Understanding The Piriformis Puzzle
This week on the Unreal Results podcast, we’re going to put together the puzzle that is the piriformis. The piriformis is classically known for its stability of the hip but also for being the “cause” of a lot of problems around the hip and beyond. In this episode, you’ll hear about piriformis anatomy & biomechanics and how they relate to effective assessment and treatment of the piriformis. You’ll also hear specifics regarding why clamshells aren’t bad, closed-chain exercise benefits, and the connection between the piriformis, pelvis, and sacrum.
Resources Mentioned In This Episode
Episode 6: The Mysterious, Misunderstood, & Mistreated SI Joint
Episode 54: A Better Way To Assess The SI Joint
Episode 93: Lateral Line Love
Exercise Video: Pelvic Leveling To Prep For T Hip Mobility
Exercise Video: T Hip Mobility
Exercise Video: SL RDL w/ Band for Cueing
Journal of Biomechanics Article by Delp
Blog "stretching the piriformis"
Blog "Relationship Between the Pelvis and Piriformis"
Blog "T-Hip Mobility"
Blog "A Knee of an old, unlucky running back"
Learn the LTAP™ In-Person in one of my upcoming courses
Considering the viscera as a source of musculoskeletal pain and dysfunction is a great way to ensure a more true whole body approach to care, however it can be a bit overwhelming on where to start, which is exactly why I created the Visceral Referral Cheat Sheet. This FREE download will help you to learn the most common visceral referral patterns affecting the musculoskeletal system. Download it at www.unrealresultspod.com
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Anna Hartman: Hey there, and welcome. I'm Anna Hartman, and this is Unreal Results, a podcast where I help you get better outcomes and gain the confidence that you can help anyone, even the most complex cases. Join me as I teach about the influence of the visceral organs and the nervous system on movement, pain, and injuries, all while shifting the paradigm of what whole body assessment and treatment really looks like.
I'm glad you're here. Let's dive in.
Hello, hello. Welcome to another episode of the Unreal Results podcast. I, I laugh at the beginning because I've changed the lighting in here. I've changed door open, door shut, which I guess is technically changing the lighting. I just moved my microphone away around. And then finally I was like, maybe it's the color shirt I'm wearing.
So then I switched to this gray top. Um, I don't know. I just, sometimes it's like, also I'm using a new camera, so I gotta get used to like, the video and the lighting. This is, third world problems where you're like, really picky about the video, like I wish I could put a filter on it, but whatever. Um, here we are.
Um, the last episode I filmed, I talked about the lateral line. It was called called lateral line love. And I was like, Oh, we'll link in the show notes, this episode about the piriformis and you can learn more. And then Joe was like, Anna, I don't think there's an episode. He's like, if there is, I'm not sure which one it is.
Could you help me out? And I looked through our episode list, which is a lot of episodes so far, like almost a hundred. It's how exciting is that? Um, And yeah, sure enough, uh, it wasn't there. And so I'm sure that I've talked about it inside other episodes that weren't specifically about it. And we linked those in the show notes of that episode.
But then I was like, wow, I guess that performance episode is just like literally in my head still. So surprise, surprise. That's what this episode is about. So just going to go over briefly a little bit more about the performance that I touched on in the last episode. So if you haven't watched or listened to that yet, it was called a lateral line love and you're going to want to.
Listen to that too. So, but, um, so if you, if you're a longtime listener, you've probably heard me talk about one of the first ever continuing education courses I took as a professional. And it was, um, I think it was like, it was either 2003, 2004, or 2005. So either way, it was about 20 years ago. And I lucked out and, um, went to these great manual therapy, assessment and manual therapy courses, um, that were technically like muscle energy courses, but the instructor was excellent.
And some of the things he taught me, really, I continue to use to this day, 20 years later, which I think is pretty freaking phenomenal. But one of the biggest things to come out of that course, was an understanding on the anatomy of the piriformis and Its relationship to the spine as well as the hip so piriformis pretty famous muscle it is classically known for its role in hip stability.
Almost, um, referred to as, not almost, it is referred to often as one of the muscles of the rotator cuff of the hip. So it is a rotator of the hip as well as a centrator of the hip. So it helps to center the femur in the hip socket. And it is, um, blamed for a lot of problems and it's targeted by a lot of exercises.
So nowadays, this day and age, clamshells get a really bad rap. Um, people still use them, but a lot of people, at least in the social media world, are like, Stop doing clamshells, don't waste your time. And I'm like, mmm, just do them right. And understanding the function of the piriformis and the other hip rotators, to be honest, um, allows that
exercise to be done better and you get more out of it. Any exercise not done right is kind of a worthless exercise. So I don't know why we're just saying that the performance is bad and then people are like, Oh, do more integrated exercises, isolated exercises. You're not helpful. Hard disagree there.
Isolated exercises can be very helpful. Um, they just shouldn't be your only thing you're doing. And then just because it's an integrated exercise, something that is, um, looking more like a fundamental movement pattern or a functional pattern doesn't necessarily mean you're using your deep stabilizing muscles or even your superficial stabilizing muscles.
It doesn't mean that you're doing it Well, and that, and this is kind of like what I talked about last week is in terms of like a lot of times most people, athletes, 100%, but most people too, um, sort of cheat good single leg stability. And so you don't realize that there's a weakness there because you're not paying attention to the right things.
So part of that, um, really goes back to this, um, a deeper understanding of what the piriformis, where the piriformis originates and attaches and then how its actions change with different ranges of motion of the hip from extension through flexion. So, and even though, um, the hip is a very mobile joint and should have some hip extension on most people.
Like even normal hip extension is only 10 degrees of extension. So, um, maybe 15 in some of the literature that you read, but it's like if I see somebody with that can get to zero degrees, I'm happy. 10 degrees would be a plus. Um, so just also remember when we're talking about hip range of motion, most of the time, I mean, we're talking about degrees of flexion.
and then a little bit of extension. So anyways, um, as the hip moves through those degrees of flexion, the role of the lateral stabilizers and external rotators and internal rotators often change. And so understanding this can be helpful. Now going back to sort of what I talked about that first class that I took from Pete Emerson, I want, I always want to say Pete Mitchell, but that.
Anybody know who Pete Mitchell is? That's Top Gun. That's Maverick. Um, so it's not Pete Mitchell, uh, Pete Emerson, I believe was his name. But anyways, what I learned from him, we were stretching the piriformis. So the reason why we're stretching the piriformis in this muscle energy techniques course was because we learned that sacral torsions, specifically forward sacral torsions are soft tissue issues, meaning it's not a true joint thing.
It is just the soft tissue being sort of tight and dynamically holding things in a certain position. And that happens to be the because of the role the piriformis plays in our gait. And it's roll in trunk rotation and trunk lateral flexion and understanding that role of the piriformis and gait allows us to One, assess it better, but then two, um, actually stretch it when we're stretching it.
So one of the, like one of my big pet peeves is people are like, Oh, your piriformis is tight. Let's do all the figure four stretching in the world, or let's do all the pigeon pose in the world, which is great, but also it, it could be better if you understood the mechanics of the piriformis a little bit better and the relationship to gait.
So as we're walking, one of the things that helps or that is part of the rotational pattern because I don't want to say it creates the rotational pattern because if you've heard me talk about gait before we know it's actually the motion of gait the rotational locomotion pattern is actually created in our trunk not our legs our legs amplify it but this rotational connection especially to the sacrum and grab sacrum here
When the sacrum rotates, that's what's referred to in sacral mechanics land as a torsion. The thing that rotates it, to one side, is the piriformis on the opposite side. That's part of it, right? I said it's coming from the trunk. But what happens to the piriformis, and this is where, like, understanding its origin is helpful, the piriformis then, like, Shortens a little bit if that makes sense.
So it rotates it that way
Okay, now if you saw my face just now I was like, oh my gosh Interesting is that so it's the opposite. Oh my gosh, what is happening?
This is what happens when you start teaching and when you start looking at it, you're like wait I was I've been doing it backwards doesn't matter They work together.
If it's a right forward sacral torsion, it's usually the left that's tight.
So, it must be driven. See, this is how you work through anatomy. So, it must be driven by more of the posterior fibers of the piriformis. Woo! Tough. Which, we need the ilium for that. They attach to the ilium that level of the PSIS, this guy, and then attach to the greater trocanter. They also attach to the sacrotuberous ligament.
Sacrotuberous ligament goes from the sacrum to the tibial tuberosity. So that is the, one of the attachments, one of the origins of the piriformis. The other origin is the anterior part of the sacrum. This is crazy. My brain is like, wow, I never really thought about it like this. But when you have a, going back to the rotation, when you have a torsion, we'll say right torsion.
So when this trunk rotates to the right, The piriformis on the left is helping that part of what's happening too is when you rotate to the right in that single leg stance, your hip abductors and the piriformis has to lift up the opposite side of your pelvis as it comes up and forward and rotates to the other side.
So the piriformis is one of the main muscles that does that helps out the rotation as well as creates side bending of the lateral, sorry, side bending or lateral flexion of the spine. It does this main thing through this anterior attachment because it comes so close to the midline here on the sacrum.
It, it along with the ilium and the glute medius and glute minimus do this action of the sacrum, and if you can imagine the rest of the spine, it's taking the tail to the right, so the opposite way. So it's creating contralateral lateral flexion as it. It then switches legs and goes to the other side. So this is sort of what your sacrum and your pelvis is doing through the gait cycle.
Now as I talk this through, I'm realizing, yeah, if you're listening to this, you might want to head to YouTube and watch because I have a bone model out and I'm kind of showing you what's going on. But, when you start to consider even, even if you're not watching this and you're just listening to this, I hope you realize that then it makes sense why maybe clamshells are not the only thing we can do to help strengthen this muscle or help mobilize this muscle.
Um, it is a piece of it because the muscle is more complex and it has a lot to do with also is the leg fixed on the ground as described of now the function through the gait cycle or is the leg more open chain and not fixed to the ground when the leg is more open chain then it's different now instead of the action being on the sacrum the action is going to be on the leg in the hip joint itself, which even when it's acting on the sacrum, it's still affecting the hip joint, obviously, because it's crossing the two, but it's a little bit more about what's happening at the spine and the pelvis versus just at the hip joint.
Because now we're looking at the hip joint, even in a different scenario, we're looking at pelvis on hip motion in rotation and extension and flexion versus um, hip or thigh on pelvis motion. Understanding and being able to coach people through, assess or treat. Both of these relationships is so important.
You can't just look at hip flexion, hip, internal, hip, external rotation, only in closed chain. You have to be also considering it in, in, um, sorry, in only an open chain, you have to be considering it also in closed chain because most of the time that's how it's going to be functioning. Whoo. This is, I'm like, side note this is like why it's important to look at the anatomy look at the bones like think about how it works in the body because You're you would be shocked at how often you just take someone's word for it when you're learning an exercise or you're learning an assessment of like Why things act the way they do and unless you're reading more of the biomechanics or unless you're reading more like research on it.
Like, you gotta always go back to the anatomy and this is also like why so many of these podcast episodes like we do go back to it. And, um, Yeah, this blows my mind. So going back to that muscle energy course, the profound thing he said was when you are stretching the piriformis, instead of doing it in a figure four, You want to make sure one thing is happening, which is the most important, and it is the thigh is crossing or on its way towards the midline.
And I talked about this in that lateral line love podcast a lot, how important hip adduction was. That was the whole point of the lateral line. conversation. But when we're stretching the piriformis, we want to make sure even, let's say we're stretching it in your classic, like figure four type of stretch.
You want to make sure the thigh is across the midline. This is why the pigeon pose tends to be a little bit better of a stretch for the piriformis is because if it's done correctly, it brings the knee to the midline and it holds the knee to the midline. And that's a really important part because as you add external rotation, to stretch the piriformis.
If they're tight, oftentimes you'll see their thigh drift away from the midline. And this is like a game, you know, like a teeter totter game, which is why you got to hold one side still. Now to further improve the stretch, um, um, experience, he suggested adding in trunk or pelvic lateral flexion with a hip hike.
So when you're stretching the piriformis, let's say you're stretching the right, we're bringing the right leg to the midline at 90 degrees of hip flexion or above, then adding external rotation of the thigh. And then we're hip hiking to the same side. What this hip hike does is it basically creates a contract relax or a hold relax type of PNF
situation. And helps us to sort of inhibit the piriformis by this antagonist agonist relationship that the QL has with the piriformis. So with the, um, QL, the same side, the same side is a, Antagonist, the opposite side is a synergist. And this is what we talked about in that last episode, talking about how we're looking at single leg.
We want to look at is their pelvis moving into lateral tilt or hip hike or lateral flexion, whatever you're talking or you're talking about it, however you're talking about it. So understanding this one allows us to be more specific with that stretch, but then it also allows us to take that idea of the role of the piriformis plays in lateral flexion and utilize it to our advantage in exercises that we're trying to centrate the hip, mobility and this is like one of my favorite things is just like the rotator cuff in the shoulder when we can get the rotator cuff in the shoulder to turn on it helps to centrate the joint and it actually increases mobility into internal and external rotation as well as flexion.
Same thing happens in the hip when we can really get things to turn on and lengthen. So right, right. So that full range of muscular, um, expression, eccentric, concentric, then now the hip sinks in the socket a little bit better. And then it actually improves our hip mobility and our internal external rotation range of motion, which then we're going to get out of the exercises.
So clamshells done well, single leg balance done well, single leg RDL done well, not only can potentially strengthen the hip but improve our mobility as well in a very like specific like, oh, like inferior posterior glide aspect, which is so great.
So how do I assess the piriformis? Um, from a mobility standpoint, I'm looking at it at And this is kind of where I talked about, like, as your hip flexion changes, the function of the muscle changes. So this is best described in this article in 1999 in the Journal of Biomechanics by DELP. D E L P. I'll have Joe link that in the show notes.
But um, what we learn there is that, and this is like, this is not new, it shouldn't be any new information. But, And I kind of talked about it if you, if you were following me on that analysis of the gait and the differences in open chain versus closed chains, I already talked about it, but basically when the leg is in neutral, zero degrees of hip flexion or extension, the piriformis is a powerful external rotator and hip abductor.
And it works alongside The glute medius and the glute max as a hip external rotator and hip abductor. As we move into hip flexion, the action of the piriformis changes into being a hip internal rotator and hip abductor.
So, when we assess it, I assess it in a supine position with passive hip adduction and passive hip internal rotation. And then I also go into 90 degrees of hip flexion and now I test it with hip, um, external rotation. Right? So I'm checking internal rotation at zero and external rotation at, um, 90. Okay.
And you can look at it in prone too if you don't like the supine position, but I prefer supine because a lot of times when somebody's laying in prone, they actually don't have that much hip flexion and so you're getting kind of like faulty information. So Those are good indications. If anything too, I feel like the hip adduction piece is a little bit better of assessment.
And then two, I'm looking at the sacral torsion. So I am looking at that in prone, but I can, um, put pillows under if they don't have full hip extension, but I'm looking at like, what's happening in their sacrum too. Do they have a forward sacral torsion? And you know, you have a forward sacral torsion when the sacral sulcus on one side is deeper than the other, but then they go up on their elbows, they move into extension and it goes away.
That's a true forward sacral torsion and the piriformis is implicated in that. Now I'll also check hip adduction in that supine hip flexion at 90 degrees too, because I want to get an appreciation of like, is this just performance or is there some glute max resistance as well? I'm always kind of trying to weed out like what muscle this is.
And that Delp article is a really helpful article to sort of like think through all the different pieces because of the 18 hip muscles there, 15 of them reverse their action from external rotator to internal rotation as you move through hip flexion.
So let me check my notes and make sure I like shared everything I want to share about this. We talked about how it's a lot of reflection of the spine along with glute mean and glute minimus, um, Fun fact about glute med, the anterior fibers are an internal rotator. Um, so when it's just using anterior fibers, you're going to see hip abduction and internal rotation, which we talked about that during the lateral line love thing is it's like one of the, movement dysfunctions that I'm looking for.
I want, when I'm testing just true hip A-B-duction, I want the whole shebang. So I shouldn't see internal rotation. I see internal rotation when the anterior fibers are dominating or TFL is dominating, which they kind of go together. They're actually innervated by the same nerve too. So that makes sense. Um, we talked about the, um, test positions.
Um, with hip flexion at zero and at 90 and how that changes. We talked about how the hip, how it is a centrator to the hip joint. This is not on its own. This is along with glute min, minimus as, and the glute minimus and the rest of the deep hip rotators, which I like the mnemonic P go, go Q. So P is the performance.
Go is gemelli superior obturator externus and then gemelli inferior obturator internus, and the Q is the quadratus femoris. So those are the hip rotators. They are all centrators of the joint because they attach from either the sacrum and the ilium to the greater trochanter. The piriformis is innervated by two little spinal nerves from S1, S2.
The anterior rameae of the spinal nerves make up this nerve called the piriformis. Nerve to the piriformis. Um, so I find that in, well, I don't know if I find that interesting. I just find that interesting that it's like a very high up on the sacral plexus and, um, the spinal nerves. So it, it, it is not actually part of the nerves that are integrated with the lumbo sacral plexus.
It's just the sacral plexus. Um, we already talked about the origin, but just to reiterate, it's the anterior surface of the sacrum between S2 and S4, and then the gluteal surface of the ilium near the PIIS as well as the sacrotuberous ligament. So those are powerful parts of what creates some of that torsion as well, though the lateral flexion is probably more driven from
the anterior fibers of it. It attaches, like I said, to the greater trochanter. It's, um, arterial supply is the gluteal, superior and inferior gluteal artery, as well as the internal pudendal artery. And so, um, you know, we talk about pelvic floor stiffness quite a bit, and this can affect the performance, right?
Because if the blood flow is affected, it's going to really affect function of the muscles. And so, um, you know, Um, and then we often talk about, I'm not sure on the podcast, but we talk about the piriformis as a possible, a common entrapment site, entrapment site for the nerves to, and vascular structures to the lower extremity.
And you actually have entrapment sites on both sides of the piriformis, the superior side or the suprapiriformis. area and the infrapirformis area. The piriformis itself sort of cuts the greater sciatic foramen in half and the contents that go above it, the suprapiriformis part of the greater sciatic foramen are going to be the superior gluteal artery, the L4 through S1 nerve root.
And then inferior is where the majority of the things are that commonly get entrapped. Most famously the sciatic nerve, the inferior gluteal nerve, and the posterior cutaneous femoral nerve. So a lot of these, these ones are big, um, symptom drivers in what creates, you know, quote unquote performance syndrome.
And then, um, the pudendal nerve actually comes, um, out of this area too, as it goes, it travels out and then it goes back in the pelvis to the saddle region. Um, as well as the last thing, the nerve to the quadratus femoris. So, if you've listened to any of my podcasts on the SI joint, you know too that a lot of those nerves that I just talked about are also nerves that innervate the SI joint.
So, this too is another reason why piriformis function tends to drive, um, some SI joint mobility stuff. And going back to that kind of concept, if, if you have listened to those SI joint, um, episodes, which we'll have Joe link in the show notes, if you didn't, the SI joint is very, um, one of those joints that's hypo mobile because of strategic things.
A lot of times, 75. I'd say 75 percent of the time is driven by viscera and the nervous system, the central nervous system. And when you look at the anatomy, it sort of starts to make a little bit sense, too, of why we have such a sensitive, um, relationship between the viscera and the SI joint. Because, too, um, and the hip joint, because the piriformis, that, those anterior fibers of it, it's inside the pelvic bowl.
So it is intimately connected to the fascia that's holding all the organs in space. So it's no surprise that the piriformis can be inhibited, and inhibited meaning not turning on well, or. And so it's just like one more piece of anatomy of like why we know and why we assess the role that the viscera and the central nervous system has in this process.
on the musculoskeletal system. So, um, you know, the next person that comes in with, you know, quote unquote piriformis syndrome, like, I hope you think like, Ooh, what could this visceral be viscerally been driven by? How does this affect their lateral line? And is there a central nervous system component to that?
Like we talked about during that lateral line podcast episode. And then how does this relate to some of their orthopedic tests in their lower extremity? And how am I going to cue this in their exercises to get more out of the exercise? So When I already talked about it in the lateral line thing, but what I didn't talk about, I just talked about in the relationship to the single leg balance.
But when you take it one step further and you think about like a single leg RDL, it's one of my favorite ways to get at this piriformis, hip centration, hip stability component. And the first thing I have people do is learn how to draw that pelvic. the pelvic leveling or the pelvic unleveling we talked about in that previous podcast episode about driving the foot into the ground and letting that initiate the contralateral side pelvis lifting and the best way to teach this and it cleans so much stuff up in the single leg RDL think about how many times you've tried to cue people to square up their hips to straighten their leg or to keep their knees soft to like Not twist around like a, you know, a windmill and if you put a band on their other leg and opposite shoulder.
It helps to facilitate that lateral flexion to the opposite side and it sinks them in that hip and it allows for them to go through that full range of hip flexion with really good rotational control. And if you're adding in like a T hip mobility or a warrior three aspect, Oh my gosh, it's so easy for them now.
And then all you have to really pay attention to is keeping their length on the. side of the leg that's moving in the trunk and side bending on the opposite. And it cleans people's movements up so good. So I've shared that exercise on Instagram. So I'll make sure Joe links that in the show notes so you can see that too, as well as the single leg balance video on Vimeo I have.
So I get excited as you can tell, like, this is like so good because the better you can understand this, the simpler the exercises are. And then. Man, the sky is the limit for the client taking this movement pattern into everything they do and maximizing the most out of the strength and the mobility and that kind of thing.
So, but we can't forget, like I said, those initial pieces of first determining it, right? Using the LTAP to determine like, is this a visceral or nervous system reason why things are not moving well? What? What? activating well and then knowing how to assess it, knowing how to, um, treat it. We didn't even talk about the manual therapy options for it, but, um, starting to see, like, just from a movement standpoint, there's so many ways that we could get really specific with it.
Besides clamshells, though, I'm a big clamshell fan and I'm going to link that tutorial in the show notes too, just so you can see how to use it correctly. And. using the same concept. So you're going to see in that video how I use these same concepts of what's going on with the spine and lateral flexion and how that can like, significantly improve the movement experience.
And then I have one blog post on the piriformis stretch. Um, so if you want to add that in, you're never going to have to do figure four again. It's great. So anyways, that's it. I hope you, um, Um, had a great Christmas, and I think this episode is going to drop on New Year's Day, so enjoy New Year's Day, and go Ducks, because we're in the Rose Bowl.
Alright, see you next time.