Massage Professionals Article Archive

Plantar fasciitis is a common painful inflammation of the plantar fascia, the fibrous band of tissue on the sole of the foot. This tissue is instrumental in helping to support the arch and in acting as one of the body’s shock absorbers. Plantar fasciitis occurs when this band of tissue is overloaded or overstretched. This tension produces small tears in the fibers of the fascia, especially where the fascia meets the anterior calcaneous.

Plantar fasciitis is common in many types of people. Those afflicted include, but are not limited to, obese people, pregnant women, diabetics, people who repeatedly walk or stand on a hard surface, athletes and weekend warriors. In a pronated (low arch) foot, the fascia is under a constant stretch. In a supinated (high arch) foot, the fascia is under constant tension. Both of these arch extremes can easily lead to plantar fasciitis. Worn or poorly constructed shoes can contribute to the problem if they do not provide enough arch support, heel cushion or sole flexibility. In athletes, plantar fasciitis may follow intense training, especially in runners who push themselves too quickly to run longer distances.

The physiology of plantar fasciitis is a debated topic. It is widely acknowledged that this condition is associated with small tears in the fascia. However, further analysis of the tissue’s integrity is unclear. While the term uses the suffix –itis, indicating an inflammatory condition, many believe otherwise. Whitney Lowe, in issue #105 of Massage Magazine, says “There is mounting evidence that many common tendonitis complaints are actually not inflammatory problems at all, but instead are caused by a degeneration of the collagen matrix within the tissue. It has been suggested that plantar fasciitis is similar to these tendon pathologies, and that the problem is collagen degeneration in the fascial tissue.”

Symptoms of plantar fasciitis extend beyond foot pain following activity. According to Janet G. Travell, MD, and David G. Simons, MD, symptoms of plantar fasciitis primarily revolve around pain in the region of the plantar aponeurosis and/or pain in the heel. A unique characteristic of plantar fasciitis is marked pain upon arising in the morning. The first 10-12 steps are severely painful until the plantar fascia and the muscles have been stretched. The pain worsens again in the evening and after weight bearing activities.

Bodywork is extremely effective in helping people overcome the pain and limitations of plantar fasciitis. According to Art Riggs, Certified Advanced Rolfer, CMT, in his Deep Tissue Massage book, “The pain [of plantar fasciitis] is caused by tight and inflexible plantar fascia and, also by tight calf muscles. Medication and rest may improve symptoms, but if the causes are not addressed, the likelihood of recurrence is increased.”

In helping your clients overcome this condition, a focus on the plantar surface of the foot must be combined with lower posterior leg work. The posterior leg muscles attach via the achilles tendon to the calcaneous. Tightness in these muscles, mostly the gastrocnemius and the soleus, will pull on the calcaneous and add tension to the plantar fascia. It is recommended to have training in the individual bodywork techniques discussed below before applying them to your clients.

Plantar Surface of the Foot

1. Glide on the plantar surface – Following some warm-up, glide your elbow, knuckles or thumbs from the foot pad to the heel. This will help the fascia migrate back up against the calcaneus. This can prevent heel spur development. Gliding on the lateral, medial and tranverse arches on the foot also contribute to relaxing of the plantar fascia.

2. Mobilize the calcaneous – This method is courtesy of Riggs’ video series Deep Tissue Massage and Myofascial Release. With the client supine, cup your bottom hand between the ankle and heel. Use your upper hand to hold the distal part of the foot, including the ball of the foot and toes. Use your lower hand to create movement in the heel by rocking it side to side (medial and lateral) and even up and down (superior and inferior). Because the plantar fascia attaches to the calcaneous, this mobilization can aid in freeing up restrictions of the plantar fascia.

3. Strip and stretch the plantar fascia – With the client supine, grasp the toes and ball of foot with one hand and dorsiflex the foot by stretching the plantar fascia. Use thumbs or knuckles to strip the plantar fascia from the ball of the foot to the heel. This may be very painful, but very helpful. Icing the foot afterward will speed the healing process.

4. Deep transverse friction – According to Lowe, “Deep transverse friction may be used directly on the plantar fascia to stimulate fibroblast activity and tissue healing from chronic overuse. However, caution should be used in applying friction massage near the attachment on the calcaneous because of the possibility of a bone spur.” This technique can be very painful. Use the maximum amount of pressure tolerable to your client. Icing the foot afterward will speed the healing process.

5. Wring the foot – The client is prone, with his/her knee at a 90-degree angle. Using a twisting motion, wring the foot as if you were wringing out a washcloth. This can be done for the entire foot, with one hand on the heel, and the other on the ball of the foot. This can also be done for the cuneiform joints, by having one hand on the ball of the foot, and the other on the center of the instep. As the muscles relax, you can increase the speed and intensity of the wringing to bring increased circulation and range of motion to the entire foot.

Posterior Lower Leg

1. Myofascial release of the lower posterior fascial line – This technique is described in the Institute for Integrative Healthcare Studies’ Myofascial Release manual. Position your client prone with the foot off the table to assess the leg’s fascia. Cross your arms and place one hand on the calf (proximal to the belly of the gastrocnemius muscle) and the other on the lower leg (just proximal to the ankle). Stretch and wait for a release. Allow the fascia to unwind in its own time.

2. Work the plantar flexors – With the client prone, put the Achilles tendon in a stretch by placing the client’s foot against your belly. Then use your thumbs to friction the sides of the Achilles tendon. Release the foot from your belly and use one thumb to push the tendon aside. Working at the level of the malleoli, rotate your other hand in order to cross fiber the anterior part of the Achilles tendon with your index finger. Follow with a forearm glide and/or stripping up the posterior leg being careful not to put pressure on the posterior knee.

3. Treat trigger points – Use ischemic compression on trigger points of the soleus, gastrocnemius and flexor digitorum longus. James Mally, ND, in the Institute for Integrative Healthcare Studies’ Sports Massage manual, suggests having the client prone, pressing the trigger point, flexing the client’s knee and dorsiflexing the ankle. Then, Mally says to find the position where the client does not feel any pain in the trigger point (except if the point is in the soleus). Hold the point for 30-90 seconds or until a release is felt. Then bring the client back to a neutral position while continuing to hold the trigger point.

4. Posterior fascial line stretch - Have your client stretch this line by performing a forward lunge, keeping the back leg straight and the feet flat on the floor. Hold for 20 seconds without any bouncing. Release for several seconds and repeat the stretch. This stretch can also be achieved by standing on the edge of a step. The balls of the feet are on the step while the heels hang off the step. Slowly, allow the body weight to shift into the heels, so that they drop below the step. This provides a great posterior lower leg stretch.

In addition to the above massage suggestions, here are some additional tips to offer your clients with plantar fasciitis:

• Rest is recommended for the acute stage.
• A physical therapist and/or athletic trainer can offer ultrasound, a stretching protocol, strengthening exercises and adequate taping.
• Supportive shoes or heel cups are helpful to many people.
• A podiatrist can fit your client for orthotics and/or a nighttime brace.
• Ice decreases inflammation and reduces the pain. Roll the foot over a firm cold object, such as frozen golf balls or a can of frozen juice concentrate.
• Surgery is available, hopefully as a last resort.

Plantar fasciitis is an increasingly common condition. An understanding of the anatomy and physiology of the foot and lower leg is very important in rendering appropriate care. Communication and collaboration with other healthcare professionals will provide your clients with the most comprehensive and effective treatment plan. Because massage therapists have such powerful tools to relieve plantar fasciitis, more bodyworkers will focus on and team up with professionals who treat this condition. Mastering the techniques described here, and making them your own, will give you a leg up on the pain of plantar fasciitis.

Recommended Study
Myofascial Release, Sports Massage

Insomnia means trouble either falling asleep or staying asleep. The prevalence of insomnia is staggering, with more than 30 percent of American adults suffering from occasional bouts of insomnia and 10 percent of Americans experiencing chronic insomnia. While insomnia may be a symptom on its own, it also can be connected to a long list of healthcare problems.

Chronic insomnia is poor sleep every night or most nights for more than six months. This endless cycle can cause extreme fatigue, problems with concentration and can adversely affect a person’s mood and well-being. Recurring insomnia should be evaluated by a healthcare professional or a sleep disorder specialist.

Methods of treating insomnia cover a wide span of lifestyle adjustments, psychological services, Western medical treatments and complementary/alternative medical choices. Under that last category, complementary/alternative medical choices, be certain to include massage therapy as a viable option to help the sleep deprived. While it may not be the first appointment that an insomniac thinks to make, looking at the neurochemistry of sleep, and the effect massage has on that neurochemistry, may provide a solid link between massage and insomnia treatment.

The neurochemistry of sleep is very complex. While there are many aspects of the brain and its chemicals that contribute to sleep, we will look at the serotonin component of sleep.

Serotonin is an extremely important neurotransmitter that is essential to our survival. Serotonin plays a role in mood, behavior, body temperature, physical coordination, appetite and sleep. Derived from the amino acid tryptophan, serotonin can also be converted by the brain into melatonin.

The involvement of serotonin in sleep has been repeatedly proven. However, the mechanism of that involvement remains unclear. A number of studies revolve around a specific area of the brain that mediates deep sleep. This area of the brain is called the raphe nuclei. The raphe nuclei contain nerve cells that use serotonin to communicate with each other. In laboratory experiments using cats as subjects, destruction of the cats’ raphe nuclei resulted in their inability to sleep. Another experiment consisted of blocking serotonin synthesis with a drug (p-chlorophenylalanine). Administration of this drug produced insomnia, an effect which was reversed by the subsequent administration of serotonin.(1) These studies all demonstrate the necessity of serotonin for healthy sleep.

Serotonin is a precursor to the body’s rendering of melatonin. Melatonin is a hormone released by the brain’s pineal gland to quiet and reset the part of the brain (the suprachiasmatic nucleus) that directs circadian cycles to prepare for sleep. According to Charles Czeisler, professor and chair of the Division of Sleep Medicine at Brigham and Women’s Hospital, Boston, MA, circadian cycles are internal periodic rhythms that profoundly affect sleep and wakefulness.(2)

The chemistry of sleep is relevant to massage therapists because massage can directly influence the body’s production of serotonin. A study on back pain, conducted in January 2000 by the Touch Research Institute in conjunction with the University of Miami School of Medicine and Iris Burman of Miami’s Educating Hands School of Massage demonstrated that in addition to a decrease in long-term pain, subjects receiving massage experienced improved sleep and an increase in serotonin levels.(3)

This massage study employed twice-weekly, 30 minute massages for five weeks. Starting in the prone position, the following techniques were used:
• Kneading and pressing the back muscles
• Stroking both sides of the spine and hips
• Gliding strokes to the legs
• Kneading and pressing the thighs

In the supine position, participants received:
• Gliding strokes to the neck and abdomen
• Kneading of the rectus and oblique muscles that help bend the trunk of the body forward
• Stroking of the legs
• Kneading of the anterior thighs
• Flexing of the thighs and knees
• Gentle pulling on both legs

In addition to other assessments, a sleep scale to measure quality of sleep and urine samples to measure levels of serotonin were used. The results of this study were originally published in the International Journal of Neuroscience in 2001.

Massage is an intelligent, healthy and substance free choice to help the scores of people that have insomnia. Because serotonin plays a role in sleep in multiple areas of the brain, it is logical to seek ways to increase serotonin levels for people that are sleep deprived. In addition, serotonin is needed for our bodies to produce melatonin. As melatonin influences the sleep stage of our circadian rhythm, a natural way of boosting serotonin is a positive sleep inducing option. This connection calls for further research showing the direct affects massage therapy has on serotonin and sleep. In the meantime, the existing evidence is certainly enough to condone regular massages for sleepless clients.

References:

1. Shepherd, Gordon M., MD, D.Phil., Neurobiology, Oxford University Press, 1988.
(pp 517-528).

2. Lambert, Craig, PhD. “Deep into Sleep,” Harvard Magazine, July/August 2005.

3. “Research: Massage Eases Lower Back Pain, Increases Range of Motion,” Massage Magazine, January/February 2002.

The indulgence of a mint on your pillow at a hotel or the practicality of handi-wipes at the entrance of a grocery store to clean your shopping cart are examples of thoughtful and considerate marketing gems that encourage repeat business. Similarly, those small thoughtful and considerate actions that originate from your heart make your massage noteworthy. Because massage therapists span across the service industry from health and rehabilitation to relaxation and luxury, there are many opportunities for you to come from the heart and communicate, “I’m here for you.”

To keep your clients raving about your massage and service, booking more sessions and referring new clients, consider implementing the following heartfelt touches:

1. Use your massage room for treatments, not for chatting with your clients. Set up your massage room as a sacred healing space with soft lighting, music and all the tools that you need to perform your work. When your client arrives for a massage, talk outside the massage room, catch up on their life since you saw them last, and talk about what needs working on today. Communicate to your client that when they enter the massage room, they are entering a space that holds the intention for their healing.

2. Select the music you will use before your client arrives and have it playing when they enter your massage room. The client will feel the difference as they step from the busy world into your healing space.

3. Create a small dressing area in your massage room that provides clients with a place to adequately hang their clothing on hangers, a small table to place their jewelry and other belongings, a mirror for grooming and a chair to sit in to remove their shoes. Provide a towel to wrap up with when going from the dressing area to the table. First time massage clients appreciate clear instructions about what clothing to take off and/or leave on, and what position to assume on the massage table.

4. Flannel sheets are the epitome of comfort and warmth, and are thicker than your regular cotton or poly-blend sheets and provide a substantial barrier when draping. A bonus for the therapist is that flannel lasts longer, and since the fibers are natural, oils are easier to remove in the wash.

5. When in the prone position for an extended time, a client’s sinuses can get congested. A tissue or a few cotton balls with a drop or two of eucalyptus essential oil placed just under the headrest can pleasantly open your client’s nasal passages and maintain clear breathing. Check with your client first to see if they find the eucalyptus essential oil an acceptable aroma, and substitute peppermint or ginger if necessary.

6. When working on your client in the side-lying position, provide them with a body pillow to support their upper arm and leg. This positioning will keep the brachial plexus and inguinal areas open and maximize circulation in the extremities. Pregnant women require this support as your entire massage will be performed with them in this position and it is very important to maintain circulation.

7. If your client must use the restroom during a session, have a clean robe and slippers for them to wear, especially if the restroom is outside of your massage room. Many therapists have the client use the top sheet or towel to wrap up, but this may not be very comfortable if your client must walk down a busy hallway to the restroom.

8. Check in with your client about their massage lubricant preference and remember to use their choice each time you give them a massage. Some people find oils unpleasant, particularly if they are heavy and are not absorbed completely. Feeling a slippery residue on the body after a massage can make the client feel the need for a shower before dressing. If this is the case, consider a cream or lotion that is absorbed quickly and leaves no residue.

9. At the close of your massage, make certain that your client steps down off the table onto a warm, soft surface. A small fluffy rug to envelope your client’s feet will be a welcome transition back to earth.

10. As you exit the treatment room after the massage, leave a bottle of water for your client on the table near his/her belongings. This small contribution to your client’s health and well-being goes a long way in communicating your care and concern.

11. Everyone loves a free gift – especially when they are useful. Leave a small container of Epsom salts scented with your client’s favorite essential oil on the table next to his/her belongings. Include a small card with personalized instructions for a therapeutic post-massage bath to help release toxins and alleviate muscle soreness. Use your creativity and personalize each gift.

Listening to what your clients have to share before the massage can not only give you direction in your therapy, but can also help you personalize it for each person. When you begin to listen and think from your heart, thoughtful and considerate actions are likely to arise effortlessly.

Please click here to send us your heartfelt touches. We will select from these contributions to share them in a future article.

Editor’s Note: This article is a follow-up to our previous article The Therapeutic Relationship in Post Traumatic Stress Disorder (July 21, 2005).

The therapeutic use of essential oils, known as aromatherapy, is finding its way into the healing arena as an effective and worthwhile contributor in the mind-body-spirit sphere of holistic healing. Carefully selected essential oils are ideal for addressing Post Traumatic Stress Disorder (PTSD). Both physical and emotional aspects of trauma can respond powerfully to appropriate essential oil use. Massage therapists incorporating an integrative approach can include the use of aromatherapy to enhance their work with PTSD clients who display any of the following physical and emotional symptoms associated with the traumatic experience:

• Depression
• Irritability
• Panic and panic attacks
• Self-blame
• Withdrawal from life
• Insomnia
• Headaches and other physical pain

A closer look at the olfactory system and its connection to the brain lends significantly to our understanding of the affect of aromatic essential oils on the physical and emotional aspects of PTSD. Researchers have shown how aromas cause the brain to react activating the hypothalamus gland, the pituitary gland, the body's hormones and the limbic system. The limbic system links the left and right brain and the voluntary and involuntary nervous system centers.

Smell is processed in the limbic system, the oldest part of the brain in evolutionary terms. The limbic system houses our emotions, sexual feelings, memory and learning. Aromatic essential oil molecules are absorbed in the cilia of the nose, where one end of the olfactory receptors reside, then travel to the olfactory epithelium at the posterior top portion of the nose. The cribiform plate of the ethmoid bone delivers the aroma message to the olfactory bulb located above and behind the nose at the base of the brain. From here the message is amplified and then transmitted to the limbic system and the hypothalamus.

In her book, Molecules of Emotion, Candice Pert, PhD, states that 85 percent of the neuropeptide receptors for emotion are located in the limbic structures. This means that the sense of smell can bypass other cognitive structures in the brain facilitating a more direct and strong association of memory and smell. For example, a favorite aunt who held and rocked you to sleep when you were an infant wore lavender, and now, as an adult, the smell of lavender conjures up the memory of being comforted and loved. In this instance, lavender may assist you with restful sleep. The opposite effect is possible if your aunt who wore lavender was cruel and scared you as a child. In this situation, the smell of lavender may be unpleasant and produce some feelings of discomfort, even if you did not consciously associate the smell of lavender with her. Depending on the association, using lavender with a client could be either soothing and nurturing, or it could exacerbate feelings of irritability and depression.

The theory of Neurolinguistic Programming, or NLP, attributes the association of a particular smell with the emotional memory to the concept of anchoring. Anchoring is the internal process by which the brain forms a connection between the event and the memory associated with the event. Using the above example, the essential oil of lavender becomes the anchor that defines the association between your aunt who was either loving or scary and the associated memory of feeling either security or discomfort.

Therapists can use this associative process to anchor changes in behavior and emotions when working with those with PTSD. Sheryll Ryan, a certified aromatherapist and author of the Institute for Integrative Healthcare Studies’ Aromatherapy Essentials, instructs therapists to anchor any emotional shifts made during therapy with the application of essential oils. Individual essential oils work well, but a blend is often more effective because of its complexity or synergy of smell. A blend will circumvent the cognitive brain’s attempt to identify the smell, and the process of anchoring the “new” feeling will be met with greater success.

Creating useful and potent blends of essential oils to use as anchors when working with PTSD clients is an interactive process that takes place between practitioner and client. In her article Aromatherapy, Jeanne Rose recommends using spikenard and rose for women who have been affected by painful sexual, psychological or physical traumas. Blended, they are considered to be “spiritually uplifting and capable of encouraging pure love and true forgiveness.”

The grounding and calming properties of spikenard complement the angelic qualities of rose and when inhaled or applied to the skin can lift one above personal pain. Together they are powerful for healing the emotional wounds from trauma. Spikenard has a regulating action on the nervous system when inhaled and a calming effect on the heart when inhaled or applied topically. Creating a warm and stabilizing effect, spikenard helps one overcome emotional wounds, grief and deep anxieties.

Rose, called “the queen of flowers,” has the ability to heal the self-blame associated with deep emotional wounds by awakening the heart and opening one to a deeper sense of self-love. Rose also acts on the liver with its cleansing and cooling properties and can help reduce anger and depression. Two drops of rose on a tissue placed under the face-rest of a massage table during bodywork in the prone position, or on a cotton ball placed under one’s pillowcase before bedtime, induces relaxation and can help with insomnia. The client can inhale rose, the anchor, anytime during the day or night to revive the associated feeling of being relaxed during therapy. Lemon oil added to the spikenard and rose formula will lighten the scent.

In addition, the following comforting essential oils are specified for emotional needs:

• Cedar – calming, protective and grounding
• German Chamomile – anti-inflammatory, soothing and calming
• Roman Chamomile – antidepressant, restorative and sedative
• Clary Sage – relaxing and euphoric
• Helichrysum – wound-healing for deep traumatic bruising
• Lavender – gentle and healing effects, migraines
• Ylang-Ylang – sedating and antidepressant

The following blends are women’s formulas suggested in Jeanne Rose’s article Aromatherapy:

Emotional Trauma
9 drops Rose
5 drops Spinkenard
2 drops Lemon
1 oz. carrier oil

Physical Trauma
3 drops Rose
4 drops Spikenard
3 drops Helichrysum
1 oz. carrier oil

Fearfulness and Withdrawal From Life
3 drops Rose Geranium
3 drops Spikenard
4 drops Lavender
1 oz. carrier oil

Although these formulations were created for women, aromatherapy transcends gender. A blend will be effective when it invokes a positive reaction from the client.

The mind-body connection is very obvious in the case of panic attacks. A thought of the past trauma begins in the mind and can set off a whole range of physical sensations such as hyperventilation, perspiration, dizziness, fainting, nausea and shaking. The heart can start to race, the breath can be difficult to catch and, with some people, it may feel as if they are having a heart attack. Although it may feel as if one is dying, panic attacks do not last long and the body gradually returns to normal. Lavender essential oil applied directly on the chest and neck area, combined with deep and slow abdominal breathing, can help prevent or manage an oncoming panic attack. Lavender mixed with a carrier oil is excellent for massaging the abdomen, shoulders and neck of a client suffering from panic attacks. Infuse lavender in the room during a massage to create a relaxing atmosphere and have the client take a bath using 5-10 drops of lavender before bedtime to assist with restful sleep.

Valerie Ann Wormwood, in her book The Fragrant Mind, suggests the following blend of essential oils to address panic attacks:

Panic Attack Calming Blend
10 drops Lavender
5 drops Frankincense
10 drops Helichrysum
5 drops Marjoram
1 oz. carrier oil

Research studies have confirmed lavender’s success in helping people cope with traumatic experiences. When lavender was used before and during examinations, college students reported that their test taking experience was one of calmness and clear thought. A significant number of patients using lavender before and during magnetic resonance imaging reported less anxiety than the control group. Used in massage therapy at the Royal Sussex County Hospital, lavender significantly decreased blood pressure, heart rate, respiratory rate, pain and wakefulness. Further studies have shown the depression levels of elderly people living in assisted facilities were reduced when the aromas of lavender, rose, chamomile, jasmine and rosemary were diffused into the air in various living areas.

Science is finally proving what aromatherapists have been saying for years — Aromas improve performance, increase alertness, initiate relaxation and are powerful vehicles for healing. As humans, we have the ability to distinguish between 10,000 different aromas and each one can take us to a multitude of physical and/or emotional responses. Helen Keller summed up the dynamic impact of the olfactory system on our lives when she said, “Smell is a potent wizard that transports us across thousands of miles and all the years we have lived.”

As a skilled massage therapist assists PTSD clients in the release of patterns held in the body’s tissues, buried emotions and repressed memories, aromatherapy can assist in anchoring the transformed feelings of courage, self-love and forgiveness. These transformed feelings can be experienced and reinforced using essential oils anytime, in the company of or absence of others. Over time the trauma gives way to the newly developed coping mechanism. Massage therapists can facilitate this transformation by supporting clients with safe nurturing touch and using the healing energy of essential oils.

Recommended Study
Aromatherapy Essentials

Resources:

Buckle, Jane. Clinical Aromatherapy, Essential Oils in Practice, Churchill Livingstone,
Second Edition, 2003.

Price, Shirley and Price, Len. Aromatherapy for Health Professionals, Churchill
Livingstone, Second Edition, 2002.

Rose, Jeanne. Aromatherapy, in Massage and Bodywork, October/November, 2001.

Ryan, Sheryll. Aromatherapy Essentials, Natural Wellness, 2001.

Tisserand, Robert B. The Art of Aromatherapy, Healing Arts Press, 1977.

Wormwood, Valerie Ann. The Fragrant Mind, New World Library, 1996.

Sciatica refers to pain that begins in the hip and buttocks and continues all the way down the leg. This condition is often accompanied by low back pain, which can be more or less severe than the leg pain. In addition to pain, other sensations include spasms, tingling or numbness along the sciatic nerve that can travel down the hamstrings, legs and feet. These symptoms can be bilateral or can occur on one side.

The cause of sciatica can range from a misaligned vertebra or disc, to tightened muscles surrounding these structures, to tightened muscles anywhere along the length of the sciatic nerve. It is called true sciatica when a herniated lumbar disc compresses one of the contributing roots of the sciatic nerve. It is called false sciatica when contracted musculature in the buttocks or lower extremity compresses the sciatic nerve. The symptoms are the same for true or false sciatica.

The sciatic nerve passes through a mass of the hip’s external rotator muscles. The sciatic nerve exits the greater sciatic foramen and can run superficial to, deep to or even through the pirformis muscle. Spasm in the piriformis muscle can cause compression on the sciatic nerve sending pain, tingling and numbness down the posterior leg. This description falls into the category of false sciatica and is referred to as piriformis muscle syndrome.

Piriformis syndrome is sometimes referred to as “back pocket” sciatica. People that keep a wallet in their back pocket and sit on it throughout the day often develop symptoms of pain in the rear and down the leg. The extra pressure on the buttocks can cause tightening of the buttock muscles which can compress the sciatic nerve. In “back pocket” sciatica, the removal of the offending wallet usually brings relief.

Thanks to the Institute for Integrative Healthcare Studies’ Neuromuscular Therapy and Advanced Deep Tissue Manual, massage therapists have a guide for determining piriformis muscle involvement. If the following three tests are positive, there is a strong indication of piriformis muscle involvement in a client’s sciatica symptoms.

Three Piriformis Syndrome Tests:

1. In the supine position, the affected side’s foot lays out in external rotation (at least 45-degrees), indicating tight external rotators.
2. In the prone position, there is restriction or pain when doing this range of motion (ROM) test for the external hip rotators. Grasp the ankle and bend the knee to 90-degrees. Stabilize the pelvis with one hand on the sacrum and pull the leg toward you (internally rotate the femur). Normal ROM of the leg is about 30-degrees; less than this indicates a restriction. Test both sides and compare.
3. Palpation of the piriformis muscle elicits pain and tenderness.

Important Considerations for Piriformis Work:

1. During ischemic compression, it is normal for there to be some soreness. The pain and any referral of pain should diminish slowly within 30 seconds. If the pain or referral intensifies, this may indicate pressure on a nerve instead of a muscle. If this is the case, release the pressure.
2. Be careful not to go in too aggressively in an attempt to work through the gluteus maximus to contact the external rotators. Instead, visualize sinking through the gluteus and direct your attention to the piriformis. Myofascial release can be used here to access the piriformis.
3. Repeatedly check in with your client, as you do not want to further irritate an already inflamed sciatic nerve.

Locating the Piriformis:

The piriformis is deep to the gluteus maximus. It laterally rotates the hip and adducts the thigh, when the hip is flexed. Its origin is the anterior surface of the sacrum and it inserts on the greater trochanter of the femur.

Art Riggs, Certified Advanced Rolfer, CMT, gives us help in finding this muscle in his book, Deep Tissue Massage:

1. Locate the top of the greater trochanter.
2. Palpate for the piriformis tendon about half of an inch medial to the trochanter.
3. Locate the midpoint of the sacrum’s lateral border.
4. Draw a line between the top of the trochanter and the midpoint of the sacrum’s lateral border – the piriformis follows this line beneath the gluteus maximus.

Massage techniques for Piriformis Syndrome:

According to Whitney Lowe in Issue 106 of Massage Magazine, the following massage techniques are highly effective in releasing the piriformis muscle:

1. Use static compression on piriformis myofascial trigger points.
2. Do longitudinal stripping along the length of the piriformis muscle.
3. Have the client prone with the knee flexed to 90-degrees. Ask the client to hold the hip in that position as the therapist tries to medially rotate the hip by pulling the leg into medial rotation. With a moderate degree of contraction, the client is to slowly release the contraction. With this release of tension, the practitioner applies longitudinal stripping to the pirifomis. Compressing and stripping the muscle while it is under contraction magnifies the effect of force and allows the therapist to go deeper into the muscle.

According to Sean Riehl in the The Institute for Integrative Healthcare Studies’ Neuromuscular Therapy and Advanced Deep Tissue Manual, the following techniques are also highly effective in initiating piriformis release:

1. Either skin roll or pull out and hold the gluteal fascia with no oil.
2. Elbow strip from the iliac crest, inferiorly between the sacrum and to the greater trochanter. Add internal and external rotation of the hip with the leg bent at 90-degrees to increase range of motion.
3. Thumb friction medial to the greater trochanter, superior to inferior over the attachments of the external rotator muscles.
4. Friction the quadratus femoris at the femur attachment, then apply static elbow point pressure.
5. Apply static thumb pressure to the piriformis where it attaches to the sacrum. Should the piriformis spasm, bend the knee to 90-degrees and internally rotate the leg while applying pressure to the piriformis; then have the client attempt to externally rotate his/her leg against your resistance to activate the internal rotators. This will engage the piriformis and calm it down.
6. After releasing the external rotators, place the client in supine position and stretch by bringing his/her knee up and across his/her body. Stabilize the torso with your other hand. Ask him/her where he/she feels the stretch and move the leg around to get the stretch in the appropriate place.

Riggs cautions massage therapists to maintain a global view of a muscular imbalance. He encourages us to remember that the piriformis may be tight because motor nerves from the spine are making it contract. He advises to include massage on all of the hip rotators and muscles in the low back for sciatica pain.

For those massage therapists addressing sciatica, one final reminder remains stressed by every author of piriformis massage — continually communicate with your client. Ask to be informed of any nerve sensations that travel down the leg as you work. This will be the therapist’s gauge to alter his/her pressure, adjust the direction of force or focus on a different location. Further irritation of the sciatic nerve will deliver results contrary to that which is desired. The practitioner’s goal of alleviating piriformis muscle syndrome can be achieved by inquiring and respecting the directions given by the client.

Recommended Study
Neuromuscular Therapy & Advanced Deep Tissue

A client comes in for a massage, enters a cozy environment and expects to relax. He or she lies down on the massage table, takes a deep breath and anticipates a warm nurturing touch. The atmosphere that a massage therapist has worked so hard to create can be suddenly stopped — like a turntable’s needle careening off of a vinyl record — when ice cold hands contact the client’s skin. As cold contracts tissues, cold hands beginning a massage act against the intended outcome.

Before cruising down this list of warming suggestions, make certain that your hands are not cold due to a medical condition. Thyroid imbalance, diabetes mellitus, Raynaud’s disease, atherosclerosis and congestive heart failure can be contributors to cold extremities that require medical attention.

Listed below are seven ways for a massage therapist to warm their hands before giving a treatment:

1. Hydrotherapy – This is a little different than simply running your hands under hot water to warm them. If you have access to two basins, fill one with cold (not icy) water and one with hot (not scalding) water. Dip your hands in the hot basin for 30 seconds then plunge them into the cold water for 10 seconds. Repeat a few times. The alternation of temperature creates a pumping action that increases circulation.

2. Hot Stone – Convenient if you do Stone Massage, holding a hot or warmed stone can transmit that warmth to your hands.

3. Imagery – Spend a few moments to think your hands hot. You can use a memory such as imagining yourself on a beach in the summertime, and pouring the heated sand from hand to hand. A mantra such as “My hands are warm,” can focus your physical energy to match your thoughts.

4. Paraffin – If you have a warm paraffin wax basin, use it to dip your hands into. Not only does the paraffin warm your mitts, but it also softens them. This probably goes without saying, but remove the wax before beginning a session!

5. Chemical Heat Pack – These resourceful devices are inexpensive little packs that can be found in a sport or ski shop. When activated, they maintain heat for quite a few hours. You can keep the pack in a pocket and use it to warm your hands in between clients.

6. The Windmill – Make sure you have plenty of space for this exercise. With a comfortable forward stance (front foot pointing forward, the rear foot at a 45-degree angle), extend the arm on the same side as your rear foot by straightening your elbow, wrist and hand. Focus your energy out of your middle finger and swing your arm around in a windmill fashion 10 to 15 times. Switch directions of your circling. Repeat on the other side. Do not attempt if you have a shoulder injury. This exercise will bring a rush of blood, and therefore warmth, to your upper extremities.

7. Qi Ball - The qi ball exercise teaches you how to feel your own energy and increase its accessibility at your fingertips. Stand in a relaxed position with your feet shoulder width apart, your knees slightly bent and your pelvis tilted forward. With your elbows bent and your arms held away from your body, configure your arms and hands as if you were holding a basketball. Hold this position until you can feel the imaginary ball (this may take several minutes). Then slowly and steadily move your hands apart and together ever so slightly. As you pull your hands apart and then push your hands together, you may experience a magnetic feeling between your palms. When your palms get close together, you will feel a radiation of heat between them.

The last suggestion is just one of the many qi gong methods that can warm cold hands. Qi gong is an ancient Asian art form that may or may not use physical movement to exercise one’s energy internally. Its purpose is to perpetuate health by invigorating qi (energy) flow within the body. Qi gong is the basis for all martial arts and energetic touch modalities.

Many massage therapists struggle with low hand temperature. This struggle is especially common in colder climates. Look through this list of suggestions and experiment with the choices that appeal to you. Before you know it, your freezing digits will be a thing of the past.