Dr. Stephen Gangemi, aka the “Sock Doc” discusses some natural and effective ways to deal with low back, hip, and leg pain as well as what is known as piriformis syndrome. Also, Dr. Gangemi discusses sciatica – how it is often misdiagnosed and how it can be treated.– NRC
In this video I discuss piriformis syndrome, low back pain, and “sciatic pain”, which is often not true sciatica, but another type of pain known as sclerotenogeous pain. Many athletes suffer from hip pain and back pain. Hip flexion problems are very common in runners and those who use their bodies to jump and kick. Extension-type pains can be an issue with these athletes too, and especially with cyclists.
Your sciatic nerve is a thick nerve originating from many fibers in the lower back and sacral area. Actually it’s the sensations in the lower leg & foot – weakness, pain, numbness – that are typically true signs of “sciatica” symptoms as the sciatic nerve comes out from behind the knee and branches out into the tibial nerve and common peroneal nerve where they supply movement and sensations to much of the lower leg and foot. Pain above the knee – usually referred to as sclerotenogeous type pain – is pain originating from a muscle, tendon, or ligament. That is usually what is causing pain in the lower back and hamstring/thigh area, if not a local muscle or tendon strain. Though there may be disc involvement as well as other nerve related problems, (other than sciatica), most lower back, thigh pain, and hip pain is from muscular imbalances as well as inflammation in the body.
The muscles discussed in this video have significant involvement in the stability, strength, and movement of the lower back, hip, and legs. Piriformis – this muscle extends from under the front side of the sacrum and attaches to the greater trochanter in the upper leg. The major action is to laterally rotate the hip as well as turn the foot out. The sciatic nerve actually comes out right under the piriformis, but in 15-20% of people, it goes through it. “Piriformis syndrome” irritates the sciatic nerve. An imbalance in the muscle often causes pain and can cause the foot to turn outwards. Since the pirformis muscles stabilize the sacrum and therefore the base of the entire spine a person can have pain all the way up to their neck or down to their foot from a piriformis issue.
Gluteus maximus – this powerful muscle extends the hip and rotates the thigh laterally a bit too, just like piriformis. Many people think they’re having hamstring pain or hip pain from a bad disc, when really it’s because they have a glut max that isn’t functioning properly. Also, a lot of knee pain is because of a strained glut max. This muscle also makes up a significant amount of the ITB – another common injury I discuss here. On the front side of the body are the psoas and abdominals muscles and they are often involved in low back pain, hip pain, sciatica, and disc problems.
Leg flexion, hip rotation, and the ability to reach down and touch your toes is made possible by the action of these two muscles. So pain performing these movements means that they are not working correctly. Can’t sit up because of pain or weakness from laying on your back? Pain putting on your shoes or flexing forward to pick something off the ground? Pain running, jumping, or kicking? Psoas and abdominal involvement.
No stretching! No orthotics!
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what exercises do u do if pain radiates from buttocks to upper hamstring
Mike, pain from the butt to the upper hamstring is either a glut max or piriformis problem. So if it’s the glut max then you look for the trigger points in the glut as I demonstrate and if it’s the piriformis, same thing for that muscle. I don’t recommend or advise any exercises when there is still pain in the muscle because that means the muscle is still neurologically inhibited (essentially it is weak). Exercising the muscle(s) will not get it to fire. Once it does though, I like Russian Kettlebell Single Leg Deadlifts, or even Russian Single Leg raises w/o the kettlebell are great too for strengthening the glutes and overall stability.
Please discuss how to make the glut max function properly then – Thanks
Hi Sandy, pretty much same answer as I left Mike. Check for trigger points both sides, that’s how you get it to fire again (most often), and then you can try some Russian SLRs (good demos on YouTube). Also note the hormonal relationship I mention in the video. There is a strong correlation between the glutes and piriformis muscles and sex hormones. Many women are estrogen dominant and progesterone deficient, and many also take birth control pills or some other form of HRT. These will often cause muscle imbalances in those pelvis muscles. So if you have hormonal imbalances the trigger points won’t work – you have to address the hormonal issues.
I enjoyed the video and have a question. You said this about the piriformis: “Piriformis – this muscle extends from under the front side of the sacrum and attaches to the greater trochanter in the upper leg. The major action is to laterally rotate the hip as well as turn the foot out.” I am a long time competitive runnner and my left foot turns out so it is not pointing the same direction as the knee. Could this be related to the piriromis? I do have a lot of problems on the left side including a pain in the butt post runs, I had arthroscopic surgery to repair a torn labrum in the hip this summer, but the foot twising out is always there (sometimes worse than others). I am curious about the pirifrmis’ effect on this or does the twist create the pain in the butt?
Hi Jim, yes I’d say that is exactly what is happening to you. The left foot would be the tight piriformis (could be your psoas too), with the right side being inhibited (“weak”). The twist is really not what is causing the pain, but the piriformis being too tight is causing both the pain and the lateral rotation – that puts a significant amount of stress on your labrum, hence your surgery.
Thanks (and sorry for so many spelling errors). I just had an MRI for the lower back and was told yesterday that my back looks very good. I will be sent to another musculo-skeletal doctor who will look a little deeper into what my body is doing and one thing they mentioned was possible trigger point injections. I might guess they would find something in the piriformis area. It was also recommended by someone else to see a doctor called Thomas Michaud who just wrote a book called “Human Locomotion” which all about stuff like this. He is quite busy as my appointment won’t be until April! It is all very interesting to learn how the body works.
I have butt pain, and also lower leg and foot pain, numbness from the knee down, and foot drop. It came on suddenly one month ago, while taking a break from running. I have been a competitive runner for 30 years. My MRI shows no compression of the nerve root. My pelvis MRI was also unremarkable. Is it possible to have compression of the peroneal nerve at the knee that would cause pain in the butt? Would an MRI of the knee be helpful? Thanks!
Rick, I usually joke with patients that if the first MRI didn’t fix the problem then the second one won’t either. Of course MRI’s don’t treat, they are meant for diagnosis, and I’m all for using them when appropriate, but they’re way over-used and many people are misled by their findings. After all, if your MRI says you have a nerve entrapment that doesn’t tell you how it happened, or how to fix it – and many times, especially in the case of low back disc problems, patients have the bulge decompressed or removed and see zero improvement.
You’re looking for a nerve problem but it’s probably more of a muscular problem. Did you check the piriformis trigger points as I show in the video? The foot drop could be from a local muscle weakness or, as you note, from a nerve entrapment. And yes, the foot issue could be causing the glute pain.
(sorry I did not see this comment 2 months ago)
Hello, I see Rick’s foot drop was not caused by a disc injury.I was lead to believe foot drop indicated a definate disc injury – is that not so? I currently have foot drop and sciatic pain diagnosed as L4/L5 disc herniation (no MRI). Initially I couldnt lift my foot against gravity, one week after its onset I can now lift my foot against gravity still have no strength in my big toe. I have been suffering sciatic pain and foot drop following two accidents, the first of which gave me back pain, the second of which gave me excruciating sciatic pain, the foot drop, but my back pain disappeared. (I cannot bend more than about 10 degrees at the waist, or put my left foot out more than about a foot in front of me before shooting sciatic pain comes in. If I approach that painful area slowly, I can also feel a fuzzy numb feeling in my foot).My question, is might my foot drop be caused by something other than a disc injury?
Thank you for your informative video. I am suffering from piriformis syndrome and have noticeable lack of flexibility/range of motion in one hip compared to the other. I experience low back pain and pain that shoots down my leg into my foot. I’ve been prescribed stretching exercises which only seem to exacerbate the problem. I noticed you pushed on the pressure points. Is this something to do on a regular basis to “loosen” up the the muscle and is there anything else I could do to help with this issue? Thank you!
Renee, the trigger point(s) could be on either hip – the tight side or the “looser” side. So you have to check them both. Yes, you may have to treat them more than once but if it’s over and over again then you would need to figure out (or see someone to figure out) why they are there and the muscles are not working properly. Correct, I would never stretch them out.
(sorry I did not see this comment 2 months ago)
I fell on ice two years ago, and after 5 weeks of PT had an MRI (no disc problems)which revealed an ovarian cyst and resulted in a total hysterectomy due to endometriosis. To deal with my piriformis and SI pain (and pain/numbness in my foot) I have subsequently tried chiropractic, PT for pelvic dysfunction, therapeutic massage, injection into my SI joint, more PT, and another round of chiropractic. Unfortunately, I am one of the twenty percent whose sciatic nerve runs through my piriformis. I have been told repeatedly to stretch the piriformis. Now the pain is on both sides. I will definitely stop stretching and see if things will improve.
Okay – no stretching the piriformis. Is it okay to stretch other areas that have tightened up (despite being hypermobile) such as hamstrings, quads, QL, ITB and psoas?
Linda – no, I don’t think you should ever static stretch to treat these areas. Natural movement of the muscles is fine, but if you have to hold and stretch to feel better then you’re simply blocking some pain temporarily and probably delaying the healing. Sorry to hear you’ve seen so many docs and therapists without any success. You’re welcome to come to the Sock Doc office. It is most likely not a coincidence that you have hip and lower back problems and have had significant hormonal problems. There is a direct muscle relationship between the uterus/ovaries and all the muscles of the pelvis. Sometimes, even with a total hysterectomy, the pain just doesn’t disappear as quickly as the surgery removes the problem organs.
Thank you so much for your reply. (I’m disappointed in myself – that I didn’t listen to my body months ago when I felt better after a short period of not stretching.) Found your bio very interesting as I have said repeatedly that my body – from foot to neck – hurts more as soon as I put my shoes on. (Including those that are “good” for my feet – not high heels, pointy toed shoes, etc.)
I didn’t have the pain in my foot, back. hip and SI joint until I fell (getting out of the car – direct force to my right buttock)- felt that the trauma caused my pain. But hormonal changes could be contributing to my problem?
Certainly wish I lived near Chapel Hill. Haven’t been able to find anyone who can get me back on track – and I would love to be able to road cycle again.
Thank you again!