Have you encountered the sort of pain that makes prolonged sitting feel like a fitness test, a searing, scorching sharp pain that starts deeply in your buttocks and moves down to your leg? This is known as sciatica due to piriformis, a condition in which the sciatic nerve is compressed by the piriformis, one of your hip’s hidden muscles, making routine activities painful. The good news? This article covers the 6 best exercises to treat piriformis sciatica, its diagnosis, & everything you need to know about this malady.
What is a Piriformis muscle?
A cone shaped, triangular, flat muscle present in the buttocks that emerges from the anterior surface of the sacrum through three separate finger-like projections, at the level of 2nd, 3rd & 4th sacral vertebrae is known as piriformis muscle. The also originates from the ilium surface next to posterior inferior iliac spine, the sacroiliac joint & the greater sciatic notch where it ends in the greater trochanter of femur bone. It is innervated via the piriformis nerve. The piriformis muscle is the crucial point of reference in the gluteal region. It functions as the external rotator of the hip.
This description of the muscle’s origin & insertion matters as it helps in understanding the function whilst giving the readers a knowledge of why the symptoms emerge. Once you know about the symptoms, you can easily grasp the concept of 6 best exercises to treat piriformis sciatica.
Deep Gluteal Syndrome
When the longest nerve of the body, that is the sciatic nerve, gets trapped by the piriformis muscle it is known as piriformis syndrome or the deep gluteal syndrome. The piriformis muscle impinges the sciatic nerve, leading to a referred pain called sciatica. The cause of it is often confused with disc herniation. Therefore, it is necessary to understand the major culprit leading to sciatica. Dive deeper into the diagnosis details & read Sciatica Diagnosis: Disc vs Piriformis.
The anatomical breakdown of Piriformis Syndrome
The piriformis syndrome occurs in both of the following variations:
- When the piriformis muscle is lengthened
The main anatomical position that causes pain is Hip flexion along with internal rotation & adduction. When the limb moves in such a way that the legs are crossed over, the piriformis muscle is excessively stretched. This unrestrained stretch places a tension on the muscle causing it to spasm or tighten reflexively to safeguard itself.
- When the piriformis muscle is shortened
When the muscle is overused in daily life due to prolonged sitting & poor posture, it causes the piriformis to become shortened & hyperreactive. With time, the body adapts to this posture & the piriformis loses its ability to relax properly. In this condition, it exerts greater pressure on the sciatic nerve, which passes through or directly beneath it.
These mechanisms around the sciatic nerve lead to its irritation. As a result of this, the normal blood flow & neuronal conduction of the sciatic nerve is disturbed causing symptoms like tingling, numbness, & sharp shooting pain radiating down to the leg.
Causes
This piriformis syndrome occurs as a result of trauma, ischemia, overuse, strain, hypertrophy or even anatomical variations of the piriformis muscle. This muscle may also be shortened due to overuse or disrupted biomechanics of the lower limb.
Why Physiotherapy plays an important role in treating Sciatica due to Piriformis?
Physiotherapy is a game changer when it comes to treating sciatica due to piriformis as it not only treats the pain but also eradicates the source of it. In many cases, the underlying cause of such pain is faulty biomechanics, poor posture, & overuse of the muscle. Persistent physiotherapy lessens the chance of recurrent pain & nerve irritation. Hence, these 6 best exercises to treat piriformis sciatica are to be incorporated in daily life.
Physical Therapy Plan of Care; What you need to know?
Before diving into the 6 best exercises to treat piriformis sciatica, it is crucial to comprehend a few significant variables. These fundamental steps guarantee that the exercises truly benefit you and lay the groundwork for safe, efficient treatment.
We recently came across a 66 year old male patient who presented with the symptoms of sciatica & upon clinical examination, sciatica due to piriformis was ruled out. He also reported that in the first two weeks of his plan of care, whenever he attempted to perform three or more reps of Side lying SLR & seated piriformis stretch, he endured intense, excruciating pain down his leg. This response to exercise made it very evident that the sciatic nerve was highly sensitized. Instead of enduring repeated loads, the nerve responded aggressively, indicating that conventional stretching or strengthening would not be enough. Let’s examine the true significance of this and why treatment is affected.
What do we mean by “Nerve Sensitized”?
In piriformis syndrome, the sciatic nerve becomes highly sensitized meaning it reacts uncommonly to normal movements, its activation threshold shrinks, so even mundane tasks like sitting or stretching might trigger the symptoms, & this also indicates that the blood flow around the nerve is reduced leading to increase in its sensitivity. In short, the sciatic nerve acts like a short tempered wire, giving pain signals too swiftly.
How do we manage the Sensitized Nerve?
The answer is simple, by nerve flossing. In contrast to muscles, nerves must move smoothly through the surrounding tissues because of their less elasticity. Hence, when a set of exercises is used to mobilize the nerve, it is known as nerve flossing. This mechanism is helpful as it restores the normal sliding movement, improves the blood supply to the nerve, reduces hypersensitivity by gradually introducing movement patterns, & prevents the tight muscles from gluing the nerve in one place.
In this case, the patient’s sciatic nerve was flossed through the following mechanism:
- The patient was positioned upright on the chair with his both feet flat on the ground.
- The therapist then extended the knee on the affected side until the 0 degree extension was reached while keeping the ankle relaxed, that is, toes pointing upwards.
- At the same time, the patient was asked to look up to perform neck extension hence reducing the tension gently.
- This exercise was followed for 5 to 6 reps in the beginning and later on for 8 to 10 reps as tolerated by the patient.
Remember: The goal is to mobilize the nerve not to stretch it prior to the 6 best exercises to treat piriformis sciatica.
Electrotherapy
In addition to exercises, electrotherapy is a crucial step in the treatment of sciatica caused by the piriformis. Since the pain, muscular spasm, or nerve sensitivity is just too intense to tolerate, many patients find it difficult to perform even the basic stretching & strengthening exercises. This is where modalities like Transcutaneous electric nerve stimulation (TENS), Interferential therapy (IFT) & even Ultrasound therapy play their part. These modalities function by reducing pain perception, calming overactive nerve signals, & improving the blood flow to the damaged area. As a result, the muscle can relax & the patient is able to perform the 6 best exercises to treat piriformis sciatica more comfortably.
When the sciatic nerve is extremely sensitive, as in patients who feel excruciating pain even with limited movement, electrotherapy before exercise is particularly effective. It is also beneficial when exercise becomes unbearable due to severe pain or when muscle spasm is the primary limiting factor.
Releasing the Myofascial Trigger points
Myofascial trigger points are tense, extremely irritable knots that can form in a muscle as a result of strain, overuse, or improper posture. These trigger points frequently develop in the piriformis or adjacent gluteal muscles in piriformis syndrome, causing severe buttock discomfort that occasionally resembles sciatica. The muscle remains shortened & tensed when these trigger points are active which further makes it difficult to perform the exercise.
By releasing these trigger points, the muscle relaxes, blood flow returns to the disrupted area is increased, and referred pain is minimised. This is particularly beneficial when done prior to the 6 best exercises to treat piriformis sciatica since it makes it undemanding and more effective for the patients to complete their stretching and strengthening regimens.
6 Best Exercises to treat Piriformis Sciatica
When discussing the 6 best exercises to treat piriformis sciatica, we must move with a strategy. Stretching increases flexibility and length, which helps release tense muscles. While strengthening helps improve hip stability & enhances the mobility of the muscle. When used together, they can attenuate the numbness and radiating pain associated with piriformis syndrome.
1. KNEE TO CHEST STRETCH
- Ask the patient to lie down in a relaxed supine state.
- Now gently flex your one knee and bring to your chest.
- Hold this position with your hands wrapped around the knee for additional stretch for about 5 to 10 seconds then relax your leg.
- Perform 5 reps, each of 5 second hold & gradually add your other knee to it with the same technique.
- This causes posterior pelvic tilt along with the flexion of the lumbar spine & hip which helps lengthen the piriformis & surrounding gluteal muscles.
- This also helps in improving the hip joint mobility & enhances the blood flow to the affected area which speeds up the process of healing.
- For detailed guide watch Knee to Chest Stretch
PRECAUTION
Avoid forcefully pulling the knee to your chest as overstretching can further irritate the muscle. In case of hip arthritis or replacement surgeries, avoid deep flexion as the cartilage could be worn out further.
2. SIDE LYING LUMBAR STRETCH
- Ask the patient to lie supine on the couch.
- Adjust the patient into the side lying position gradually.
- Flex the knee of the upper side.
- Place the foot of the above leg behind the opposite knee & hold it.
- Now move your arm to the opposite side, making your upper limb turn.
- Give gentle stretches & hold for 5 to 10 seconds.
- For better understanding, watch Side Lying Lumbar Stretch
PRECAUTION
Do not perform this stretch in case of disc herniation or after spinal surgery. Avoid overstretching as it can lead to muscle spasm.
3. FAIR TEST STRETCH
- Adjust the patient in supine position & ask him to flex his affected leg to 90 degree.
- Perform hip flexion, adduction & internal rotation by bringing the knee across the body towards the opposite shoulder.
- Gently push the ankle outwards so the knee turns inward.
- Stabilize the pelvis with one hand.
- For complete guide watch Fair Test Stretch
PRECAUTION
Avoid performing the FAIR test stretch in case of hip fracture, hip arthritis or lumbar disc herniation
4. SEATED PIRIFORMIS STRETCH
- Position the patient upright on a chair.
- Ask the patient to cross one leg over the other placing the ankle on the opposite knee, creating a figure of 4-shape.
- Lean forward towards your ankle to feel the stretch on your buttock.
- Hold for 5 to 10 seconds.
- Repeat on the other side.
- Watch here Seated Piriformis Stretch
PRECAUTION
Do not bend deeply when leaning forward & avoid rounding the spine to greater extent as it may irritate the discs.
5. GLUTE BRIDGES
- Ask the patient to lie supine on the plinth with both knees flexed.
- Instruct the patient to hold his weight on the ankles & lift the buttocks.
- Hold this position for around 10 to 15 seconds or as per patient tolerance.
- Make sure the glutes are engaged, not the spine.
- For better understanding on how to perform safely, watch Glute Bridges
PRECAUTION
Avoid lumbar overextension & don’t drop the body suddenly on the couch.
6. STANDING HIP EXTENSION
- Position the patient in a straight standing state.
- Place the resistance band around the ankles.
- Ask the patient to extend one leg backwards without moving his spine.
- Repeat this exercise 2 sets of 10 reps twice or as per patient tolerance & symptoms.
- Watch Standing Hip Extension
PRECAUTION
Keep the spine neutral to avoid stress to it, extend the hip only for lower ranges without aggravating the symptoms. Make sure the patient stands with a safe environment nearby to avoid fall & injuries related to fall.
NOTE: Now that we have discussed the 6 best exercises to treat piriformis sciatica it is also important to understand that every patient presents with a unique set of symptoms, history & clinical findings. These 6 best exercises to treat piriformis sciatica are provided by a physical therapist with years of clinical expertise & are meant as a general guideline for the fellow therapists & students. If a patient’s pain or symptoms intensify, they should see their physician or physiotherapist right away. Exercise should only be done in moderation and only after being authorized by a licensed healthcare professional. Remember, excess of anything is harmful.
The use of Magnesium Glycinate as a Muscle Relaxant
Returning to the case study as discussed earlier, despite taking medicines and actively engaging in physiotherapy sessions performing the 6 best exercises to treat piriformis sciatica, the patient’s discomfort did not improve swiftly. At this point, the function of a muscle relaxant was taken into account. It was crucial to rule out any underlying systemic or metabolic problems before medication. Therefore, a complete set of lab investigations were advised, including:
- Complete blood count (CBC)
- Serum Electrolytes
- HbA1c
- Lipid profile
- Serum uric acid
- Renal Function Tests (RFTs)
- Liver Function Tests (LFTs)
- Cardiac Evaluation
All these results were found to be within the normal set of range, clearing the patient for supplementation. The patient was then advised the use of Magnesium Glycinate, & you may wonder, why magnesium glycinate? The answer is simple.
The physiology of Magnesium Glycinate
Magnesium is a vital micronutrient responsible for energy mass production as well as storage, autonomic nervous system regulation, cardiac excitability & the most importantly muscle contraction. This helps ease the stress that comes with performing the 6 best exercises to treat piriformis sciatica. Whereas, the glycinate is a compound to which the magnesium bonds resulting in the formation of magnesium glycinate. This glycinate itself has the properties to calm your nervous system & plays an essential part in protein synthesis.
Magnesium along with glycinate is considered to be more gut friendly meaning that it is more easily absorbed with glycinate. Since glycine has a calming impact on muscles and nerves, which is why magnesium glycinate is frequently used for conditions like cramping, tight muscles, tension, anxiety, and trouble sleeping.
Safety first
- Consult your doctor prior to taking any form of supplementations.
- Get your major lab tests done to be sure.
- Avoid overdose.
- Professional consultation is a must in Pregnancy & Breastfeeding women.
- Timing with other supplements is also necessary to be considered.
- People with any underlying condition like Myasthenia Gravis, Bleeding disorders should never opt to take such supplements on their own.
What NOT TO DO with Piriformis related Sciatica
- High impact activities such as running, jogging etc
- Sleeping on the affected side without support
- Crossing legs whilst sitting
- Sitting for prolonged period of time
- Climbing stairs repeatedly
- Repeated object lifting with poor posture
- Performing these 6 best exercises to treat piriformis sciatica excessively