Issue link: https://www.massageandbodyworkdigital.com/i/72343
YOU CAN SEE TECHNIQUES FROM THIS COLUMN IN MASSAGE & BODYWORK'S DIGITAL EDITION, WHICH FEATURES A VIDEO CLIP FROM ADVANCED-TRAININGS.COM'S ADVANCED MYOFASCIAL TECHNIQUES DVD AND SEMINAR SERIES. THE LINK IS AVAILABLE AT BOTH WWW.MASSAGEANDBODYWORK.COM AND WWW.ABMP.COM. WORKING WITH APPENDICULAR SCIATICA, PART 3 Sciatic pain, that is, pain involving the lower back or buttocks that radiates down the posterior leg, comes in at least two varieties: axial and appendicular. In the first installment of this article ("Assessing Sciatic Pain," July/ August 2011, page 110), we discussed ways to assess axial sciatica (which originates from impingements of the nerve roots at the lumbar spine), and to differentiate it from appendicular sciatica (which arises from nerve entrapment distal to the nerve roots). A brief review: because axial sciatica can be associated with spinal instability (which can be worsened by indiscriminate deep work), the safest approach to this type of sciatica is easing the whole- body guarding and stress that accompany chronic pain, rather than performing deep, focused work on the lumbar nerve roots themselves. Persistent axial sciatic symptoms (as described in Part 1) can be a reason for referral to a rehabilitation specialist, such as a physical therapist, chiropractor, or orthopedist. By contrast, with appendicular sciatica, our approach is different. Appendicular sciatica is characterized by increased pain from sitting, stepping up stairs or inclines, the direct pressure of sexual intercourse in women, or with resisted active external rotation of the femur. Appendicular sciatica can be just as painful as axial sciatica, but is generally more amenable and responsive to soft-tissue work. This is because in appendicular sciatica, it is usually soft tissue itself that entraps the sciatic nerve, as opposed to the boney or fibrocartilaginous entrapments typical in axial sciatica. Our intention when working with appendicular sciatica is to facilitate normal nerve glide by releasing the tethering or compressing myofascial entrapments. These entrapment sites can be identified using the Sciatic Nerve Glide Test described in the second part of this article ("Assessing Sciatic Nerve Glide," September/ October 2011, page 110). Now, in this third installment, I will describe techniques from Advanced-Trainings. com's Advanced Myofascial Techniques series that have proven both safe and effective for easing the most common appendicular sciatic nerve entrapments. ROTATOR (PIRIFORMIS) TECHNIQUE Sciatic nerve entrapment by the piriformis ("pear-shaped") muscle is probably the most common cause of appendicular sciatica, the piriformis accounts for about 70 percent of all nonlumbar sciatic pain, according to one large-scale study1 ). Piriformis syndrome was first described in 1928, and its causes have been well studied and debated in the years since. It is also known as "pseudosciatica," or Type II Sciatica in chiropractic terminology. (In our trainings at Advanced- Trainings.com, we emphasize the broader term "appendicular sciatica," since piriformis-related entrapment is just one of several types of nonspinal sciatic nerve impingement.) Although sciatic symptoms are about equally common in men and women, piriformis syndrome occurs six times more frequently in women than in men,2 and some studies suggest that women's sciatica is often more severe.3 (On the other hand, lumbar disc issues, often the cause of axial sciatica, are twice as common in men as in women.4 ) Anatomical variations in the sciatic nerve's pathway in relationship to the piriformis have long been thought to be the cause of piriformis-related sciatic pain. In most people, the sciatic nerve passes deep to the piriformis (as it does in Image 1), but 15–30 percent of people have variations in this arrangement,5 which can include: • The nerve passing superficial to the piriformis. • The nerve passing through the split belly of the muscle. • The split nerve passing in two parts around the piriformis. However, some researchers question whether these anatomical variations have any significant bearing on sciatic symptoms.6 In a manual therapy setting, these variations are probably more interesting as anatomical trivia than as tune in to your practice at ABMPtv 111