Thinking about piriformis, and the advanced p. stretch

[Kit_L]

Talking about the advanced piriformis exercise, I think what most anatomists don't get is that the medial attachment of p. extends from the top to the bottom of the midline of the sacrum, so spanning 2+ inches, and can be considered one side of a triangle; the greater trochanter attachment, by comparison, can be considered a 'point', in thinking about this in terms of complex, 3D movement. 

 

To get the leg into the starting position requires both flexion and external rotation of the femur in the hip joint, I believe. What makes the real difference between this p. exercise and all others is that the sacrum is moved ~90 degrees (if you can do it completely, as in lie on your front foot), in comparison to the p. exercises where the femur is moved across the body to the opposite shoulder, because in this latter movement, the 'point' attachment pulls more or less evenly on the whole muscle.  In the advanced movement, in comparison, the upper fibres of p. are stretched more than the lower fibres (because WRT to the greater trochanter point, the top part of the sacrum moves so much further than the bottom part in the exercise's movement), so that the shortening that external rotation necessitates in the first instance is completely overcome by the whole movement, and the movement becomes a serious stretch (as everyone who has tried the movement knows!). 

 

And (this is a separate important part) anyone with p. syndrome has the muscle pierced by one or more nerves—and it is this differential stretching effect between the upper fibres and the lower fibres that provides the tangible relief to this problem, I believe. Of course, this is a massive simplification and does not take any possible fascial adhesions into account, but it does provide a new way of considering from which process the indisputable therapeutic effects arise. 

 

And for all exercises requiring movement of the pelvis WRT the femurs (sitting for meditation, sitting cross legged, tailor pose) where hamstring and adductor tension are not a major limitation to moving the pelvis (because the knees are bent), any resistance to movement of the pelvis is compensated by lumbar flexion. This is because p. is limiting the pelvis movement through the identical mechanism (upper fibres will not allow anterior pelvis tilt. I see this on every retreat: beginners who simply can't sit upright. And this effect is compounded by tight hamstrings and adductors when sitting in the starting position of the pancake and the pike—and we see this in all the beginner's photographs posted here—again (though with additional limiting factors) they cannot sit upright. 

 

I feel that sieging p. and experiencing pelvic movement (as Olivia has been suggesting for years) is a fundamental part of the acquisition of pike and pancake, through the experience of the movement of the pelvis in its least restricted position. Once this has been felt, the same movement can be more easily acquired in the more difficult movements. 

[[DW]]

"so spanning 2+ inches"

 

If I recall correctly, from the Chiba et al article (which I had the NLA pull out of archive), it can (in some specimens) extend up to 4 inches and onto the inside of the lumbar-sacral junction.. I'll try and find the article and edit if incorrect.

[terje]

Kit, that was very educational for me. Thank you.

[Kit_L]

Dave: brilliant. And today, while doing this same exercise, I realised that there is a substantial twisting of these same fibres through the sacral movement, so if this attachment line is closer to 4", this strengthens the argument, I believe (the base of the triangle is widened).

[terje]

Kit, following your advice on another thread I have been working on this stretch lately. Working on the correct alignment is quite a challenge and its "doing a lot of things" in my hip region. I have the impression that, somewhat counter intuitively, it seems to help internal rotation as well (such as in the hero pose - i.e. when hips are flexed). Is that your experience too?

[Kit_L]

Terje, re. "hero pose"—do you mean virasana? If so, the femurs are neutral (these determinations, by convention, are WRT to the standing "anatomical position"), I believe). In some women there is a small amount of internal rotation, but in men, the front of the thighs are pointing to the ceiling.

 

On the other hand, loosening p. does make virasana easier, not because of internal rotation, but because this allows the pelvis to tilt anteriorly (until sacrum is vertical) more easily (and the same benefit flows to all sitting poses).

[terje]

Kit, yes, that's the one. Right, in retrospect I should have used as an example the hurdle stretch with knee completely folded and beside the stretched out leg, or the 90/90 stretch (emphasizing the back leg).

[Kit_L]

Yes, that's completely accurate, for some people: when you loosen the external rotators, anatomical logic says that internal rotation must be improved (internal rotation being limited, in this model, by external rotators). But (there's always a but!), in me, with very loose external rotators, internal rotation had not improved that much; using the internal rotation exercise from the bottom of the squat position has really helped this though. 

[terje]

Kit, I have all your programs, but I am not sure what you are referring to in "the internal rotation exercise from the bottom of the squat position has really helped this though". Sounds like something I should try! Also, how do you know that your external rotators are loose when internal rotation is limited? Just trying to learn.

[Craig]

The exercise is basically this:

 

go into a full flat footed ATG squat.  Your feet need to be reasonably wide.  Shift your weight so the left leg is taking most of it.  drop the right leg inwards as if you were trying to use your right knee to touch your left toe.  You should roll over the arch of the right foot when you do this, and the heel, the whole inner line of the foot and the big toe should remain in  contact with the ground.  If you have decent internal rotation, you should be able to lie the entire lower leg on the ground so that the knee, inner calf, ankle, heel, arch, and big toe are all lying on the ground.  Then repeat with the other side.

[Ciaran]

**Moved from Kit's ballistic thread**

 

@Kit -- I am getting quite a bit of discomfort on the lateral side of my knees when doing this. following the directions my top leg is probably more at 100 degrees, i don't think i can actually get it to 90 physically due to limb lengths. IF i i put the resting leg further onto my knee to reduce the lever, then no knee problems but a significant loss of stretch! thoughts? *This was yesterday*

After today's session I got a pop in the left lateral side of the knee. Feels fine now in chair sitting, but there is discomfort/ache in standing around the joint line (on both knees, especially left lateral knee). Sitting cross-legged is a no go. (knee pain bilaterally on lateral side). On palpation, definite tenderness and lasting pain, once pushed, on the fibular insertion of the lateral collateral ligament of the left knee (about where the 'pop' was). I'll see if the discomfort/pain is gone in the morning and report back, I can't imagine it would have been enough force to strain the ligament.

 

Clearly this position is putting some sort of varus force through my knee, opening up the lateral side. I don't know if this is because my piriformis are exceptionally tight, or just tight hip musculature in general not allowing me to flex forward significantly at the hip during the ballistic movement (results in some bouncing with the support leg). I'll have to experiment with some less advanced piriformis stretches and see if I can bring the ballistic element to it if this persists.

 

EDIT: This is in relation to the Hawaiian squat variation (example).

[[DW]]

[Craig]

the set up with multiple piercings looks inauspicious :S

[Frederik]

Dave: are you trying to say that the peroneal part(or some variation hereof) of the sciatic nerve might be involved in this gentleman's problems?

[[DW]]

Dave: are you trying to say that the peroneal part(or some variation hereof) of the sciatic nerve might be involved in this gentleman's problems?

No.  It may be, I am not sure. I am simply posting some images from the article I mentioned earlier up in the thread because they are interesting in relation to piriformis entrapment in general. 

[Ciaran]

The site of pain doesn't intersect with the common peroneal nerve pathway. I can definitely find the nerve around the fibular head, with a nice tingle in the foot when i give it a flick! In fact with some further poking around, the specific site of pain is actually on the tibia right next to the proximal tibiofibular joint. Can't think of anything that attaches in that area. Maybe some retinaculum or strands from the ITB, maybe. Varus stress test gives no pain or laxity! No reaction when mobilising the fibular head either. Shit is a bloody mystery man! Maybe some fascia got yanked off the bone lol?

[Kit_L]

Consider this: in any movement you want, if there is a muscular restriction (so, causally, neural/fascial/patterning/simple tightness), some other part of that joint chain must yield. And to stretch piriformis in the squat position (so beautifully described by MH) or in the adv. P. stretch, there is considerable torque on the knee, plus a lateral force, IF the hip joint does not allow the movement easily. This is why I recommend to students to master the sitting p. exercise first, because none of these forces exist in this exercise.

 

So (@Cregan, now), think about the movement that created the pop—what you describe is likely fascial in origin. Now I know that I might be open to criticism in saying this (because the fascial system seem to be the current era's "residual category—where anything you can't explain goes) but my recent experiences with stretching (wherein there was much more soreness in the structures adjacent to what I thought I was stretching, using the standard anatomical descriptions) leads me to make the following points:

 

Very often what we think (using the standard models) we are stretching we are not, and

 

Exercise real caution when levering a hip stretch via the knee joint. 

[Ciaran]

@Kit -- thank you for the reply. before responding i'll describe my experiences today. the pain is till in a very specific spot but has lessened since yesterday. The only movement that is currently restricted (by pain) is inner active knee flexion. Passive knee flexion is painfree. After playing with some mobilisations of the proximal tib/fib joint I am finding that an AP glide of the fibular head reduces pain considerably with active knee flexion. It is quite the opposite with a PA glide.

 

My current thoughts are aligned with yours, that it is fascial in nature, given the painful site lies between two anatomical points where there is supposedly no significant attachments. I am assuming there must have been some adhesion around the tib/fib joint and Gerdy's tubercle (ITB attachment). Once it has settled it will be interesting to compare the left to the right side as I can now feel tightness in the same area on the right.

 

More caution will certainly be given in the future! I was finding there just wasn't enough of a stretch anymore with the sitting piriformis stretch from the 'Daily 5'. I had moved on to the the advanced sitting version but I admit, I was extremely tempted to try a ballistic version as I can feel that a massive release is near (especially on the left).

 

Can you recommend any other versions that may allow a ballistic movement but at the same time, maintain stability around the knee? After some thought, I am going to try the advanced seated version (i will reference the pg. number from the book when i get home), with the ballistic action coming from the trunk and hip flexion OR I might try a similar stretch position to the Hawaaiin squat but instead have the leg up on a ledge, at hip height, so that the whole leg is supported.

[Ciaran]

*Just an update*

 

I am now feeling normal (or back to pre-injury self). That was about 3-4 weeks, so follows with the timeline for tissue healing. Must have strained something. Basically, it seems you shouldn't do hawaiian squat ballistics unless you have extensive experience stretching the piriformis already. Go figure. Instead, I have since been doing the basic pose from the daily 5 with 'pulsing' movements combined with C-R.

[perplexed]

Does advanced p pose stretch the front leg adductors in any way? As my torso got close to or started to hit my front foot, the less I felt a piriformis stretch and the more brutal it was on my adductors. After a round of ballistics I'd feel very sore and weak in either my adductors or gracilis  ( can't pinpoint the spot). My legs would feel like jello and i'd have difficulty walking around. Next day I'd be fine, but then I'd have adductor DOMS. 

[Naldaramjo]

3 hours ago, perplexed said:

Does advanced p pose stretch the front leg adductors in any way? As my torso got close to or started to hit my front foot, the less I felt a piriformis stretch and the more brutal it was on my adductors. After a round of ballistics I'd feel very sore and weak in either my adductors or gracilis  ( can't pinpoint the spot). My legs would feel like jello and i'd have difficulty walking around. Next day I'd be fine, but then I'd have adductor DOMS. 

Hi Perplexed,

Interestingly, I was just writing about this in my own mobility log. There are many piriformis stretches where I simply can't feel the piriformis stretching. It feels as if the limiting factor in the movement is the adductors. That said, the chair piriformis stretch, as in the ABSS, as worked well for me (even without the pulling of the knee along the torso).

Also, I've found my groin area muscles to just be significantly tighter than everything else, and for me, that's just a sign that I need to focus on there before I work more intensely on the piriformis directly. 

[Pat (pogo69)]

6 hours ago, perplexed said:

Does advanced p pose stretch the front leg adductors in any way? As my torso got close to or started to hit my front foot, the less I felt a piriformis stretch and the more brutal it was on my adductors. 

I sometimes experience that, too.

But I can always choose the target of the stretch, by playing around with some combination of angle (torso facing more towards foot or knee), and bolster height (I need a bolster to allow the advanced p. to stretch me effectively - for me at my level of flexibility, more is generally better).

[perplexed]

Perhaps the common denominator between us three is tight adductors? My adductors are *extremely* tight. Even though my piriformis is on the looser side now, my butterfly stretch is horrible due to my adductors, and my middle splits are horrendous. The advanced p. stretch is my absolute favorite piriformis stretch. I agree with you pogo about changing the angle, but once my chest moves past the midshin toward the foot, my adductors get brutalized, haha. I guess we have to work on groin flexibility more as well!

[Pat (pogo69)]

22 hours ago, perplexed said:

Perhaps the common denominator between us three is tight adductors? My adductors are *extremely* tight. Even though my piriformis is on the looser side now, my butterfly stretch is horrible due to my adductors, and my middle splits are horrendous. The advanced p. stretch is my absolute favorite piriformis stretch. I agree with you pogo about changing the angle, but once my chest moves past the midshin toward the foot, my adductors get brutalized, haha. I guess we have to work on groin flexibility more as well!

It certainly is a problem area for me!

My Tailor Pose is disgraceful.

Also discovered a gracilis issue during my last trail race.  I experienced truly awful cramping in my adductors for most of the race.  That triggered a tendinopathy in the medial left knee area.  Turns out it was excessively tight, overworked gracilis - they REALLY hurt when the physio applied minimal pressure.  Physio did some dry needling on them and it let go almost instantaneously.

Re: piriformis.  I'm not at the stage where I need to (nor indeed can) lower my body that far, so I may have a little more time up my sleeve!

[stankanovic]

Hi there! i have been doing the advanced piriformis exercise with support a lot recently and have added a third contraction which has been quite useful for me to get deeper into the stretch, basically trying to lift the front foot off the ground and use that contraction to pull myself further down, anyone try something similar?