Polishing off with Piriformis

The last mention of butt muscles for a while will be the piriformis. I see a fair few problems relating to this one muscle, and the end result is often sciatica. That’s an inflammation or irritation of the sciatic nerve that can come from the spinal outlets but also from direct pressure from a tight piriformis.

The piriformis attaches at the anterior surface (the inside) of your sacrum and the greater trochanter (the lump on the outside of your hip) of the femur. It essentially externally rotates the hip (turns your foot out) but also abducts your femur when your hip is bent.

Problems arise when the muscle becomes too tight. This can often be from poor habits that we get into, such as walking or standing with the toes pointing out. Be aware when doing exercises such as squats that the feet should point roughly forward and not be in a Charlie Chaplin stance. Tension in the piriformis can cause the belly of the muscle to put pressure on the sciatic nerve, which is quite thick.

In a small percentage of people, the sciatic nerve can actually pass through the piriformis muscle, heightening sciatic pain. It is important to also build the gluteus maximus to take pressure of the deeper muscles of the buttocks. Bowen Therapy or remedial massage should aid in reducing tension that is present.

Gluteus Medius

The last post on the gluteus maximus naturally gives way to talking about the other muscles of the area. Today I’ll discuss the gluteus medius. This muscle sits underneath the gluteus maximus, attaching at one end to the ilium of the pelvis and at the other to the greater trochanter of the femur – that’s the knobbly bit you can feel when you stick your hip out to one side.

This muscle isn’t used for standing in the same way that gluteus maximus is. This one is essential for walking. It, together with the gluteus minimus and the tensor fascia latae, supports the body upright when one foot is raised from the ground. Essentially, it stops you from falling over to one side when walking. The action of the muscle is to abduct the femur – that is, take the thigh away from the midline of the body. It also turns the knee inwards (internal rotation) when the hip is flexed (knee raised in front) and turns the knee outward (external rotation) when the hip is extended (leg behind you).

The test for this is to get a patient standing level and then ask them to raise one leg slowly. If the opposite hip drops, it suggests a weak or impeded gluteus medius. Another sign that can be observed is the tendency to scuff the inside of the shoes. A weakness in the medius can lead to the inside of the feet rubbing past each other when walking. A tight gluteus medius will often come from activities that require one leg to support the whole person, such as in soccer when you are supporting on one side and kicking with the other.

But never fear, it’s not the end of the world. If your muscle is in spasm, Bowen therapy or remedial massage can help. If the muscle is weak, then good old clams can help to strengthen it. Lying on the floor on your side with the knees bent slightly in front of you, slowly raise the topmost knee in the air while keeping the ankles together and then close. It looks kind of like a mollusc opening and closing it’s shell. Of course, you really need to get this checked professionally and not do a Google Doctor on yourself!

Gluteus Maximus

Your gluteus maximus, the big outer buttock muscle, is a much neglected thing. This muscle is one of the things that keeps us upright and separates us from our ape ancestors. The development of this muscle allowed the pelvis and spine to be pulled into an upright position, and it also is important in the everyday action of walking.

The gluteus maximus attaches to the ilium (one of the pelvic bones), the sacrum and coccyx (the lowest two sections of the spine) and the femur or thigh bone. It is the larger outer muscle of the buttocks, very much what gives us that classic human shape. When standing, it helps to pull the pelvis back to keep the spine erect, but it also the muscle that helps push us from a sitting to a standing position by contracting and forcing the hip to straighten. When standing, a contraction of the muscle pulls the femur back behind the pelvis (it extends the leg) to propel us forward. That is, it makes us walk.

Like any muscle, this can go wrong. From injury or habit, it can not fire properly. In this event, when walking or running, the hamstrings and muscles of the lower spine overwork to compensate, and this can result in lower back pain or hamstring strains. I have treated ballet dancers in clinic, who are trained to not engage the gluteus maximus to avoid having a “big bum”. This can result in overuse and potential damage to the hamstrings. In others, a tight psoas can impede the firing of this muscle and have a similar result. I’m sure you’ve all seen people with little shape to their posterior, sometimes called “old man arse” where it seems a straight line from shoulder to thigh. This can be indicative of a lack of glut maximus strength and result in other problems.

This is fairly easy to remedy. If there is an issue with the psoas impeding the glut, then you will probably need some release work with Bowen Therapy or physiotherapy. Then, it’s a case of squats. If you have a trainer or go to the gym, then you can start there. A trained Pilates instructor can make a big difference. Always start unloaded, with feet shoulder width apart, and angled so that the knees track naturally over the toes. Do NOT do the Charlie Chaplin stance with the feet turned out. Lift the chest and pull the navel towards the spine to engage your core. Then bend the knees and allow your top half to lower. When you are as low as is comfortable (preferable with thighs parallel to the ground), squeeze your butt and push yourself upright. Try to push down through your heels to make sure your gluteus maximus is doing the work and not your quads. Use your mirrors to check the posture.

If you aren’t a gym goer, don’t give up. You can do simple squats with a fixed chair. Adopting the above posture, simply lower your bum until you tap the seat, then, without lingering, squeeze your butt to push yourself upright. Come to a set of stairs? Think of squeezing that butt as you ascend. Don’t pull yourself up with your quads, push yourself with your gluteus maximus.

We can’t all be bootylicious, but we can keep our muscles working as they’re intended.

Rotator Cuff

I’ve had a few people in with shoulder problems related to their rotator cuff. I’ve found injuries always come in “runs”, so I thought this’d be a good time to briefly discuss the group. A lot of people are diagnosed with a rotator cuff tear or dysfunction without anyone ever really going into what is happening or even specifically which muscle is involved.

The rotator cuff is made up of four muscles that both stabilise and move the shoulder joint. The glenohumeral (shoulder) joint is not overly stable due to the very shallow socket of the glenoid fossa but this is what allows the huge range of motion in this joint. As a result of the shallowness and instability, the muscles that cross the joint aid the ligaments of the area in strengthening the joint. Direct impacts to the shoulder or falling on an outstretched hand can easily dislocate or strain the joint damaging both ligaments and the tendons of the muscles.

The rotator consists of: the supraspinatus, which abducts (raises to the side) the arm; the infraspinatus and teres minor muscles, which both externally rotate (turn the hand palm out) the arm; and the subscapularis that internally rotates (turns the hand palm in) the arm.

Many of the patients I see with problem are troubled by having their arms stretched out for long periods. Hairdressers are commonly affected by having their arms at shoulder height all day. People who drive with extended arms and similarly people who work on laptops or with the keyboard pushed too far away can also experience problems. From a sleeping point of view, sleeping with your arms above your head can leave these muscles in spasm.

Most tightness and spasm will react well to Bowen therapy or remedial massage, however tears may need to be referred on to a surgeon depending on the grade of tear and any instability in the shoulder. Stretching these muscles isn’t overly easy due their attachment to the highly mobile scapula but there a few things that can be done.

Sciatica

I’ve had a few sciatica patients in the last little while, so I thought it’d be a good time to talk briefly about it. Sciatica is pain brought about by impingement or irritation of the sciatic nerve. It can manifest as pain anywhere from the buttock (and even lower back) to the foot and may produce neural symptoms in the foot (pins and needles etc). While this can result from injuries or structural problems in the lower back, by far the most common cause in my clinic is from piriformis syndrome.

Briefly looking at the anatomy of the nerve and surrounding tissue, the sciatic nerve originates from several nerves of the lower lumbar and sacral spine joining together. This nerve then comes from under the sacrum and passes almost vertically down, deep in the buttock. It continues down the rear of the leg innervating the back of the thigh, the entire lower leg and most of the skin on your leg.

Impingement of the nerve can occur at the spinal outlets from disc compression (bulge/herniation/degeneration) or from conditions such as spondylolisthesis (backwards or forwards displacement of the vertebrae). Downwards pressure of a swollen uterus during pregnancy can also cause it. The cause I see most frequently is referred to as piriformis syndrome. While the sciatic nerve passes almost vertically, the piriformis runs almost horizontally from the sacrum to the greater trochanter (that lump on the side of your hip) of the femur. The muscle sits adjacent to the nerve and in some people the nerve actually passes through the muscle. These people are particularly prone to piriformis syndrome. The upshot is that a tight piriformis can easily compress the nerve producing pain and nerve-related symptoms like pins and needles. Over a period the compression can lead to inflammation that can take time to recede.

The piriformis is used by your body to laterally rotate the femur – that is, turn your foot out. This will give some idea of things that can cause tightness. Do you walk with your feet turning out? Do you do squats with the feet turned out? These sort of activities encourage the tighening and shortening of the muscle and increase pressure on the nerve. It pays to keep the gluteus maximus (the big outer bum muscle) strong to take pressure off the deeper muscles.

Remedial massage and Bowen Therapy are both great for this, although Bowen has the advantage of being non-inflammatory. If the body is non-responsive after one or two sessions then scans may be required to check the health of the intervertebral discs and refer on if there is a problem.