Aoife (Ireland): Could I ask a question please relating to a student of mine with a ruptured disc with the herniation moving forwards (towards navel). She thought it was sciatica coming from hip/piriformis. Pain from her upper buttock down the leg. I advised her a couple of times to get it checked and when she did it was ruptured L4 L5. Muscles all around area went into spasm too. She was doing really well with lots of curve-first-then-length (CFTL) exercises and core strengthening. Something that has cropped up recently is that when she lies on her back with these same principles (CFTL & engaging core) and with bent knees she experiences the pinching no matter what she does. She is quite lordotic even though she doesn't look like she has much lordosis. Her feet used to turn out also. I am completely baffled. Any ideas/suggestions would be really helpful. Thanks Martin.

 

Martin: Her excess lordosis would make sense for a disc rupture going forward as you described. Her lumbar discs would be compressed at the rear and the shock waves of walking would force her nucleus pulposus toward the front of her spine. That could create a bulge going forward. She could live with a forward bulge for a long time and never know it since the spinal cord and nerve roots are at the rear.  

   

I have a question about her pain. Does she get the sensations when she first lies on her back or when she bends her knees or when she tries to apply one of the CFTL principles? Precisely where is the pinching? 

 

Aoife: She gets it whenever she is on her back from her first lying down to bending in her knees. It does not shift even when applying the CFTL principles. She says she has to sleep on her side always. When I asked her where the pinching is she points to a place in her right buttock just to the right side of her spine. It sounds like sciatica. I hope this answers your questions. 

 

Martin: Hi Aoife, she may have multiple issues affecting her simultaneously. The ruptured disc is clearly a problem that must be addressed. It could be causing impingement of her sciatic nerve leading to the pain down her leg and in her buttocks. When a disc ruptures the fluid escapes and the disc deflates or collapses. The bony spaces where the nerve roots leave the spinal column (intervertebral foramina) will shrink as well as the vertebral space collapses. This shrinking can compress the nerve roots leading to sciatica or other muscular pain.

 

It is possible that she is also experiencing piriformis syndrome. Piriformis syndrome involves impingement of the sciatic nerve as it exits the pelvis through the greater sciatic notch. It shares the notch with the piriformis muscle which is also exiting the pelvis through the same space. Sciatica symptoms can result whether the nerve is impinged at the nerve roots as described above or in the notch by a spasming piriformis muscle. It is not uncommon to see clients with both issues since both issues can be caused and aggravated by the same misalignments. 

  

Here is a something you can try with her to help relieve her symptoms. One her back with her knees bent, put a yoga strap under the top of her sacrum and thread the ends around her waist and between her legs. Hold the ends with your hands and pull on the strap. This increases curve and pull length at the same time and can make space for the nerve roots near the ruptured disc. See if this helps her. If you wrap the strap around your hands, this will be easier for you and you can just lean back to create the pull. Let me know how this goes.

 

Aoife: Thanks Martin. I tried a similar adjustment to the one you mentioned above only with my wrists crossed and my hands creating the inner spiral of the thighs and this did not alleviate it. I will try the strap next week and let you know.

 

Martin: Aoife, CFTL would not immediately release a pirifomis spasm. Here's another test you can do for her piriformis. If she can do Uttanasana (standing forward bend) with no pain, have her do it with her greater trochanter directly over her mid ankle. Massage into her buttocks using a tennis ball or your thumbs or elbows. Massage the area directly between her sacrum and her greater trochanter. Both are prominent landmarks that you can feel for. If her piriformis is in spasm you will find places that create a lot of pain or send a nerve-like sensation down her leg - she may jump when you find the spot. If she has discomfort or pain in Uttanasana, have  her do wall dog and do the same tennis-ball massage.  If she has pain, this test is also her therapy. Let us know what you find.

 

Here is some more information on piriformis syndrome. Some people are more prone to piriformis syndrome than others. This is because the pathway taken through the greater sciatic notch can vary. The sciatic nerve consists of the tibial nerve and the common fibular nerve. For some, it can bifurcate at the notch -- each nerve branch can take a different path. The image above shows the path where both branches pass beneath the piriformis. It is also possible for one branch to pass below and one branch to pass above the muscle. For approximately 15% to 30% of the population some or all of the sciatic nerve passes THROUGH the piriformis muscle. For this group the piriformis forms with two heads leaving a pathway for the sciatic nerve to pass through. Each group will be more or less vulnerable to piriformis impingement of their sciatic nerve depending upon how the muscle is spasming and the position of their femur. The most vulnerable groups will be those with some or all of the nerve passing between piriformis heads.  

 

Aoife: Thanks again so much Martin. She is actually heading stateside (Florida) this weekend for a week so will do this when she gets back. Piriformis spasm is what she thought was going on before the herniation so maybe her old nemesis has come back now that she is doing so well with the herniation Will let you know how it goes.  

 

Martin: Be sure to stretch out her quads very well before the long plane ride. Airplane seats are usually terrible ergonomically and can really aggravate piriformis syndrome or a damaged disc. While she is traveling, have her practice rooting her thigh bones down and draw her tailbone underneath her. The combination of CFTL should help her maintain more length in her spine. She can also take a tennis ball to sit on from time to time to massage her piriformis. Let me know how she does.

 

When she returns from her trip here are some other therapeutic exercises to have her do.

 

For Ruptured Disc 

 

Active CFTL in Tadasana: Stand in Tadasana with a block between your thighs. On inhale, squeeze the block and roll your thighs inwardly to move the block back (curve). On exhale, keep the block back, and engage your pelvic floor muscles to draw your tailbone down under your pelvic floor. You should feel your spine lengthen. Stretch your arms up to increase your length. Hold for several breaths.

 

For Piriformis Spasm

 

Engage/Align/Use: Lie on your side with the sore side facing up. Keep your bottom leg straight and flex your top hip to 90 degrees.  Your knee will also be flexed 90 degrees. Spread your toes and engage your top-leg foot. On inhale, lift your top leg/foot off the floor by abduction. The piriformis is an abductor in this position, so you are using it to lift. On exhale, slowly lower your leg back to the floor. Keep your pelvis vertically stacked - do not tilt forward or back. Repeat 7-10 times, rest and repeat. The exercise should challenge you so here are ways to make it more challenging.

 

•  Add weight such as ankle weights or a small bag of beans just above her knee.
• You can also give her resistance with your hand on her leg above her knee if you are with her.  
• Self massage the sore spot in the piriformis with a tennis ball during the repetitions.

 After Her Trip 

 

Aoife: My student found the tennis ball massage on her piriformis was very helpful once she had dealt with the pain of her ruptured disc.The therapy she found most beneficial was the one all fours squeezing a block between inner thighs, creating curve and then length and holding her core muscles. She called it "the sweet spot" when the pain went away. Her recovery was amazing as she ended up cancelling her planned discectomy!

 

Much Love,