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70 m a s s a g e & b o d y w o r k s e p t e m b e r / o c t o b e r 2 0 1 9 Because the piriformis can also abduct the thigh at the hip joint, it is important when stretching it to have the thigh adducted (or at least have the thigh in a neutral frontal plane position and not abducted). Hip Joint Flexed When the thigh is flexed at the hip joint to 90 degrees, the line of pull of the piriformis moves to the anterior side of the joint (Image 3B). Therefore, the piriformis becomes a medial rotator of the thigh at the hip joint; consequently, stretching it is accomplished by laterally rotating the hip joint. When the thigh is flexed at the hip joint to 90 degrees, the piriformis can also be described as a horizontal abductor of the thigh at the hip joint. Therefore, the piriformis can be stretched by horizontally adducting the thigh at the hip joint. Using the Leg as a Lever to Rotate the Thigh Because of the soft tissues that surround the femur, it is logistically difficult to directly contact the thigh to rotate the femur. Instead, the (lower) leg is usually used as a lever to rotate the thigh/femur at the hip joint. This is extremely efficient but does place a torque (rotational force) into the knee joint. For this reason, if the client has an unhealthy knee, any protocol that uses the leg as a lever to stretch the piriformis is either precautioned against or contraindicated. When in anatomic position, the line of pull of the piriformis crosses posterior to the hip joint; therefore, the piriformis is a lateral rotator of the thigh (3A). However, when the hip joint is flexed to 90 degrees, the line of pull of the piriformis changes to pass anterior to the joint; therefore, the piriformis becomes a medial rotator (3B). Artwork by Dave Carlson. STRETCHING PROTOCOLS FOR THE PIRIFORMIS Given that the piriformis has multiple possible joint actions, there are many choices when it comes to stretching it. Following are some of the more common protocols that are used to effectively stretch the piriformis. Prone Position When the client is prone, the hip joint is in anatomic position; therefore, the piriformis is a lateral rotator at the hip joint and would be stretched with medial rotation. Because it is difficult to rotate the client's thigh by directly contacting it, the (lower) leg is used as a lever to rotate the thigh (see Using the Leg as a Lever to Rotate the Thigh, below). To do this, the therapist stands to the side of the client. The client's leg is flexed at the knee joint to 90 degrees, and the therapist contacts the client's distal leg. The client takes a breath in, and then—as the client exhales—the therapist brings the distal leg outward, which brings the thigh into medial rotation at the hip joint, stretching the piriformis (Image 4). Because the reverse closed-chain action of the piriformis is to contralaterally rotate the pelvis at the hip joint, the therapist stabilizes the pelvis with the other hand by pressing on the opposite-side (contralateral) posterior superior iliac spine (PSIS). One precaution when using this stretching protocol is that using the leg as a lever to rotate the thigh torques the knee joint, so this protocol is not recommended if the client has a knee pathology. Note: Bringing the client's distal leg outward may seem counterintuitive to medially rotate the thigh, but keep in mind that rotation is always named for where the anterior surface of the body part orients. When the leg is brought outward, the anterior surface of the thigh orients inward/medially. Supine Position—Lateral Rotation There are many ways the piriformis can be stretched when the client is supine. Perhaps the best known protocol is the stretch that is sometimes referred to as the figure-4 stretch because the positioning of the lower extremities resembles the numeral 4. Using the figure-4 stretch protocol, the client's hip joint is flexed and laterally rotated, and the knee joint is flexed to 90 degrees. The therapist then places a force into the client's (lower) leg, using it as a lever to laterally rotate the thigh at the hip joint, thereby stretching the piriformis. 3A 3B Axis of rotation Line of pull Axis of rotation Line of pull Watch "Piriformis Becomes a Medial Rotator of the Thigh"