Sciatica & Yoga


"What a pain in the butt! No, a real pain - sometimes it shoots down the back of the leg and sometimes it is a dull ache. Is this sciatica?"
In yoga classes a student will often come to a teacher before class and state that she is suffering from sciatica. Too often the teacher may think that it must be due to "piriformis syndrome" and suggest some postures that could actually make the condition worse. To properly treat sciatica, first we must know what is causing it. Let's investigate this systematically: first let's look at what sciatica is, then what causes it, and finally what we should do about it.      

WARNING!
Some significant symptoms should be addressed immediately: if you experience any shooting pain going down your leg while sneezing or coughing, or if you have sciatica and notice that your bowels or bladder function is not normal - go to your doctor immediately! This could be a sign of a sign of cauda equina syndrome, which should be treated quickly.

What is Sciatica?

Sciatica is the pain that results from irritation or inflammation of the sciatica nerve as it winds its way from the lumbar spine down through the legs. Irritation anywhere along this path, including stretching the nerve which often happens in a yoga class, can result in a variety of painful symptoms: from sharp and burning sensations to dull and achy; a radiating pain that starts in the lower back and shoots down the buttocks and the back of the legs; an ache in the butt; tingling or electrical sensations; it can be in the lower back, or it may reach all the way down to the back of the calves or into the feet. Sciatica often affects just one side of the body. Women tend to experience sciatica more often than men. About 40% of adults will experience sciatica at some point. The pain may be worse when sitting or standing, especially for long periods of time, and it may be worse when sneezing or coughing; but the sensations may lessen when lying down. Sometimes the pain is like a persistent leg cramp; sometimes muscular weakness accompanies the pain.

Sciatica is not sacroiliac (SI) pain, but these two often get confused: SI pain is usually deep in the joint (a dull ache in the bones above the buttocks) while sciatica is felt in the deep soft tissues of the butt and can radiate down the leg.1

A few pictures may be useful here: notice in the first graphic (above) how the sciatic nerve emerges from several vertebrae, not just one. It comes out between the lower lumbar vertebrae (L4/5) and the sacral vertebrae (S1/2/3) and then these roots join up to form the main body of the sciatic nerve, one of the largest nerves in the body (about the diameter of your little finger - that's pretty thick!)

The second graphic shows the path that the sciatic nerve (highlighted in yellow) takes as it moves through the muscles of the buttocks and leg. This is a long nerve! You can see how pain associated with sciatica can be felt almost anywhere down the leg, because that is where the nerve goes. Even if the source of irritation is high, the pain may seem to be coming from lower down the leg: this is known as referred pain: you feel it in one place but the cause is somewhere else.

What Causes Sciatica?

Damage, compression, stretching, or other sources of irritation anywhere along the nerve may result in the painful symptoms of sciatica, however, there is a lot of debate over the exact mechanism, and if we don't know what is causing the pain, trying to figure our what to do about it is challenging. If we try to fix the wrong thing, we may make matters worse. Normally our nerves can slide a bit, but if the nerve gets stuck and unable to slide the nerve becomes stretched, which can be problematic: stretching a nerve is not good but often in our yoga practice this is what happens: the nerve, being stuck, becomes stretched by the postures, creating the pain of sciatica.2

The general consensus in the medical community is that the most common cause of sciatica comes from the spine: disc pathologies can create direct pressure on the roots of the sciatic nerve.3 These are known as discogenic causes.

A herniated disc appears to be the most frequent source of the problem. The picture here illustrates what happens when the center "jelly" of the disc bulges out the back of the disc and starts to press against the sciatic nerve root: not good. Some specialists estimate that 66% of all sciatica comes from discogenic sources; that is - problems with the intervertebral discs. As one study reported, "Based upon epidemiological studies of sciatic patients, we know that nerve root compression is the most common cause."4 However, that estimate is debatable. Other researchers feel that, just because there is a disc problem, this does not mean that the disc problem is the cause of the sciatica: correlation is not causation!5 Many people have significant disc problems with no sciatica.

Piriformis Syndrome

Next to disc issues, the most common cause of sciatica is something quaintly known as piriformis syndrome, but unfortunately, this condition is rarely mentioned in medical texts. This is the cause that too often yoga teachers will assume their students must be suffering from: and sometimes, it is the cause! If you look at the graphic showing the upper thigh you will see that the sciatic nerve passes under the big butt muscles (which have been retracted) and more specifically under the piriformis muscle. Sometimes, in 15% of people, the sciatic nerve actually passes through the piriformis muscle: we are not all the same! Other rarer presentations can also occur. The key assumption in piriformis syndrome is that the piriformis has somehow become shortened or more contracted, pressing down upon the poor defenseless sciatic nerve, and this pressure results in the pain of sciatica.

The piriformis muscle is an external rotator and an abductor of the leg. However, there are some researchers who believe that this muscle is not meant to rotate or abduct the legs at all, rather, being a rather weak muscle, its main purpose is to cushion and support the sciatic nerve and protect it from the compression of the bigger butt muscles sitting overtop the piriformis. It may be that the poor piriformis is being blamed for pressure caused by the gluteus maximus. This would also explain why many people have more significant sciatica when they are sitting down: the piriformis is no longer cushioning the sciatic nerve; your full weight is compressing the nerve.

However! If the source of the problem is a disc abnormality, the student may experience more sciatica pain while standing. It is very important to realize that when a student approaches a yoga teacher complaining about sciatica, the cause is not always piriformis syndrome, and the treatments for piriformis syndrome can be quite harmful to the student if the problem is actually discogenic. Knowing the cause of the problem is important before prescribing a cure!

Other Causes

There are many potential causes of sciatica. Let's say disc issues cause 50% of the cases: some studies have shown 66% of the remaining non-disc occurrences of sciatica are attributable to the piriformis (so about 33% of all cases).6 What causes the remaining 1 out of 6 cases? Here are some of the more common sources:
  • Gynecological problems7
  • Sacral fractures
  • Sacroiliac joint issues
  • Tumors
  • Infections
  • Trauma
  • Arthritis
  • A host of other, rarer pathologies
  • Idiopathic (unknown) causes

Diagnosing Sciatica

The symptoms give some clues to the cause of sciatica but to be sure more investigation may be needed. There are several ways to diagnose the problem, from provocation to MRI imaging. In provocation a therapist will move the body to see if the condition is made worse. For example: if flexing the hip, moving the leg inward (adduction) and rotating the thigh internally creates or worsens the pain, there is a good chance that the cause is piriformis syndrome.8 MRIs can be useful in discriminating disc issues, but we may also get some false positive correlations because many people have disc abnormalities that do not create any pain. Plus MRIs can miss subtle problems.9

What do to do about Sciatica?

That was a lot of background but it was necessary because, as we have seen, depending upon the cause of sciatica the cure can be quite different. Many times, just leaving things alone is enough: avoid movements or activities that cause or make the symptoms worse. However, for persistent occurrences more definitive solutions are needed. Since discogenic causes are the most common, let's begin here and see what, if anything, yoga can offer.

When the Cause is Discogenic

Options here range from therapy to surgery to steroids. Unfortunately, the use of steroids has been found ineffective, although many doctors are still prescribing this approach.10 Surgery may be required to repair a degenerated or herniated disk and many people have found permanent relief through this option. However, delaying surgery has also found to be effective! Allowing time for the body to heal using more conservative treatments often works; thus the lesson may be - don't rush to go under the knife. There are also several physiotherapeutic approaches including yoga practices that could prevent the need for surgery.

McKenzie Therapy: If the cause of sciatica is a bulging or herniated disc, then flexion of the spine is contraindicated; it would simply make matters worse. The idea is to move the spine in the opposite direction: Sphinx Pose or Seal Pose may help. The spine is placed into extension, which effectively pushes the jelly back into the disc, relieving the stress on the sciatic nerve roots.

Spinal Flossing: Occasionally the bones of the spine grow, perhaps creating little spurs that press against the nerve. Arthritis and other degeneration of the bones may also cause the nerve to become adhered to the bone. Nerves can release a chemical that can "melt away" the bones that press against them, but only if the nerve is free to slide a little bit. If a nerve is stuck, flossing of the nerve can stimulate secretions from the nerve that will dissolve the impingement.11

Traditionally, flossing of the whole spinal cord is done by a therapist, often while the patient is seated, as shown here. The idea is to pull up on the whole spinal cord by flexing the neck, keeping the pelvis and legs neutral; and then pull down on the spinal cord by returning the head to neutral or extending the neck while flexing the hips or by extending the legs. By pulling at one end of the spinal cord and releasing at the other we assist in moving (or flossing) the nerves along their pathways, which can help dissolve away any adhesions. There are several yoga practices that serve the same function.
  • Up Cat/Down Cat (aka Cat/Cow) - on hands and knees undulate the spine up and down. You can enhance the effectiveness of the spinal flossing by moving the hips closer to the heels as you look up, and moving the hips forward as you round the back high.
   
  • Lying on the back hip/neck flexions - Lie down with your arms under you, palms flat on the floor under the pelvis (to provide support for the lumbar), knees bent, feet on the floor. Inhale and straighten the right leg straight up in the air; exhale, lower the foot back to the floor as you raise your head, bringing your chin to your chest. Again, inhale, lowering your head and raise the other leg up in the air. Keep alternating legs. You could raise both legs together if you like: maybe work up towards that. If the neck starts to tire, use your hands to support the head. Repeat for a minute or two. If there is any pain, don't do this!
   

Spinal flossing has helped many people, but it can also create an acute sciatica experience. Go slowly at first, and let your health care provider know what you are planning to do!

When the Cause is Piriformis Syndrome

Sitting, as we have seen, can also cause sciatica symptom: the pressure compresses the nerve and part of that pressure may be coming from a tight, short piriformis. There are many styles of yoga that involve a lot of seated poses, such as the Primary Series of Ashtanga yoga. It is not surprising that our yoga practice, when overdone, can actually lead to problems. We have to pay attention and notice when problems arise so that we can correlate what we have been doing to what we are experiencing, and then consciously decide to, perhaps, try something different.

If the piriformis is the culprit, if it is tight and short, then we need to take action to lengthen it. Remember: when the piriformis contracts it externally rotates and abducts the leg, and to a very small degree can extend the hip. Moving the leg in the opposite directions, then, will stretch the piriformis; and there are many poses that can perform these movements, some more effectively than others, which is welcomed because some of the poses may not be available to everybody. For example, students who have had a hip replaced are often strongly advised never to adduct the legs and perhaps avoid internal rotations as well. In those cases only flexion postures would be advisable for stretching the piriformis.

Pursuing the Perfect Pigeon

Just as we are all unique and different, no two pigeons are exactly alike. Some versions of Pigeon Pose can be very useful in addressing piriformis syndrome but other versions are less than helpful. The version shown in the picture at the left below shows a very tradition Pigeon Pose where the front leg is externally rotated, abducted and there is some flexion of the hip of the front leg. If we are looking for internal rotation and adduction to stretch the piriformis, this version of Pigeon will not be helpful in curing the problem (it may however help relieve any current pain.) However, the middle picture shows a different version of Pigeon. Notice here that the front leg is not out to the side but is in towards the midline of the body (adducted) and neutrally rotated. With the upper body folding forward, as shown in the right picture, there is more flexion in the hips; so this version of Pigeon is moving the body in two of the key directions we need to stretch the piriformis. This version of Pigeon may be great for healing piriformis syndrome, and in the Yin Yoga world, where the pose is known as Sleeping Swan you may marinate here for many minutes.

  

There is some confusion over Pigeon (or Swan) being a solution for piriformis syndrome: it is only a solution if the front knee is in, so that the front leg is adducted, not abducted, and ensuring that there is no external rotation happening, because active external rotation contracts the piriformis muscle, whereas we want to stretch it.

For some people, even the Sleeping Pigeon is not available due to pain in the knee. In these cases there are a couple of other options: the Sitting Swan or the Wall Eye-of-the-Needle. These are shown here and can be effective as well because there is still flexion and adduction of the hips but there is less stress on the knee.12 And, of course, there is the traditional lying down version of Eye-of-the-Needle.

Again, the point is to stretch the piriformis muscle by moving it into adduction and flexion, and if you can find a pose that offers some internal rotation along the way - great! But do listen to your knees - don't swap one problem for another.

When to Use These Yoga Tools

B.K.S. Iyengar in his book The Path to Holistic Health makes a crucial distinction for dealing with sciatica. His remedies include what to do when you are currently experiencing pain and what to do when you are pain free and want to avoid future problems. This is an important observation: when you are already experiencing sciatica, especially if it is due to piriformis syndrome, attempting to stretch the piriformis will just further aggravate your symptoms because these movements also stretch the sciatic nerve. However, if your cause is discogenic, or more specifically a bulging disc, then doing the poses recommended above may help both reduce pain and fix the underlying problem at the same time.

Let's consider piriformis syndrome again: if you have pain right now, it is caused by the piriformis pressing down on the sciatic nerve. If you tried now to flex, adduct and internally rotate (FAIR) your leg, this would increase the stress on the nerve and increase the sciatica pain. So, point #1 - "No FAIR!" when you are currently in pain caused by piriformis syndrome. Instead, we want to take the pressure off the nerve and we do that by moving the in the opposite direction of FAIR (the no-FAIR direction.) This means we abduct the legs and we externally rotate the legs (think Butterfly or Straddle in the Yin Yoga world or Baddhakonasana or Upavistakonasana in the Yang world), and we can extend the hips too (think reclining Butterfly or Supta Baddhakonasana.) These poses and similar ones will relax the piriformis and hopefully reduce the stress on the sciatica nerve, providing some relief from the pain. Point #2 - when the pain is gone, then try the postures that are FAIR, as described above, but only if they don't provoke pain again.

Unfortunately it is not easy to get "out of pain" when the symptoms are upon us: other remedies can include anti-inflammatories, rest, and easy breath work such as ocean breathing or alternate nostril breathing.

Other Yoga Poses

Many seasoned and senior teachers have offered their advice for helping with sciatica, and while working with these teachers in person would allow the greatest chance to experiment and modify the poses to suit the individual student, sometimes the only access we have to these teachers is through their writings. Unfortunately, this drastically limits the value of the advice. For example, there are suggestions offered in several books that include flexions of the hips, such as Janusirsasana (one-legged, seated, forward fold); Paschimottanasa (both legs straight, seated, forward fold); and Downward Facing Dog. These do provide a stretch to the piriformis muscle via flexion of the hips, but they also lead to flexion of the spine for many students, especially those who do not have a teacher handy to advise them to keep the spine straight in these postures: flexion of the spine may be exactly the wrong remedy if the cause of sciatica is discogenic. Plus sitting may be the cause of the sciatica and adding more seated posture may not be what the student needs. Finally, if the student is currently experiencing sciatica, these poses would not be helpful at this time. The cause and currency of the problem must be considered before poses can be prescribed!

Don't Take Advice From the Internet!

By now it should be obvious: sciatica is a complicated problem with many possible causes and many possible solutions, but unless you know the cause, some solutions may make the pain worse instead of better. Check with a knowledgeable health care professional or yoga teacher. The advice offered here are just some ideas and guidance that you can use, in consultation with your health care team, to see if you can avoid the more drastic remedies of surgery or steroids. Practice mindfully with full attention to what you are feeling and with a clear intention of what you are trying to accomplish. And, good luck!

Footnotes:
  1. See Back Care Basics: A Doctor's Gentle Yoga Program for Back and Neck Pain Relief, by Mary Pullig Schatz, M.D., page 133-4
  2. See Low Back Disorders: Evidenced-Based Prevention and Rehabilitation by Stuart McGill, pages 216 - 217
  3. See Review of the principal extra spinal pathologies causing sciatica and new MRI approaches by A AILIANOU, MD, et al, published in 2012 by The British Journal of Radiology, 85 (2012), 672-681
  4. Sciatica of nondisc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment by Aaron G. Filler et al, Journal of Neurosurgery: Spine February 2005/ Vol. 2 / No. 2 / Pages 99-115
  5. See Magnetic resonance imaging of the lumbar spine in people without back pain by Jensen et al, JS. New England Journal of Medicine; 1994:69-73. This study found that 30% of people who had significant spinal abnormalities were completely pain free.
  6. Sciatica of nondisc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment by Aaron G. Filler et al, Journal of Neurosurgery: Spine February 2005/ Vol. 2 / No. 2 / Pages 99-115
  7. "Piriformis syndrome and gynaecological conditions account for most cases of extralumbar sciatica" Also: "Gynaecological conditions such as ectopic endometriosis, ovarian cysts and pregnancy may result in sciatica, with a tendency to affect the right side " See Review of the principal extra spinal pathologies causing sciatica and new MRI approaches by A AILIANOU, MD, et al, published in 2012 by The British Journal of Radiology, 85 (2012), 672-681 and Diagnostic features of sciatica without lumbar nerve root compression, by Yoshimoto M et al. Journal of Spinal Disorders Tech. 2009;22:328-33.
  8. This provocation test is referred to as the FAIR assessment: flexion, adduction and internal rotation. There are other provocation techniques that can be used as well.
  9. MRIs are not able to image nerves directly, however, a new methodology called Magnetic Imaging Neurography can image nerves. MIN has detected many previous unknown causes of sciatica. See New Way to Diagnose Sciatica May Point To a Different Cause by Cedars-Sinai Medical Center, Feb 2, 2005 as reported in ScienceDaily
  10. See Spinal steroid shots may have little effect on sciatica by Andrew Seaman, published by Reuters Health, Nov 12,2012
  11. See Low Back Disorders: Evidenced-Based Prevention and Rehabilitation by Stuart McGill page 216 - 217
  12. For information on how to come into these poses, check out the YinYoga.com Newsletters #2 and #6



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