs (roughly under the arm pit), have them side bend over my hand (thoracic spine has to be the segment which bends), and person will go “That feels better / there’s no pain.” (If you ever wanted a crystal clear indication of what causes back pain, that’s it right there. Lower back moves = pain; lower back doesn’t move = no pain.)
So, exercise wise, I work on how the person side bends, where ADL wise I typically get the person to stop any bending or twisting as much as possible, as I haven’t had good success trying to get people to change how they bend or twist during the day. Bit too much going on when one is at a desk or whatever to think of that. It’s easier for a person to grasp “Just don’t twist or bend.”
Hope that makes sense.
Adam
July 15, 2014
Makes sense, thanks Brian!