The sciatic and peroneal nerve, pictured above, is a thickest and longest nerve in the body. Sometimes both of these nerves pass the underside of the piriformis muscle before dividing (first picture on left),and sometimes they divide and only the sciatic nerve passes through the piriformis muscle (second picture above). Other times they both pass through the piriformis muscle before travelling down the back of the leg, and eventually branching off and ending in the top and the sole of the feet.(See third photo below). Compression of these nerves, particularly in the instances of pictures 2 and 3 above, can be caused by spasm of the piriformis muscle.

The anatomy

Note the large Gluteus Maximus which covers the deep hip rotators

Note the piriformis muscle, lying deep to the Gluteus Maximus

Anatomical features

Piriformis Syndrome Signs and Symptoms

Piriformis syndrome usually starts with pain, tingling, or numbness in the buttocks. Pain can be severe and extend down the length of the sciatic nerve (called sciatica). The pain is due to the piriformis muscle compressing the sciatic nerve, such as while sitting on a car seat or running. Pain may also be triggered while climbing stairs, applying firm pressure directly over the piriformis muscle, or sitting for long periods of time. Most cases of sciatica, however, are not due to piriformis syndrome.

Piriformis Syndrome DiagnosisThere is no definitive test for piriformis syndrome. In many cases, there is a history of trauma to the area, repetitive, vigorous activity such as long-distance running, or prolonged sitting. Diagnosis of piriformis syndrome is made by the patient’s report of symptoms and by physical exam using a variety of movements to elicit pain to the piriformis muscle. In some cases, a contracted or tender piriformis muscle can be found on physical exam.Because symptoms can be similar in other conditions, radiologic tests such as MRIs may be required to rule out other causes of sciatic nerve compression, such as a herniated disc.

How can Pilates help?First, establish that your client has piriformis syndrome. If so, in consultation with their physical therapist, commence a program of stretching, and then strengthening the entire gluteal region.

Which exercise should I start with?

Gentle, contract/relax stretching, with several days in between for recovery is a skillful way to start. Try the stretches below, and see how you or your client responds. Send information to their physical therapist too, and get the OK from them before commencing.

Lying Hamstring stretch with adductionLie on the reformer as pictured, and allow the carriage to take

your leg into flexion. Stretch just to the point of mild tension

piriformis

You can see the piriformis muscle below, deep under the Gluteus Maximus

Next, without lifting the bottom from the carriage, take the leg

across the body

Here’s a perspective from below the reformer. You can see the piriformis muscle, and how it will be stretched, if the leg is taken across the body.

Piriformis muscle

If you want to introduce a contract/relax element to the stretch, it’s simple.

Hold the rope, or if you have a partner, have them hold the rope, and lightly press your leg back in the other direction.

That is, away from center in a movement called abduction.

Don’t let the leg move, and press for 5 seconds.

After 5, stop pressing, relax, breathe in, and on a breathe out, take your leg a little further across your body. This could be

toward the midline, or even past it.

Hold for 15 breaths before stopping

Now lets try a stretch on a boxFirst, sit on the box as pictured. As much as you can, try to

level your hips, like in photo 2. Don’t force it-this is the

stretch in itself for many. Hold the position for 5 breaths

To enhance the stretch, lets add the contract/relax component

First, press the leg on the box down into the box for five

seconds

Use only half of your maximal strength

After 5, relax, breathe in, and on a breath out, try to lean the

center of your chest towards your foot

Do not allow your pelvis to roll backwards. It must remain in a

neutral position

Hold the final position for 15 breaths.

Remember that pain is your guide. The stretch should not feel

more intense than around 6 out of ten at any stage.

Try this approach for 3 to four weeks, practicing one of the stretches every second day, at least twice on that day. Practice it for the full length of time suggested.

Gauge your progress, and relay that back to your Pilates teacher and Physical therapist.

Therapy is an evolving process. No one knows how you will respond to their treatment, we only have the history of others as our guide. For a general guide on releasing sympathetic nervous system tension and muscle pain, please refer to our “Five Tibetans” article http://anthonylett.com.au/index.php?q=news-articles-put-new-news-pages-under-here/