Video Transcript
Hey, this is Doctor Gangemi, the Sock Doc. Today’s Sock Doc video is on piriformis syndrome, lower back issues, and sciatic-type pain, or what many people perceive as sciatic-type pain. Lara O’Brien, who is a principal dancer with Carolina Ballet, is going to be helping us out today, and we’re going to go through some of these common ailments and some things that you can do, hopefully at home or with a friend, to alleviate some of the pain that you might be having.
First on sciatic nerve, let’s talk about that. Your sciatic nerve comes down the back of your thigh here and comes all the way down and exits the back of your knee, which is called the popliteal region, and then forms two common nerves: your common peroneal and your tibialis nerve.
Down here in the lower leg is where most people experience actually true sciatic-type pain. This is where you might get some numbness, some tingling, some loss of feeling in your toes, your foot area, or your calf.
A lot of people think that this area, just because the sciatic nerve comes down through here and in your glute region, is actually sciatic-type pain, but it’s actually usually not that. It’s called sclerotogenous-type pain. What pain in this region is, this sclerotogenous pain, is a referred pain from other areas, other areas of tissue, most common muscles, ligaments, and tendons. Or it can even be a direct tightness of the hamstring muscle, or even your glute max, which we’re going to talk about in a minute.
Sciatica is a symptom most often misdiagnosed, but when the sciatic nerve is even pinched up in the lower back region here, it could be from a disc issue, it could be from some arthritis, or it could be from some muscle imbalance, some instability of your bio mechanics of your pelvis, that’s impairing the sciatic nerve, putting some pressure on it, resulting in pressure all the way down and causing numbness, or pain, or discomfort in the foot. However, you end up dealing with the issue way up here, where the sciatic nerve originates or starts to come together from the nerves of the lower back and the sacral region.
The most common muscle is your piriformis. The piriformis muscle comes off of the front part of your sacrum actually, tucked in on the side here, and then comes to the outside of your hip here. That piriformis muscle, like this, if you can turn around, does two things: It turns your foot out, and it brings your leg up and elevates it, which you can do that on both sides. You can see they’re pretty symmetrical. Someone with pretty bad piriformis syndrome, or pain in their piriformis, is, first of all, they’re going to feel pain deep in their butt region, in the glute, especially right here on the side, and they’re going to have some imbalance or pain doing that motion from side to side.
The sciatic nerve, pretty much in most people, 80% it is said, the sciatic nerve comes below your piriformis muscle. In about 20% of people, the sciatic nerve actually goes through that piriformis muscle. If you had an injury to your piriformis muscle, resulting in an imbalance or resulting in a hip rotation issue, then that can put pressure on that sciatic nerve and cause pain in your foot.
I’m going to show you in a minute how to deal with that sciatic nerve, but the other muscle we’re going to talk about real quick for a second is the glute max. Your glute max, as I talked about in the ITB syndrome, iliotibial band video, is that big hip extensor muscle that comes, actually, all the way down into your thigh here and joins with your tensor fasciae latae to make up your iliotibial band. Most people think of their glute max, or butt muscle, just as this area right here, but you’ve actually got to think all the way down here. Glute issues, which have to do with extension, a lot of times will cause an imbalance of the lower back, obviously cause a person to have lower back problems and result in hip pain and lower back pain, that sort of thing.
Piriformis issues are going to do more left and right problems. Piriformis, which come off the side of your pelvis, those are major sacral stabilizers. Having a piriformis imbalance will actually cause pain anywhere up your spine, since it’s sort of like the base of your spine, like the pyramid, the foundation to your spine. You can get pain all the way up in your neck. People get shoulder problems. People get headaches from their piriformis being aggravated on one side rather than the other. That will cause your sacrum to rotate from one side to the other, or your pelvis, where glute max issues will cause your pelvis to rotate forward and backward rather than side to side like the sacrum. We’re going to think about those two things when we talk about the stability of the pelvis.
With the piriformis here, as the piriformis comes out to the side and attaches to the top of the thigh muscle here, the greater trochanter, typically there’s going to be a trigger point somewhere in there. Trigger points are these points we’ve talked about in other videos, where you’re just going to hold that or have someone hold it for you, and any sore spot you basically hold, rub it out. If you have trouble getting in there, if your hands aren’t strong enough for your partner that you’re doing this with, some people like to use their elbow, and you can come in like this. You’re kind of scooping the glute muscle out of the way a little bit and pulling it toward you to hold that in there. That’s one thing with the piriformis.
One other thing, as I’m thinking about it to mention here, is if the piriformis is painful on one side, you always want to check the other side. A lot of times, what happens is it’s the weakness on one side, the muscle that is not functioning well, that is actually the side of the problem, where the other side is going to spasm to try and balance the sacrum from left to right. She might have a lot of pain, say, standing, and doing that hip rotation, or leg rotation on side to side—she might do worse on the right, but the problem could actually be on the left-hand side.
Now, with the glute max, a simple test you can do on your own is to elevate each leg. Lift this leg up as high as you can, Lara. You can see she can lift about to right here on this right side, and then switch to the left. She’s about there, about the same on the other side. They’re not going to be exactly symmetrical, but if this leg, say, only came up to here and then she raised this leg and it went way up, then that would be obviously something typically going wrong on the right side, if there was a constriction or a weakness, some muscular inhibition on that glute max. We’re going to look for trigger points in that area to see where we can alleviate some of the imbalance of that muscle. Again, recognize that the glute max comes all the way down and intertwines and forms that iliotibial band, so what someone might perceive as hamstring pain could actually be glute max pain. You can stand back up.
I would say I see a lot more glute max issues because it’s such a powerful muscle and such a powerful mobilizer with the hip, rather than hamstring issues, even though someone thinks that they’re having a hamstring problem. Another major action of the glute max muscle is squatting and climbing stairs, so many people that have knee pain or hip pain when you’re climbing stairs or squatting down, think more your glute max, even though a lot of people like to think of their thighs. That’s what we’re going to do to start to stabilize the pelvis there and look for imbalances in the piriformis and the glute max.
One other thing to mention quickly is the role of vitamin E in the pelvic stabilizer muscle, the piriformis and the glute max. That doesn’t mean go out and buy vitamin E right away. But some people, especially women, have vitamin E imbalances, and they’re lacking the vitamin of the natural vitamin E found in wheat germ oil, found in nuts like hazelnuts and almonds, and that helps basically balance hormones in your body. Hormone imbalances will cause pelvic imbalance problems in women, as well as guys.
There’s a link between the prostate and vitamin E imbalances, and prostate and hip problems. With women, uterine and ovarian problems, and hip problems. That’s why a lot of women who have PMS or hormonal issues also have hip pain. It could be a direct muscular imbalance. It could also be a vitamin E problem. Sometimes taking the natural oils of wheat germ oil, unrefined and organic, can do wonders for you, as well as taking a little vitamin E. I typically don’t use too high of a dose, but around 50 to 100 IU of natural mixed tocopherols. That’s the natural tocopherols and the tocotrienols that can help with your pelvic imbalances.
Two other things we’re going to talk about real quick to help with stabilizing the lower back—and therefore piriformis issues and the pelvic issues, as well as what one might perceive as sciatic-type pain—are the psoas muscles, which do this—bring your leg up and out and flex it, and again on the left. This would give you more pain doing that from left to right, or just bending forward as if you were touching your toes. A lot of times if someone’s feeling, even though you might feel back pain as you go and do that, it’s actually coming from the front.
Now we’re going to talk about a couple of things that actually cause you to get back pain, even though they’re actually front problems. So you can lie on your back again. If you ever feel pain while you’re lying on your back, supine, or especially as you sit up. If she was to experience pain in her lower back right now, that’s usually going to be from the abdominal muscles, including the abdominal obliques, or the psoas muscles, which help to hold her leg like that. If you can’t hold your leg up like that, then you most likely have a psoas imbalance, and that would be the same on either side.
The psoas muscles are your powerful hip flexors, as you can see, and they actually originate mostly from the front of your lumbar spine. That’s the front. They’re very hard to get to. Then they come down, and they wrap around and attach to the inside of the leg, allowing someone to flex the hip.
A couple things we’re going to do for this is to have her touch and put a little bit of deep pressure, even though she can’t get directly on top of her lumbar spine, to put pressure on one side, if she was to have lower back pain right now, to put pressure on that psoas muscle, and then she would sit up again, and lie back down. Obviously, this is assuming that she could sit up because sometimes someone’s lower back pain is so bad that they can’t sit up at all. If she was able to sit up easier by doing that, we would look for corresponding trigger points in that area and then again would switch and check out the right side too, the opposite side. We’re always checking both sides.
We’re going about an inch over, and a couple of inches up and down on the side of the naval on either side, so like here, here, and here, and that would look like that. If that didn’t help, she could go a little bit lower and then check a couple on the opposite side, and she would sit up each time. Or if she had someone like me doing that with her, or a friend, I could hold this and you would sit up, and if it felt any better to her lower back, then we would look for areas to treat in there.
Again, just rubbing, slight pressure. Have got to be careful in here. There’s obviously digestive organs, there’s an abdominal aorta in there, so you have to be careful and don’t just be poking away. Usually it’s pretty tender if someone’s lower back is hurting from a psoas problem.
Obviously, the other muscles here are your abdominals, your rectus abdominis, and your obliques, and sometimes you’ll have trigger points or sore spots on the side here, right where they start to attach on the top of your ilium. One thing she could do there is put her hands here on the side of the pelvis, see if there’s any tender spots, or I could do that for her, and she could sit up again and see if there’s any pain in there.
One thing you’ll notice, too, is that if someone has pain while they’re sitting up, usually they’ll twist from one side to the other, indicating that there’s an imbalance on one side. You don’t always know that that’s the side of the problem it’s on because you could be twisting away from the pain, or you could be twisting toward the pain, depending on what’s going on in that area. A weakness in that psoas muscle or an imbalance of the psoas muscles from left to right, as well as the abdominal muscles, will obviously put a lot of stress on the lower back. It’s one of the reasons why people get sway back.
You think of a pregnant woman or a person with a belly. They put a lot of pressure on their lower back, causing a lot of degeneration, causing a lot of arthritis and lower back problems, which then in turn can cause sciatic-type pain and influence that sciatic nerve and cause pain all the way into the foot—numbness, pain, or similar issues. Even though it’s coming from way up here, an imbalance of those hip flexors, an imbalance of the abdominal muscles, or the glute max, or, obviously, the piriformis. Those are the four muscles that we’re going to think about for lower back issues or any disc displacements, or what might be perceived as sciatic-type pain.
In terms of exercise and therapies for these sorts of things, after you’re working out the trigger point, if they continue to come back, it’s the same thing that I’ve always said. No orthotics because you’re trying to work the muscles to their fullest by being barefoot and feeling the ground and using the muscles the way they’re intended to be, not by some false, supportive device. So you’re going barefoot and not wearing any orthotics—or trying to wean yourself off those orthotics—and wearing minimalist-type shoes whenever you can.
Of course, you’re not stretching these things because whenever you stretch a muscle that’s been injured or strained, you’re further elongating those muscles, and you’re not going to heal it. We don’t stretch our psoas muscles; we definitely don’t stretch our piriformis muscles like a lot of people like to do, like bring these over and trying to stretch the hip. It’s just going to further irritate that muscle, and if you have a sciatic issue, especially if you’re one of those people whose sciatic nerve goes through your piriformis, it’s just going to cause more problems over time.
By walking, running, dancing for her, or doing your normal daily activities, that will help to rehab those muscles once they’re actually functioning normal. Consider vitamin E, and especially fatty acids too, that help fight inflammation like fish oils and others, nuts, seeds, flax oil, that sort of thing, in those beneficial categories.
That should do it. Thanks.
In this video I discuss piriformis syndrome, low-back pain, and “sciatic pain,” which is often not true sciatica, but another type of pain known as sclerotenogeous pain. Many athletes suffer from hip pain and back pain. Hip flexion problems are very common in runners and those who use their bodies to jump and kick. Extension-type pains can be an issue with these athletes too, and especially with cyclists.
Your sciatic nerve is a thick nerve originating from many fibers in the lower back and sacral area. Actually, it’s the sensations in the lower leg and foot—weakness, pain, numbness—that are typically true signs of “sciatica” symptoms, as the sciatic nerve comes out from behind the knee and branches out into the tibial nerve and common peroneal nerve, where they supply movement and sensations to much of the lower leg and foot. Pain above the knee—usually referred to as sclerotenogeous-type pain—is pain originating from a muscle, tendon, or ligament. That is usually what is causing pain in the lower back and hamstring/thigh area, if not a local muscle or tendon strain.
Though there may be disc involvement, as well as other nerve-related problems (other than sciatica), most lower back, thigh, and hip pain is from muscular imbalances and inflammation in the body. This is a common terminology problem, even in the medical arena. That deep, gnawing, unrelenting pain is from the sclerotomal distribution, which arises from connective tissue above the knee. The type of sensation that is associated with nerve compression or nerve root compression is typically not pain, but rather decreased transmission, resulting in decreased sensation that leads to numbness or paresthesia, and that is only below the knee with respect to the sciatic nerve.
The muscles discussed in this video have significant involvement in the stability, strength, and movement of the lower back, hip, and legs.
The piriformis muscle extends from under the front side of the sacrum and attaches to the greater trochanter in the upper leg. The major action is to laterally rotate the hip and turn the foot out. The sciatic nerve actually comes out right under the piriformis, but in 15–20% of people, it goes through it. “Piriformis syndrome” irritates the sciatic nerve. An imbalance in the muscle often causes pain and can cause the foot to turn outward. Since the piriformis muscles stabilize the sacrum and therefore the base of the entire spine, a person can have pain all the way up to their neck or down to their foot from a piriformis issue.
The powerful gluteus maximus muscle extends the hip and rotates the thigh laterally a bit too, just like piriformis. Many people think they’re having hamstring pain or hip pain from a bad disc, when really it’s because they have a glut max that isn’t functioning properly. Also, a lot of knee pain is because of a strained glut max. This muscle also makes up a significant amount of the ITB—another common injury I discuss here.
On the front side of the body are the psoas and abdominal muscles, and they are often involved in low-back pain, hip pain, sciatica, and disc problems. Leg flexion, hip rotation, and the ability to reach down and touch your toes are made possible by the action of these two muscles. So pain performing these movements means that they are not working correctly. Can’t sit up because of pain or weakness from lying on your back? Pain putting on your shoes or flexing forward to pick something up off the ground? Pain running, jumping, or kicking? That’s psoas and abdominal involvement.
No stretching! No orthotics!
Enjoy the video and check out the other Sock Doc videos as well!
