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Albert Freiberg was one of the first to describe the inter-relationship between the piriformis muscle and sciatic pain, which is also known as sciatica. Sciatica relates to any type of neurogenic pain that arises from irritation along the sciatic nerve and typically presents with pain down the back of the thigh and lower leg. Because sciatica can originate at any point along the sciatic nerve, including its peripheral nerve branches, diagnosing the actual cause of neurogenic irritation can be difficult.
The two most known reasons for sciatica include irritation at the nerve root level - think mechanical and chemical irritation from a protruding disk pressing on the nerve root - and at the level of the piriformis muscle, where the bulk of the nerve passes through or under the piriformis muscle. Today’s discussion will be on the latter and how through anatomy we can better understand how to appropriately treat this diagnosis.
The piriformis muscle originates on the anterior surface of the sacrum and attaches to the superior border of the greater trochanter. The sciatic nerve, which is a combination of nerves, can pierce or split around the piriformis muscle, however, more so the sciatic nerve courses through the greater sciatic foramen and underneath the piriformis muscle. In either scenario, we can appreciate the close spatial relationship between the two structures. The actions of the piriformis muscle include hip external rotation, extension, and abduction when in the anatomical position, but if the hip is flexed to greater than ninety degrees the piriformis muscle becomes a hip internal rotator. We primarily want to talk about how the piriformis acts during stance and gait, or when the hip is not flexed past ninety degrees.
Freiberg first furnished the theory that Piriformis Syndrome and sciatica resulted from a shortened or contracted piriformis. He believed, that due to shortness of the piriformis muscle, excess compression along the sciatic nerve occurs, and stretching of the piriformis is necessary. This is the typical explanation we see shared between clinicians and taught in schools today. However, despite this, both Kendall and Sahrmann argued that a lengthened piriformis, rather than a shortened piriformis, is much more predominant. Anecdotally we agree with Kendall and Sahrmann, finding the commonality of Freiberg's consensus to be much less than previously thought. If we look at the relation of the pelvis to the femur during stance we can start to understand why this holds to be true.
In stance, due to the actions of the piriformis muscle (hip external rotator, extensor, and abductor), if there is a faulty position of hip flexion, adduction, and internal rotation we have three opposing planes of motion. This faulty position puts a significant stretch on the piriformis, theoretically compressing the sciatic nerve and causing neurogenic pain. Because repeated daily habits dictate muscle length and strength to an extent, we would argue this faulty position is relatively present throughout our lives (see pictures below). Ironically, many condemn this position for its effects on the knee joint (valgus stress) but forget about its effects on the hip and sacroiliac joint.
Here is a good video explaining the actions of the piriformis muscle:
Here are the individual positions that contribute to a lengthened piriformis:
How these positions translate to our daily activities and lives:
The first picture is a typical way people stand - shifted onto one leg and in a position of right hip flexion, adduction, and internal rotation. In the last three images we can see flexion, adduction, and internal rotation of the right hips and knees.
Without beating dead a horse, let's move on to four simple ways to test for this:
Do your symptoms decrease when you are lying on your back? - Unless you lay in a crazy position, people typically find relief by reducing the ground reaction forces or the amount of muscular force required to maintain a good hip position during walking and standing. Also, the hips and feet tend to be in a toed out positioin, which is more external rotation.
Do your symptoms increase when stretching the piriformis? - If your symptoms increase when stretching the piriformis muscle, this is a strong indicator that we need to do less of this (not exclusive).
Do your symptoms decrease if you put a small heel lift under your unaffected leg’s heel, or shift your body weight over to the nonpainful side? - A heel lift changes pelvic position, the shorter leg (the one without the heel lift) will technically be in more abduction and external rotation, therefore reducing the amount of stretch on the piriformis.
Do you find relief by putting your leg in external rotation and abduction or constantly find yourself seeking relief in this hip position? - This is a strong indicator that a long rather than short piriformis is contributing to your sciatica.
If you answered yes to all or some of these questions, then instead of stretching to solve your issue, it’s probably best to do the opposite. More often than not the solution lies in appropriate control of the hip joint during activity, not stretching.
Still confused? We can help! We are experts in recovery care and physical rehabilitation. The first thing you need to do is get assessed by one of our professionals. Everyone's different, and before we can create a game plan, we need to understand you.
What are we?
We are the Vital Six, offering the best recovery, performance, and physical rehabilitation services in the Kansas City Metro.
We help our patients get out of pain and get back to doing what they love 2-3x faster than the industry average.
Call us at 913-303-0032 to learn more.
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