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.