Sciatica is pain radiating down the path of sciatic nerve. Some cases of sciatica are from piriformis syndrome, compression of the sciatic nerve caused by a hypertonic or abnormal piriformis muscle. Massage has been found to decrease pain and disability as well as improve range of motion and quality of life in persons with these conditions, especially when combined with muscle energy techniques and heat applications.
Sciatica refers to pain radiating down the path of sciatic nerve. Pain usually originates in the lower back or hip and travels down to one side of the posterior thigh and leg, but both sides may be affected. Some cases of sciatica are from piriformis syndrome,
Most often, sciatica is a symptom of another condition such as herniated disc or stenosis from bone spur. Piriformis syndrome is another possible cause, or compression of the sciatic nerve caused by a hypertonic or abnormal piriformis muscle. Part or all of the sciatic nerve runs through the piriformis in approximately 15% of the population (Travell & Simons, 1993). However, most cases sciatica are not due to piriformis syndrome. Sometimes, the cause of sciatica is unidentified. Radicular pain originating in the lower back radiating to the buttocks and thigh is the hallmark symptom of sciatica. Paresthesia and peripheral neuropathy are common. The affected person may experience muscle weakness and have difficulty walking. The area may also be tender to the touch. Piriformis syndrome starts with pain, tingling, or numbness in the buttocks and may extend down the length of the sciatic nerve.
Initial treatment is usually conservative and may include the use of ice, massage, ultrasound, and medications (analgesics, corticosteroids, anti-inflammatories, skeletal muscle relaxants). Physical therapy and chiropractic procedures, along with back and abdominal exercises, are often helpful. A medical procedure called an epidural injection is another option and involves injecting medication into the affected area. Surgical approaches are indicated if conservative measures fail or if motor or sensory deficits are significant.
Massage Considerations – Pay close attention to the client’s level of discomfort. If the client is in severe pain while performing tasks related to getting a massage (removing a jacket, sitting in a chair, climbing on a massage table), he or she may not be a good candidate for massage. In this case, it is best to postpone massage until a day when the client is experiencing less pain.
Otherwise, position the client for comfort. If the client is uncomfortable lying prone, opt for a side-lying or seated position to address the back. Gentle decompression or traction techniques may be used to relieve symptoms. Muscle spasms along the spine may be serving a protective purpose and may remain or return shortly after the session. If relief from muscle spasms is one of the client’s treatment goals, be sure this information is conveyed to the client and reflected in the treatment plan. Avoid using aggressively applied passive stretches and joint movements to the spine or hip. Clients with sciatica are prone to additional nerve injury at pressure points (e.g., behind the knee, front of the ankle). For this reason, use a soft rather than stiff bolster in these areas.
Orthopedic physical tests such as the straight leg raise test can be used to evaluate the presence or absence of lumbar disc involvement in clients who present with symptoms of herniated or bulging disc, but do not currently have a diagnosis of this condition. A positive result may warrant referral to the client’s healthcare provider for medical evaluation.
For piriformis syndrome, massage may help reduce a tension in the piriformis, reducing subsequent sciatic nerve compression. Use deep effleurage and friction over the femoral attachment and along the length of the piriformis. This includes the lateral sacral border and just medial to the greater trochanter. Laterally rotate the hip and flex the knee and massage the muscle in a shortened position. Some practitioners use sustained pressure over the piriformis while moving passively adducting and abducting the hip by moving the leg in an arc. Consider incorporating hot packs and muscle energy techniques into the session to improve treatment outcomes. Recommend self-stretching of the piriformis to help clients maintain or improve their treatment goals.
View this video for technique recommendations for clients with lower back pain.
View this video for technique recommendations for massage over the buttock area.
Straight leg raise test. This test may identify sciatic nerve involvement, disc involvement, and lumbar radiculopathy. Assess the unaffected side first. While the client lies supine, passively flex the hip by lifting the leg off the table with one hand; maintain knee extension with the other hand. Ask the client to inform you if and when symptoms occur. Discontinue the straight leg raise when symptoms occur or when full ROM is achieved. Symptoms are more likely to occur when hip flexion reaches 35% to 70%. A positive test occurs when pain and paresthesia occurs down one or both lower extremities, and may warrant referral to the client’s healthcare provider for medical evaluation.
Research. A 45-minute massage directed mainly to the muscles of the lumbar spine, thigh, and leg regions administered once a week for 6 weeks increased ROM and decreased lower back pain and improved quality of life in a 58-year old female with sciatica (Bell, 2008). A 30-40 minute sessions of muscle energy techniques and deep friction massage administered six for 6 days in a week shows greater improvement on pain, disability and range of motion compared to the control group who received ultrasound and piriformis stretching at the same intervals among individuals with piriformis syndrome (Kutty et al, 2020). Both groups received hot pack application for 10 minutes prior to muscle stretching to induce muscle relaxation. Home care programs were taught in both groups.
Bell, J. (2008). Massage therapy helps to increase range of motion, decrease pain and assist in healing a client with low back pain and sciatica symptoms. J Bodyw Mov Ther, 12(3), 281-289.
Kutty, N.N., Siddeeque, S., Tamphaibema, H., Azharuddin, Othayoth, N., Bineesh, C. P. (2020). Effect of muscle energy technique with deep friction massage on pain, disability and internal rotation range of motion of hip joint in individuals with piriformis syndrome. Indian Journal of Physiotherapy & Occupational Therapy, 14(1), 148-153.
Travell, J. G., Simons, D. G. (1993). Myofascial pain and dysfunction, the trigger point manual, the lower extremities. Baltimore, MD: Lippincott Williams & Wilkins.
Dr. Susan Salvo is a massage therapist, author, educator, researcher, explorer, and perpetual student. To learn more, check out the “About Susan” tab. You can contact Susan at firstname.lastname@example.org.