Advanced Piriformis Muscle and Glute Stretch

A good stretch here but quite advanced.
As with everthing else on this blog, we recommend visiting a healthcare professional before undertaking any exercises featured here.

How to stretch psoas muscle

Through my experiences in clinic I have seen first-hand how tight piriformis can cause or be caused by tightness in surrounding muscles, not least the psoas major muscle.

The psoas is a big, strong muscle running from the anterior bodies and transverse process of all lumbar vertebrae down through the pelvis beneath the inguinal ligament to attach to the lesser trochanter of the femur.

I've already described a psoas MET that I personally use but patients are also recommended to stretch this important muscle themselves. The stretch that I favour is illustrated here:



The most important features of this stretch are to keep the spine upright with the rear knee firmly planted on the ground (a cushion or towel can be used for comfort). This position alone will often induce a stretch but this can be increased further by shifting the weight forward as per the red arrow. It is often advisable to balance yourself on the floor or a nearby table etc when pushing into the stretch.

As with all stretches this should not be painful but you should "feel the stretch" as you hold the position. Hold the position for 30-60 seconds each time and repeat 2 or 3 times once or twice a day. I recommend this stretch as a good daily exercise for anyone who feels stiff in the upper leg or hips before and after regular exercise.

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Muscles associated with piriformis syndrome

A large proportion of the people who come to me with piriformis syndrome symptoms seem to follow a pattern of tightness and discomfort in surrounding muscles. I have deevloped a very basic routine that lets me target the piriformis but also release the surrounding tissues:

1. Piriformis muscle itself

My favourite piriformis MET stretch has the patient prone on the couch with the affected leg bent at the knee. Using the heel of one hand as an applicator into the mid buttock, I gently rotate the leg towards the outside to stretch the muscle with little or no discomfort. To increase the degree of stretch, literally apply more rotation on the leg.

2. Quadratus Lumborum

Often, these muscles are also tight. I favour a deep tissue massage technique working towards the spine to loosen and stretch this group of muscles.

3. Gluteus Medius

More and more I find tenderness in this muscle on the same side as the tight piriformis. I like to use a direct inhibition technique with the patientside lying with the upper leg flexed at both the hip and knee. The elbow can be used as a direct applicator into the belly of the muscle.

4. Iliopsoas / Psoas Major

I finish with an MET for the iliopsoas. With the patient at the end of the coach, on their back with the non-affected knee to the chest. The affected leg dangles off the couch allowing me to apply pressure to the thigh which the patient pushing against. This is an excellent stretch and one that always raises a smile as they really try to push into the pressure.

This little routine has brought me great results already and I'm developing it every time i use it. I personally think it's a great way of tackling the tight piriformis without too much uncomfortable deep tissue work into already tender muscles.

The Anatomy of Piriformis Syndrome: #1 The Piriformis Muscle

We'll start by looking at the piriformis muscle itself as it is, unsurprisingly, the key factor in piriformis syndrome.

Taking it's name from it's pear-like shape, the pirifromis muscle is a fairly small muscle deep to the gluteus muscles across the upper buttock. It originates from the anterior surface of the sacrum and the superior margin of the greater sciatic notch. It also has attachment to the capsule of the sacro-iliac joint and also the sacrotuberous ligament.

Exiting the pelvis through the greater sciatic notch, it's fibres run almost horizontally to insert into the superior aspect of the greater trochanter of the femur, just above the insertion of obturator internus. As many muscles insert into the greater trochanter in this area, the tendon of piriformis is said to often blend with the tendons of obturator internus itself and the superior and inferior gemellus muscles.

Superficial to the piriformis is first the gluteus medius muscle followed ay the larger gluteus maximus, which covers the entire muscle as it sweeps across the posterior leg to insert into the ilio-tibial band, between vastus lateralis and adductor magnus.

The sciatic nerve, which we shall cover in more depth later, passes deep to piriformis in most cases (approximately 85% of people) but can infact pierce the piriformis itself, predisposing to piriformis syndrome and subsequent sciatica. Even if the sciatic nerve runs deep to piriformis, spasm in this muscle put direct pressure on the nerve, causing the resultant pain and discomfort.

So that's the muscle itself. The interaction between piriformis, sciatic nerve and the surrounding structures is key to understanding piriformis syndrome which we shall cover next.

(image coutesy of http://www.tpmassageball.com/)

Youtube video: Piriformis Stretch

What is Piriformis Syndrome?

Piriformis Syndrome is a very common condition where the piriformis muscle, located deep to the gluteal muscles, becomes inflammed and puts pressure onto the sciatic nerve referring pain into the lower back, deep into the buttock or down the posterior of the leg on the affected side, giving sciatica.

The causes of piriformis syndrome are numerous and we will look at these in more depth on an individual basis. Similarly, the treatments of piriformis syndrome are numerous and targetted at the precise cause. Massage and osteopathy are two approaches that are very effective along with stretches and mobilisation exercises that can be carried out at home.

Coming next: where is the piriformis muscle?