Massage Tutorial: Sciatica myofascial release techniques
Hi everyone. I'm Ian Harvey, massage therapist. This is my friend Steve, and today we're going to be talking about the sciatic nerve and sciatica pain. First let's start by talking about what sciatica pain is, then we're going to talk about the general anatomy of the pelvis and sciatic nerve, and then we'll do a nice massage demonstration with my basic protocol. If you'd like to skip ahead you can click on the time codes down in the description.
So sciatica is pain in the buttock and the low back and that sometimes travels down the leg, and the part that travels can feel like a burning, it can feel like a stabbing pain, it can even be a numbness. The sciatic nerve itself is a mixed nerve. It's both a motor and a sensory nerve so it can also be involved in weakness. The sciatic nerve originates from L4 through S3.
So L4, L5, and this is around S1, S2, S3. Just to note you can't interact directly with the spinal nerves by pressing next to the spine here. The spinal nerves come out anteriorally, so forward, and then they exit out posteriorally through the greater sciatic foramen along with piriformis. That's one reason why piriformis can be considered important here. First let's talk about some relevant landmarks. Find the iliac crest, you can come up over that and press down toward it so you can define the border of that iliac crest. Inferior to that iliac crest you're going to feel a knob of bone.
This is the greater trochanter and this is important when we're talking about the sciatic nerve. You'll know that you're on the greater trochanter when you can pinch it from either side and rock it like that or you can just palpate for it, and then rock the leg and you'll be able to feel this greater trochanter move under your fingertips. Next we want to find the ischial tuberosity. If you use a broad hand and press upward on the gluteal region you'll feel a bone that stops you from moving further up. If you've never felt this on a client before, then sit in a chair and feel for the bone that presses against the chair and that is the ischial tuberosity.
Something else I'd like you to palpate is something that runs between the ischial tuberosity and the SI joint, so find the sacrum. It's a triangular piece of bone at the posterior of the pelvis. It is the bottom-most section of the spine other than the coccyx. Feel for that triangle, and this border of the triangle represents the SI joint. This is where the sacrum and the ilium come together, the sacroiliac joint.
And palpate the ischial tuberosity. Between the two of those you're going to feel a very tight band of something. This is the sacrotuberous ligament. If you've been palpating around this area and you feel a tight band running between the ischial tuberosity and the SI joint, that's not a knot. That's not the sciatic nerve.
That's not one of the rotators that needs to be worked out. That is a ligament and it is supposed to be there. Next I'd like you to palpate for the PSIS, that's a knob of bone up at the top of this V here. It's at the top of that SI joint and between that and the coccyx, that's where the piriformis runs and it's also where the sciatic nerve emerges. The sciatic nerve is anterior to that piriformis muscle in most people and you're not going to be able to directly palpate it here. In fact, you might not be able to directly palpate piriformis either, and we're actually not going to be worrying too much about individual rotator muscles here.
We're going to be coming at this from a myofascial perspective, and so we're not going to be focusing on this muscle or this muscle, etc., but this is where it emerges and then the sciatic nerve runs here. It's between the greater trochanter and the ischial tuberosity, so this is where the sciatic nerve runs and just realize that as this tissue becomes thinner between these two landmarks here, this is a point where it's possible to accidentally put too much pressure directly on that sciatic nerve. A little bit less so as you travel up superiorally.
Now, I like to approach the hips from superior to inferior and from inferior to superior, so during a typical session where I'm working with sciatic pain I will be working with it twice, and each will feel slightly different to the client and will offer a slightly different stimulus. Hopefully between the two of them I'll have worked that area thoroughly. I'll just be working with the back and then I will undrape the hip. To undrape this hip I press here at the sacrum, I fold away, and if I need more real estate I will press here at the upper hip and then bunch away. When I'm working with my sciatica clients I find that they often have a lot of touch sensitivity here in this hip region and sometimes in the low back. I don't like to come at this from a 90 degree angle where I'm pressing straight down toward those sensitive structures. Instead I take a step back and I'm working at this from a 45 degree angle which I think of as the myofascial angle. We're taking all of this tissue and we're pressing it along forward.
We're giving it some traction inferiorally. I start with some broad contacts and I move very slowly. If you've got a client in your office who has sciatica-type symptoms, it's a good idea to talk to them about how you would like to proceed and that it might involve direct contact with their hip region. Point out exactly what you mean on your own body, reassure your client that they'll always be well draped and you can always offer the alternative that if you choose to leave your underwear on I may ask you to move it around a bit. A lot of these long flowing strokes from way high up to way low down aren't going to be as possible but you can always interrupt this stroke and start again. But when possible when working on things from a myofascial perspective I like to work from origin to insertion and beyond.
I'm not thinking about any individual muscle. I'm thinking about the fascia. I'm thinking about this thoracolumbar fascia. I'm thinking about how it interacts with the hips. I'm thinking about how the hips interact with the hamstrings and I'm starting far up and ending far down, far past where any of the relevant muscles might begin or end. So with each of these strokes I am including and acknowledging those deep rotators like piriformis and quadratus femoris.
I'm just not attacking them directly and in fact I find that that can often be counterproductive. Pressing in directly can often provoke a guarding response from those muscles, causing them to try to protect the surrounding structures. They recruit their friends and before you know it the entire region is difficult to work with because it's hypersensitive or because there's spasm. Start this massage by acclimating your client's body and their nervous system to your touch.
Err on the side of using too little pressure and going too slow. As you work with these hips, don't forget about the three dimensionality of the body. We don't want to just work with the posterior pelvis. We want to work with the lateral pelvis as well. I'm steamrolling right over that greater trochanter as if it weren't there because I'm at this angle, I'm just able to grab this tissue and traction it down inferiorally.
Now you can introduce your fists here. I'm getting over my fists and using my body weight to drag this tissue down. I'm thinking of moving that tissue down toward his feet or down toward his greater trochanter rather than pressing directly down toward the pelvis, so still using that myofascial angle for the pressure. To continue acknowledging that three dimensionality of the body we can use one fist going from the SI joint down toward the greater trochanter and we're using very broad surfaces here. This dorsal surface of these phalanges rather than just these metacarpophalangeal joints.
So not just these knuckles, but also these surfaces as well. And the other hand can just be a nice palm on the other side of the body tractioning that thoracolumbar fascia in the other direction. Try to limit the amount of time that you spend in sensitive hips to about 10 minutes especially that first session. See how they feel afterwards. If they have excessive soreness that means you did too much. If they just have a little bit of soreness that's alright as long as it didn't provoke any sort of adverse reaction. From there you can try to increase your pressure over time. It's very likely that their sensitivity will decrease over time.
I also like to approach the hips from inferior to superior. This is just a different stimulus for the nervous system. It deforms the tissue in a different way and coming at this from a myofascial perspective, I'm not trying to change any individual muscle. I'm not going to be attacking this piriformis or this quadratus femoris or any of the gemelli, etc. I just want to provide a lot of different stimuli that are safe and comfortable to these sensitive tissues and let the body figure out what to do with those stimuli. Medically speaking, a lot of cases of sciatica are considered to be from compression due to disc problems and that's very possible but what we can do as massage therapists is work with the related soft tissue. We can work with all the muscles that might be irritated or in spasm and we can work with the hypersensitivity that tends to come with any of this nerve pain. So we may not be able to work directly with a disc but I've seen some great results just from working with all of the soft tissue descending down from that area.
So right now I'm just again passing, just steamrolling over all of these areas and ignoring greater trochanter, ignoring the ischial tuberosity, making sure to be thorough in my contacts so right now I am passing over the ischial tuberosity. I can feel the greater trochanter on the thumb side of my hand but I'm not putting pressure directly on any of these. In fact my pressure is directed this way.
By the way, I've got my body braced against the table. My rear leg is resting against the table. I am giving him my body weight so I'm never having to use my back muscles to keep myself up. This is a very comfortable massage for me because I'm just leaning. Once again remember the three dimensionality of the body, work with this lateral hip tissue coming up from the IT band, passing over that greater trochanter and working up into the lateral pelvis. While it might not seem like this lateral pelvis is involved in sciatica-type symptoms, I find tightness here in pretty much 100% of my clients with sciatica symptoms. It's all involved. It's all connected fascially and some of these rotators can actually get co-mingled with gluteus medius and minimus including piriformis.
Again, working from origin to insertion and beyond, so working up into the low back just a bit. Here you can use fists as well especially as your client's hips becomes less sensitized or you can choose to use this just with little pressure. If you'd like to use fists without sinking in too much, just keep your fists close to your body instead of letting them get away from you. Keep your body connected to the table and don't lean into it too much. Support yourself in other ways and make this nice and broad. This shouldn't be knuckles sinking into sensitive hip tissue.
It should just be another form of that steamroller. As I steamroll past this SI joint, I am making a bit of contact with all of these deep rotators through gluteus maximus and while I'm not specifically working with any of them, they're all getting some deformation. They're all getting some stimulus and hopefully it's comfortable stimulus that lets them know that they don't need so much tone and that they don't need so much sensitivity. So far we've just been working with these hip rotators transversely. We can also work with them longitudinally, working out from this SI joint toward this greater trochanter. Just realize that as you do so you should originate from the SI joint rather than from further down because that can pull things apart.
That's uncomfortable, so get your body weight over this pressure and drag toward yourself. This is going to be a nice 45 degree angle down toward your greater trochanter. You can come at this from different angles starting a little higher, starting a little lower.
Just realize that the greater trochanter itself might be a little sensitive. That's the insertion site for all of those rotators and if any of them is sensitive, if any of them is acting up, that can be felt down here. You can also work up from the greater trochanter. Again we're going to start before this insertion site so we're going to start distal to it.
When you're doing this, you can use the other hand to introduce gentle rotation and I'm not really digging in with my fingers here. I'm just using them as part of my steamrolling technique. They're kind of breaking the ice in front of my actual hand tool here which is just the palmar surface of my hand. Notice that I'm tucking my elbow into my hip here and allowing my hip to drive this move. I'm not just pressing really, really hard with my pecs and with my triceps.
When you want to, you can step back and let your body weight do this using straight limbs. Now as sessions pass and this becomes less sensitive you might be able to do more with mobilization. You might be able to do some of this on your first session but I do recommend being conservative as you work with people who have quite a bit of pain here.
A good way of mobilizing this hip is to re-cover the hip as we're going to do some movement here. Prop the ankle up, bring the knee into a 90 degree flexion here and we're going to press in toward the SI joint as we allow this leg to drop back. Press in as the leg drops outward. This is bringing into internal rotation so we're stretching these external rotators as we're pinning them down toward the pelvis. We're up and down the pelvis as you do this. You can work up into that lateral pelvis once again and down toward the greater trochanter. You can bring the hip into external rotation.
I like to start by moving the knee outward just a bit and then dropping this down toward the table, again pressing toward that SI joint up into the lateral pelvis and coming down toward the ischial tuberosity. The greater trochanter is going to be in your way here so just come to the inside of that. You can play with going in and out of that. This might not work for all of your clients but you can grab the inside of their knee, bring them in further into external rotation as you bring this knee outward so we're coming up into abduction. Then you can press the knee in toward the hips so we're pressing the head of the femur here into the acetabulum and that can relieve some spasm. That can be a comforting feeling and again doing gentle compressions all around that greater trochanter up toward the SI joint. Working with the hip in a lot of different ways with the tissues in a lot of different configurations can send a variety of stimuli to the nervous system and let it know that it doesn't need all of that sensitivity.
Just as a final word, don't forget to work with the hamstrings. Don't forget about the hip flexors. Don't forget about the three dimensionality of the body. If your clients have symptoms that are persistent or recurrent or that are getting worse, please do refer them to their general practitioner but I find that if people are just having these hip, low back, leg symptoms, that we can safely work with this entire region without causing further pain.
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