This is Brent of the Brookbush Institute and in
this video we're going over static
manual release of the piriformis. Now, if
you're watching this video, I'm assuming
you're watching it for educational
purposes and that you are a manual
therapist, and in your state it
specifies that manual release techniques
are within your scope. Now, this probably
goes for all athletic trainers, physical
therapist, chiropractors, osteopaths,
licensed massage therapists. You're all in
the clear. However, personal trainers,
probably not. Now, before I have a patient
or a client on the table to do any
release technique, any manual work, I'm
going to be pretty sure from my
assessments that that technique is
necessary, especially when it comes to
things like the piriformis or adductors,
where we're getting into more sensitive
areas. Obviously, if somebody came in for
shoulder mobility issues or shoulder
pain and you start palpating their
backside, they're going to wonder what's
up. Make sure you have a good working
hypothesis before you're doing manual
techniques. I'm going to have my friend,
Brian, come out. He's going to help me
demonstrate this technique. Now, all of
these manual release techniques
basically come down to locate the muscle,
be able to palpate that muscle, and
compress that muscle. You get bonus
points if you know where the trigger
points are, because those are your common
points of tightness and having a general
idea of where to place your hands will
speed things up a little bit. I've
done the due diligence of marking out
some landmarks here that we need. I put
this piece of tape over the posterior
iliac spine, and then you can see it
curves down here. Well, I hope you guys
can see a little bit that it curves down
here over the sacrum. If you can't, you'll
get to see that in the close-up. And then
here, we have the greater trochanter.
The piriformis runs from anterior sacrum
to greater trochanter. The last thing we
need to consider, anatomically that is, is
the fact that the piriformis is actually
deeper than the glute max. So, we have to
find a way of differentiating between
glute max and piriformis fibers.
My glute max fibers generally run this way,
or vertical, whereas my piriformis is
horizontal. So you guys should be able to
notice that if you go this way, you can
strum some glute max fibers. They're
pretty thick. They're pretty broad-
that's a big, thick muscle. Now, the
piriformis fibers- if I go a little
deeper and I go superior to inferior
this way, then I start strumming. I have
to get pretty deep though. You guys can
tell if you go shallow and go superior
to inferior, you don't get any- you don't
feel fascicles, you don't feel strings of
muscle fibers. Now, as far as finding the
tense point, I'm going to go just below
my iliac crest here. I'm going to go
ahead and start around the sacrum. I
happen to know that the piriformis
trigger points are either generally very
close to the sacrum, or right in the
middle of the belly of the muscle. So if
I take this nice, broad thumb this way,
I can go from superior to inferior.
I'm going to start by looking for really
tight fascicles, because we're going to
assume that even if it's a tight trigger
point nodules, that they're still going to
pull the fascicles they're attached to
pretty tight. Once I found those tight
fascicles, I'm going to go ahead and move
maybe towards his greater trochanter if I
feel like that's where the more of the
tension is coming from. Once I find
that nodule, I would then compress. Or if
I feel like it's more towards the sacrum,
I could move back all the way to his
sacrum and see if pressing superior to
inferior, a little medial to
lateral there to find the most
dense tissue until I find that trigger
point, and then I could compress there. Now,
I'm showing you guys all of this on this
side so that you can see what I'm doing,
but the truth of the matter is that from a
technique standpoint, from a body
position standpoint, I'm going to want to
be on this side. I'm going to
want to do the piriformis that
is closer to me. I'm even going
to show you guys a little bit of a trick
here. If you have somebody in neutral
position, their piriformis is actually
not very
tight. It's actually kind of in a
neutral length, and if you just start
pressing down, you might start playing
that game of like trying to put your
finger on top of a marble, or you may
just press straight into mush. There's
not a whole lot of feedback. So what I
like to do, assuming that somebody has no
knee issues, is go ahead and take them
into knee flexion and then tuck their
foot into my arm here, right in my elbow,
on my armpit. And that way, as I'm
palpating his piriformis, here, I can pull
Brian into internal rotation, which is
going to lengthen his piriformis and
increase the tension a little bit, right
so that now those fibers are pulled just
a little taut. I'm not trying to stretch
his piriformis this way, but I want
those fibers pulled a little taut, so that
when I go to press on that trigger point
it doesn't do this to me. Alright, so I'll
pull down. Once again, broad strokes. I'm
going to go superior to inferior to find
those fascicles, and then I'm going
to go either proximally towards his
sacrum, or distally towards his greater
trochanter until I find the most tender
point. I'm going to use this hand as my
dummy thumb in this case. I'm
going to go ahead and put the other hand
to apply pressure. I'm going to try to
straighten out my arms to get as much
tension as I need here, and then I'm just
going to lean in with my body weight
until I feel that point where the tissue
density really starts ramping up. I don't
want to go all the way to the tissue end
point. I don't want to go all the way to
an end feel. I don't want so much pain
that I actually get the muscle
contracting under my fingers. Then I'll never
get a release. But if I go right up to
the point where I feel that increase in
tissue density, and I lean until I feel a
release underneath my fingers, that is a
decrease in tissue density, or Brian
tells me. You still feeling that? Alright,
he's still feeling that. I'm going to
hold for a few more seconds. If he
says that
he no longer feels the soreness, he
no longer feels the uncomfortableness,
the discomfort, then we can go ahead and
move on. It's starting to let go, right? Yes, it's a lot looser now.
Your piriformis was pretty
jacked up. Alright, next up we'll do
our close-up recap, guys, but I hope from
this position you guys can see my
body position. Manual therapists, you
always have to be thinking about you
first, and I know that sounds crazy. But
notice once I had him in position, my
arms were straight, I pulled him into
as much internal rotation as I needed,
and all I'm using is body weight.
Specifically, this hand is pressing over
this hand which is totally relaxed, so
that I'm not wearing out joints. I'm not
putting myself in a compromised position.
Okay, guys, here's our close-up recap. You
can see I've marked out the posterior
ilium. I've marked out the sacrum, here, it's
where this tape turns down. And then I've
marked out the greater trochanter. We
know his piriformis goes from anterior
sacrum to greater trochanter, deep to
those vertical glute fibers. To add
tension to his piriformis so that I'm
not playing the "try to put my finger
down on a marble," or I'm not just pushing
into mush because all of these muscles
are relaxed in this position, I can add
tension by pulling Brian into internal
rotation here. So, I'm going to tuck his
foot up in my arm. I'm going to strum
superior to inferior to find those
horizontal fibers. Once I find the
tightest fascicles- it helps to know that
most of your trigger points are going to
be located either closer to the sacrum or
in the middle of the belly of the muscle-
so once I find those tightest fascicles, I'm
going to move in one direction or the
other until I find a nodule or acute
point of increased tissue density. I'm
then going to apply pressure by letting
this hand relax and placing the other
hand over top, straightening out my arms
and leaning in.
I'm then going to hold that until I feel a
release or I can do the other protocol,
which would be five seconds on, two
seconds off, five seconds on, two seconds
off. I think I've mentioned in previous
videos that I do tend to gear towards
the the static hold, and usually 30 seconds
to 2 minutes does the trick. I hope you
guys enjoyed this video. I hope you add
static piriformis manual release to your
repertoire and use it when necessary.
Let's talk a second about what
assessments would lead me to believe
that the piriformis needs to be released.
If we're talking about the overhead
squat assessment, we're talking about
knees bow out, an inadequate forward lean,
a posterior pelvic tilt, or an
asymmetrical weight shift, that would be
the piriformis opposite the side of the
shift. If we're looking at goniometry,
we're looking at either a lack of
internal rotation in prone, or if we're
doing those supine tests, piriformis will
actually cause a reduction in range of
motion in either direction. That has to
do with that weird action of the
piriformis where if you get closer and
closer to 90 degrees, it starts to become
more and more of an internal rotator
rather than external rotator. If you don't
know what I'm talking about, look up the
piriformis article in www.brentbrookbush.com
and you guys will see. You could
possibly consider something like the
FABER test or the hip impingement test,
which are both special tests for the hip,
as also indications that this may be
tight. From a pathology perspective,
although I don't like to go from
pathology to technique, if somebody had
gotten diagnosed with piriformis
syndrome or a sciatica, I would also
definitely put this technique in my
repertoire just to see if we could get
any abatement from symptoms. Now, mind
your scope, mind your technique as far as
your body position, and, of course, stay
specific to your assessments. I look
forward to hearing your
comments. Please leave your comments
below. If you have any questions, if you
think I left anything out, please let me
know. I'll talk with you guys soon.
you