Sciatica, Piriformis Syndrome, and other Pains in the Backside
There are mountains of annoyances that are virtual pains in the butt and no amount of massage, ice, or analgesics will make them go away (although massage may help with the stress of these pains). Some people, however, have actual pain in the buttocks along with numbness, tingling and pain that can travel down the back of the leg and calf all the way to the foot. These symptoms are typically tossed into the general classification of sciatica but there are a number of musculoskeletal problems that can cause these sensations. Many people assume the problem is a bulging disc in the vertebrae of the low back but there are tight muscles, weak muscles, and trigger points that may cause the same problems.
The sciatic nerve is a combination of smaller nerves that arise from between the last two lumbar vertebrae (L4-5) and some that arise from the sacrum (S1-3). Its function is to send sensory information from the buttocks, back of the thigh, calf, and foot to the brain and carry motor information from the brain to the muscles of these areas via the spinal cord. When you feel your foot being tickled or you contract your hamstrings to flex your knee, the information is travelling through the sciatic nerve.
Causes and Treatment of Sciatic Nerve Problems:
Nerves have to travel between and around your muscles and bones to reach their destinations. Some injuries can cause these tissues to “pinch” a nerve, more properly called entrapment or impingement. When nerves are squeezed between muscles, bones or other tissues symptoms of pain, tingling, and numbness (paresthesia) as well as weakness in muscles served by that nerve arise. The sciatic nerve can be impinged or entrapped anywhere along its length but the most common areas are at the lumbar vertebrae due to disc problems and beneath the piriformis muscle in the buttocks.
Lumbar Vertebrae Disc Dysfunction:
The rubbery shock-absorbing discs between vertebrae make space for the nerves to exit the spinal cord. Several things can happen in this area that can put pressure on the nerve roots:
- Herniated or bulging discs press on the nerve
- Thinning discs narrow the space between bones
- Bone spur growth may impinge the nerve
If the nerve is being pinched either between L4 and L5 or between L5 and S1 symptoms will affect very specific areas of the leg and foot. Because the sacrum is made up of fused vertebrae there are no discs to herniate and cause symptoms.
Treatment depends on the cause. Surgery may be required to stabilize the vertebrae but be cautious as many unnecessary back surgeries are done every year. Get a second opinion and try other avenues first unless it’s a sure thing. Common non-surgical methods include injections of anti-inflammatories, physical therapy, chiropractors, acupuncture and bed rest. Most bulging and herniated disc treatments will focus on creating space and reducing pressure on the disc to allow it to reabsorb and repair itself.
Therapeutic massage can play a role by helping to create the space needed for repair while allowing the postural muscles to continue to support the back. Because symptoms may cause limping or other compensations of the body massage can be very useful in managing pain and dysfunction in muscles being overused and misused as well as keeping muscles directly served by the nerve healthy while the impingement is being treated.
Beneath your large gluteus maximus muscle is a small triangular muscle running from the outside border of the sacrum to the big knob (greater trochanter) at the top of your femur. This is the piriformis and the sciatic nerve runs beneath, or in a small percentage of the population, through it. Spasm, shortening, or enlargement of the muscle will cause it to press on the nerve.
There are a number of common activities that can cause piriformis syndrome:
- Lots of sitting. Sitting causes weakness in the gluteal muscles and shortness in the hip flexors both of which can cause the piriformis to work overtime and get irritated or enlarge.
- Sports that use a lot of leg such as running and cycling. Overuse of some muscles and weakness in others leads to shortening of the piriformis. Some activities can cause the piriformis itself to succumb to a repetitive stress injury.
- Flat feet or other problems that lead to overpronation of the foot. The piriformis gets overworked trying to prevent the legs from rotating inward.
- Wallets carried in back pockets. Back pockets on pants are often situated right on top of the piriformis and objects in them can press on and irritate the muscle.
In addition to the nerve impingement symptoms of numbness, tingling, pain, and muscle weakness a short, tight piriformis can cause the legs to rotate outward. If you notice your feet tend to turn outwards or if rotating your leg in that direction relieves the symptoms above you may have piriformis syndrome.
Massage is valuable in treating piriformis syndrome. By using the proper techniques a skilled therapist can release the spasmed muscle and relieve the compression on the sciatic nerve. In addition to massage stretching and strengthening exercises can help balance the body so the piriformis is being used properly and not overworked or shortened. If your piriformis syndrome is due to a specific activity you may have to stop that activity for a bit to allow the muscle to release and recover then find strategies to prevent further injury to the muscle.
Trigger points are small knots in muscles that send or “refer” pain to other areas of the body. Tension and trigger points in areas of the back, buttocks, and legs can cause symptoms similar to that of sciatica or piriformis syndrome. Assessment by a knowledgeable therapist can help determine if these muscles are the culprit.
Trigger points in the gluteus minimus muscles are excellent mimics of sciatica as they tend to refer pain into the lower buttock, back of the thigh, and back of the lower leg. This pain is similar to many of the symptoms of an impinged sciatic nerve without the nerve actually being pinched. Other symptoms of gluteus minimus trigger points include pain on walking, getting up from a chair, and crossing your legs. Tenderness along the top of the hip may make it difficult to lie on the effected side.
Much like piriformis syndrome the gluteus minimus muscle can be irritated by too much sitting, standing, or walking (you can’t win sometimes!), running, limping, favoring one leg, or carrying a wallet in your back pocket.
Trigger points can form in the piriformis as well. Its referral pattern is more local, typically causing pain around the sacrum and hip. A piriformis with trigger points will be tight and may cause piriformis syndrome. Here, the symptom picture is a bit more complicated including the pain referral from the trigger points as well as symptoms of sciatic entrapment.
Skilled therapeutic massage is an excellent treatment for trigger points. The treatment is similar to that of piriformis syndrome but with the focus on different muscles. Figuring out the cause of extra strain on the muscle, correcting behavior along with stretching and strengthening, and learning how to treat the trigger points at home can help keep them at bay.
If you’re having pain in your backside, don’t jump to the conclusion that you have a bulging disc. Check with your doctor and your massage therapist. It may be a muscular issue that can be resolved with a few massages along with some stretching and strengthening. That is much more pleasant than getting injections of tissue-damaging cortisone or expensive and risky back surgery. If you discover there is indeed a herniation a skilled therapist can help you manage compensation problems that may arise without causing further irritation to the disc. If you have questions about your pain feel free to email me.