by Dr. R. Turchaninov, MD and Dr. P. Novakovic, MD



This is the final part of the article about Piriformis Muscle Syndrome and we will now discuss the step by step application of MEDICAL MASSAGE PROTOCOL using the Video Library.

Before the presentation of MEDICAL MASSAGE PROTOCOL we would like to mention one more time that the clinical pictures of Piriformis Muscle Syndrome and Sciatica can be similar to that of Lumbalgia (lower back pain). In such cases, the L5 spinal nerve can be irritated by tension or spasm in the erector spinae muscle, short rotators or by inflammation in the sacroiliac joint.

Chronic irritation of the L5 spinal nerve will produce a reflex spasm in the piriformis muscle, with a subsequent development of a similar peripheral (i.e., leg and foot) clinical picture to that of Lumbalgia. Thus, the practitioner should examine the L5-sacroiliac joint area, and if the patient exhibits pathological abnormalities there, the treatment protocol should address the lower back area first.

The protocol presented below can be partly employed during the initial sessions of the Lumbalgia treatment. However, as soon as the L5 spinal nerve is free from direct irritation, the practitioner must concentrate on the Piriformis Muscle Syndrome protocol exclusively. If there are no signs and symptoms of lower back involvement, the practitioner should employ this protocol from the very beginning.

If the patient has Piriformis Muscle Syndrome, he or she can be positioned flat on the stomach. However, in cases of severe Sciatica, treatment in this position may trigger very uncomfortable sensations. In such cases, the patient should be placed in a special position which allows the practitioner to decreased pressure on the sciatic nerve and renders the treatment more comfortable. Pay attention to the placement of the pillows.

This protocol covers all aspects of the Piriformis Muscle Syndrome and Sciatic Nerve Neuralgia. Be flexible in your decisions. If the patient doesn’t have symptoms of Sciatic Nerve Neuralgia or signs of periostal reflex zones don’t include these treatments into your therapy session.

The duration of a MEDICAL MASSAGE PROTOCOL is 45 min to 1 hour long. The practitioner needs 3 (in cases of simple tension) to 10 (in cases of severe compression of the sciatic nerve) sessions. They need to be conducted with 1-2 days breaks in-between treatment. Please remember that a once a week treatment rarely produces stable clinical results. Therapy needs to be applied in several continuous sessions.

A few final thoughts. At the beginning this protocol may seem a bit complicated. However, this is the only way to obtain stable clinical results, eliminate tension in the piriformis muscle and free the sciatic nerve from irritation.

Such a complicated abnormality requires a comprehensive approach to somatic rehabilitation when all the potential players are addressed. This MEDICAL MASSAGE PROTOCOL which is presented below does exactly that.

The best way to practice this protocol, is at home on a member of the family or a friend, before working on a client. You may also place a computer in the therapy room and use the link at the bottom of the protocol to play all the steps while working on the client. Another option would be to write down a sequence of steps to follow, during the treatment. Good luck!


Step 1. Work on the gluteus maximus muscle
a. Effleurage in the direction of drainage 



Duration: 2 min
Pressure: below the pain threshold

First, the practitioner must release the protective muscle tension which would have developed in the gluteus maximus muscle as a result of irritation of the sciatic nerve by the piriformis muscle.

Start with superficial effleurage in the direction of drainage and later switch to the application of deep effleurage. Notice the change in the practitioner’s position. While applying strong effleurage strokes, use the base of the hand and give each stroke an ellipse-like shape. Strong pressure is applied only when the hand goes forward along the sacrum; light pressure is maintained as the hand comes back to the starting position above the greater trochanter.


b. Kneading of the gluteus maximus muscle



Duration: 2 min
Pressure: below the pain threshold 

When applying kneading to the gluteus maximus, be sure to work on all parts of the muscle. Be sure to use correct body mechanics when the practitioner engages body weight into each stroke to take the pressure of the hands. Otherwise the kneading will strain your hands.


Step 2 and 3. Work at the insertions of the gluteus maximus and piriformis muscles
a. Work at the various insertions of the gluteus maximus muscle 



Duration: 2 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

Consider the anatomical landmarks shown in the video: the straight dashed line indicates the edge of the sacrum, while the U-shaped dashed line indicates the greater trochanter. The sacroiliac joint is located at the upper end of the straight dashed line.

Start with the application of friction using compressed fingertips along, and later across, the insertion of the gluteus maximus muscle into the edge of the sacrum. To reinforce the effect of the cross-fiber friction, the practitioner may also use the thumb.

The next area addressed is the insertion of the gluteus maximus into the posterior edge of the greater trochanter. Apply cross-fiber friction there. Pay attention to the position of the thumb during the strokes.

Finally, work at the insertion of the gluteus maximus into the lateral surface of the sacroiliac joint. Apply friction along the fibers of the gluteus maximus and try to push the tissue laterally. Next, change the direction of the friction to cross-fiber friction and increase pressure. If the area is very sensitive, use the compressed tips of the 2nd to 4th fingers; if it isn’t, use the thumb.


b. Work at the insertion of the piriformis muscle 



Duration: 2 min
Pressure: at the level of the pain threshold (first sensation of discomfort) 

The practitioner should work on the insertion of the piriformis muscle into the greater trochanter. Refer to the anatomical landmarks at the beginning of the video: the dashed straight line indicates the sacral edge; the U-shaped dashed line, the greater trochanter; the cross sign, the insertion of the gluteus medius muscle into the tip of the greater trochanter; the circle, the insertion of the piriformis into the greater trochanter.

First, find the tip of the greater trochanter and place the thumb slightly behind where the piriformis muscle inserts into the greater trochanter. At this spot, compress the tissue against the bone and apply friction as shown in the video. Pay attention to the position of the thumb.


Step 4. Work on the piriformis muscle 



Duration: 3 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

First, become familiar with the anatomical landmarks in the area: the dashed straight line indicates the sacral edge; the U-shaped dashed line, the greater trochanter; the circle, the insertion of the piriformis into the greater trochanter; the two solid lines indicate the edges of the piriformis muscle; the black dot indicates the trigger point in the piriformis muscle.

The piriformis muscle is under the gluteus maximus muscle. The practitioner should therefore apply enough pressure to reach the piriformis muscle, however without causing unnecessary uncomfortable sensations which may trigger protective muscular tension.

Start with strong bi-manual effleurage along the piriformis muscle using both thumbs. In the video, the bulk of the soft tissue in front of the practitioner’s thumbs is the gluteus maximus muscle which is pushed up to optimize access to the pifirormis muscle. Concentrate the effleurage strokes in the area of the trigger point (the black dot in the video). If the patient does not have intense pain in the gluteal area or symptoms of Sciatica, it is better to perform this step with the patient positioned on the opposite side with the knee and hip joints flexed and a pillow between the knees.

At the end of Step 4 add the treatment of reflex zones in the piriformis muscle. The video of trigger point therapy and PIR application is shown separately at the end of this protocol (see below).


Step 5. Repeat Step 1 (see above) 
Duration: 1 min
Pressure: below the pain threshold

At the end of Step 5 the practitioner should address the areas of cutaneous and connective tissue reflex zones in the lumbosacral area, if the patient has them. Videos of treatment of cutaneous and connective tissue zones are shown separately at the end of this protocol (see below).

The areas of cutaneous reflex zones associated with the sensations of tingling, numbness, burning pain, decreased or increased local temperature.

The areas of connective tissue zones associated with tension in the superficial and deep fascias: thickening of the skin, decrease of elasticity of the fold of the skin, ‘orange peel’ sign, positive, Dickle’s and Kibler’s Tests, decrease of mobility between superficial and deep skeletal muscles.


Step 6. Work on the thigh. Use this step if the patient has symptoms of Sciatica (Sciatic Nerve Neuralgia) 
a. Effleurage 



Duration: 2 min
Pressure: below the pain threshold

Start above the ankle joint and apply effleurage with unequally distributed pressure all the way up to the gluteal fold.


b. Kneading of the knee flexors and hip adductors 



Duration: 2 min
Pressure: below the pain threshold

Start with kneading the knee flexors, employing protocol #1. Later, address the hip adductors using the same approach. Use correct body mechanics, including body weight, into each stroke.


Step 7. Work on the leg. Use this step if the patient has symptoms of Sciatica (Sciatic Nerve Neuralgia) 
a. Effleurage 



Duration: 1 min
Pressure: below the pain threshold

Repeat strong effleurage with unequally distributed pressure.


b. Kneading of the leg muscles 



Duration: 2 min
Pressure: below the pain threshold

Apply kneading of the leg muscles.


Step 8. Work along the peripheral nerves of the lower extremity. Use this step if the patient has symptoms of Sciatica (Sciatic Nerve Neuralgia) 
a. Friction along the sciatic nerve 



Duration: 1 min
Pressure: below the pain threshold

Anatomical landmarks: the two dashed lines indicate the upper and lower edges of the piriformis muscle; the solid line indicates the pathway of the sciatic nerve; the dashed line indicates the tibial nerve; the dotted line indicates the common peroneal nerve.

Apply friction along, and later across, the pathway of the sciatic nerve. Do not apply deep pressure. After friction, and apply electric vibration along the sciatic nerve.


b. Friction along the tibial and common peroneal nerve 



Duration: 2 min
Pressure: below the pain threshold

Apply friction along, and later across, the pathways of the tibial nerve and the common peroneal nerve. Do not apply deep pressure. Also, pay attention to the pathway of each nerve. After friction, apply electric vibration along each nerve.


c. Treatment on the therapy point of each nerve 



Duration: 3 min
Pressure: below the pain threshold

Apply, separately for each nerve, a combination of circular friction, manual vibration and electric vibration on the therapy point for the nerve — sciatic, tibial and common peroneal, respectively. Electric vibration is preferable. Don’t use strong pressure. Each therapy point is shown in the video as a black dot.


Step 9. Passive stretching of the piriformis muscle 



Duration: 1 min (4-5 stretches)
Pressure: below the pain threshold

Use the diagnostic test or Bonnet’s test to passively stretch the pirifomis muscle during the patient’s prolonged exhalation. The practitioner should passively re-create four movements in the knee and hip joints in order to isolate the piriformis muscle: flexion of the knee, adduction of the hip, medial rotation of the hip, flexion of the hip. Another way to stretch the piriformis muscle is to employ the second part of the PIR protocol which is presented below.


Step 10. Stretching of the sciatic nerve 



Use this step if the patient has symptoms of Sciatica (Sciatic Nerve Neuralgia) 
Duration: 2 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

The practitioner should be careful when performing this step. Always communicate with the patient. Slowly elevate the patient’s leg until he or she feels any uncomfortable sensation on the posterior thigh. When this first degree of uncomfortable sensation is reached, slowly lower the leg to the level at which the uncomfortable sensation disappears. Now, passively dorsiflex the foot during the patient’s prolonged exhalation until the uncomfortable sensation reappears in the posterior thigh area. Observe the patient’s reaction, and don’t go over the pain threshold. The white arrows indicate the direction of the dorsiflexion.



Cutaneous Reflex Zones 



Duration: 4 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

Cutaneous reflex zones are formed in the skin and include zones of tingling, numbness, burning pain, and tightness of skin.

The practitioner should apply stimulating techniques in the area of the cutaneous reflex zones: rolling kneading, superficial friction, manual or electric vibration.

The video shows the application of these techniques in the area of the cutaneous reflex zones on the sacrum.

If the patient has Sciatica, cutaneous reflex zones will form on the lower extremity. The practitioner must use the same combination of techniques on each part of the leg where the patient feels tingling, burning pain or numbness.

The treatment of the cutaneous reflex zones on the lumbo-sacral area must be added at the end of Step 5 of this protocol. The treatment of the cutaneous reflex zones on the lower extremity should be conducted at the end of Step 10.



Connective Tissue Zones 



Duration: 4 min
Pressure: below the pain threshold 

The practitioner should use connective tissue massage in the area of the connective tissue zones. Connective tissue zones are formed in superficial and/or deep fascia. The symptoms of active connective tissue zones are: increased skin thickness, adhesion of skin to the superficial fascia, decreased mobility of the superficial muscle group in regard to the deep muscle group. Use CTM after the treatment of the cutaneous reflex zones at the end of Step 5.



Reflex Zones in the Skeletal Muscles

Add these therapies at the end of Step 4


a. Trigger Point Therapy 



Duration: 5 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

The video shows the location of the trigger points (black dots) in the gluteus maximus and piriformis muscles. If the patient exhibits trigger points in the gluteus maximus muscle, the practitioner should address these first.

In the first part of the video the straight dashed line indicates the edge of the sacrum.

In the second part of the video: the straight dashed line indicates the edge of the sacrum; the U-shaped dashed line indicates the greater trochanter; the two straight solid lines indicate the upper and lower edges of the piriformis muscle; the small circle indicates the insertion of the piriformis muscle into the greater trochanter; the black dot indicates the trigger point in the piriformis muscle.

Pay attention to the angle of pressure application, especially for the trigger point in the piriformis muscle. The Video shows the location of the active trigger point in the piriformis muscle and direction of the pressure. It doesn’t present the entire protocol of Trigger Point Therapy. You may find this information in the Video Library or 2009 issues of Journal of Massage Science.


b. Postisometric Muscular Relaxation 



Duration: 4 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

The video shows the PIR protocol for the piriformis muscle. The white arrows indicate the direction of pressure during the contraction-against-resistance part of PIR. Please notice in the video that during the passive stretching, the practitioner pushes the patient’s (right) knee to the opposite (left) shoulder. At the same time, the practitioner stabilizes the pelvis with the left hand, pushing it down against the table. This makes the stretch more efficient. If the patient has active Sciatica, apply contraction-against-resistance, as well as passive stretching, only within his or her comfort level.


c. Postisometric Muscular Relaxation 



Duration: 4 min
Pressure: at the level of the pain threshold (first sensation of discomfort)

If the patient has mild to moderate symptoms of Sciatica, add one more protocol of PIR after the previous one. The initial position of the patient is the same, but he or she should combine two movements: active abduction of the thigh at the hip joint, and, after this, lateral rotation of the thigh at the hip joint which is seen as inner rotation of the leg and foot (the white arrows in the video). The practitioner must resist both movements. During passive stretching, the practitioner should adduct the lower extremity at the hip joint and simultaneously laterally rotate the leg and foot.



Periostal Reflex Zones 



Duration: 5 min
Pressure: above the pain threshold (as much as the patient can handle) 

Periostal reflex zones are painful and degenerative changes in the bone at the insertion of soft tissue.

Periostal reflex zones can be found along the sacral edge (the straight dashed line in the video), on the upper tip of the greater trochanter, and at the point of insertion of the piriformis muscle into the greater trochanter.

The white arrows indicate the direction of pressure. Periostal Massage (PM) is the best way to eliminate periostal reflex zones. If the patient exhibits pain in the areas shown in the video the practitioner should use periostal massage techniques which consist of the application of intense friction, vibration and compression on the bone.

However don’t include PM in the first sessions, but rather add this tool later when the tension in the piriformis muscle, as well as the symptoms of Sciatic Nerve Neuralgia, subside. Add PM at the very end of the session. Be sure that PM strokes are applied to the bone itself.


Category: Medical Massage

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