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One of my patients woke up the other day with pain that started on one side of her lower back and radiated down her hip, hamstring and into the side of calf. She told me this while I was making pancakes on Saturday morning for our kids. My wife is my number one patient so I’m writing this blog post for her. I know that many of you suffer from some degree of pain radiating down a leg as well. My goal with this blog post is to teach you a few simple strategies to ease these symptoms. Let’s start by defining sciatica. It’s actually an umbrella term describing pain that radiates along the course of the sciatic nerve. The sciatic nerve is a huge nerve that starts in the lower back. It comes together and courses down the hip, through the hamstring and then branches into two other nerves at the height of the knee. If you’ve ever sat on something hard like a wallet for too long on one side, you may have experienced some short term sciatica. What sciatica is and what causes sciatica are two separate things. Sciatica itself is the pain/irritation you feel down the leg. The cause of sciatica can be a number of different things. First, it could be coming from your lower back. This could be due to a bad disc herniation, poor movement at the small joints in the lower back, lack of mobility in the hip and even prolonged positional pressure like sitting on a plane to Australia. Because of the many varying causes for sciatica, my goal is to give you a number of different self-management options. We’ll cover three different areas where you could improve and ease much of the sciatica that you do experience. These areas are:
Step 1: Easing sciatica issues by getting out of positions that cause increased symptoms This seems blatantly obvious to most people. The reality is that many people stay in pain producing positions for extended periods of time. For instance, let’s take a traditional office-based job. Sciatica can be irritated with prolonged sitting, especially in a very flexed position. This puts the lower back into a flexed or rounded position. Because of this forward flexed position, the discs (think shock absorbers) of the lower back had additional stress placed on them throughout the day. Take a look at the picture below. This shows the amount of pressure on the discs of the lower back in different positions. You can see that sitting in a forward flexed position increases the amount of pressure on the discs by 85% compared to standing. Even sitting in a good position increases the pressure by 40%.  What this shows us is your best option is to stand more, if possible. Even better, stand up and walk around more. Walking is like spraying WD-40 on the joints of the lower back and hips. Getting a standing desk is a good option for most people. They are becoming much more common in workplaces and even in schools. Stand Up Kids is a great reference for some of the other health benefits to getting a stand up desk. If you are stuck sitting at a desk and you notice your back feels better when you stand, a lumbar roll may be a good option for you. These are firm rolls that are placed at the height of the lower back. They block the user into a more upright sitting position and deter much of the slouching that we see when people sit at a desk all day. You can also make yourself one of these pretty easily. Just get a gym towel, roll it up tight and duct tape around the roll. That’s it. It may not look as cool but it works. Step 2: Easing sciatica issues by adding in self-mobility work to muscles in the lower back and hips Let’s go over two areas you can start working on daily to help ease pain down the leg. For all of these areas our dosage is this: perform them twice a day, two minutes each technique per side. For all three techniques it should take you about 8-10 minutes with transitioning from one exercise to the next. The first muscle is the quadratus lumborum. We’ll just call this muscle the QL because the actual muscle name sounds like a Harry Potter spell. The QL is a muscle that is one either side of the lower back and connects from the rib to the lower back to the pelvis. This muscle can refer pain down into the back of the hip region and is notorious for being irritated in people who sit all day or lack strength in their trunk. The second muscle is actual a group of muscles. We call it the lateral hip complex but it includes fibers from the gluteus maximus, gluteus minimus, gluteus medius and deep rotators like the piriformis. These muscles, in particular the piriformis get blamed for much of the sciatica people experience. We’ll catch a little bit of all of these muscles with this one technique. Step 3: Working on improving control of the lower back and hips This step is often the one that people skip over. This is especially true if someone gets pain relief with some of the mobility techniques or a passive treatment like dry needling or massage. Controlling your own body is massively important. I love the saying, “Strength is never a weakness,” and it’s true in this case. Here are two techniques to get some control back in the right areas. The first thing we want to do is account for a huge area of dysfunction in almost every patient I see. That area is breathing! I know, you’re obviously breathing if you’re alive and reading this article. Just because you’re breathing doesn’t mean that you haven’t started doing it in a compensated way. We take an astounding 20,000 breaths per day. Many of us who have had issues with sciatica or lower back pain tend to breath in a dysfunctional pattern. The main dysfunctional pattern I see in my patients is chest breathing. These are the individuals that just raise their rib cage and shoulders every time they breath. What they neglect to use is the diaphragm to initiate the breath movement. This can happen for a number of reasons but for the purpose of this article let’s just leave it as something we want to try to correct. Below is a breathing exercise you can start using to correct this problem. Try and get 5-8 minutes of this breathing drill in per day. You can break it up into 1-2 minute bouts or get the whole 5-8 minutes in at once if you want. The last exercise you can add in is to help develop some control in extension between your lower back and hips. This is an exercise called the banded bird dog and it requires a significant amount of stability/control. It also connects the hip with the shoulder on the opposite side. This is very important because we function so much in rotational patterns. Think about throwing a ball. If you’re throwing with your right arm then your plan leg is your left leg. This diagonal control is very important for the lower back and controlling torque through the spine. Getting strong in this pattern is one of the best ways to create long term function and decrease the likelihood of sciatica issues. Try and do 3 sets to form fatigue with as much rest in between sets as you need. Form fatigue is when you can’t perform a perfect repetition anymore. If you’re like me you probably read the highlighted bullet points and then you’ll read this last paragraph (I call it efficient reading!). Let’s go ahead and summarize everything and make sure we’re clear on what to do. First, get out of positions that cause sciatica. Move to a standing desk if possible and if not get up and move around as much as you can. Next, start working on mobility to areas that can be problematic for sciatica. This includes the QL and the lateral hip. Last, start getting some control back in your hips and lower back. Control and strength in these areas will be a huge benefit to you in any physical activity you chose to do. Give this stuff a try for a week or two. If you feel like you’re not making progress or are ready to get some one on one help, we can help. We help people just like you get back to running, golf, tennis, CrossFit and cycling without sciatic pain. Check out our testimonials pain to see what others have to say about the work we do. Stop avoiding activities because of pain, get some help and get back out there. - Dr. Danny, PT, DPT, OCS, CSCS
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Last week I outlined some mobility restrictions that are likely the culprit if you have pain or trouble with squat pattern. Hopefully you have tried those mobility exercises out, even if you think you are flexible. There is sometimes a lingering asymmetry here and there from past injuries and such. So, you checked your mobility and you have the ideal mobility for a squat. What else could it be? The “butt wink” is a pelvic reversal or loss of the lumbar curve at the bottom of the squat. A few things can cause this—bony architecture and tibia to femur ratios, lack of mobility usually in hip flexion or internal rotation, and/or poor motor control throughout the squat pattern. I will not get into the debate of the first possibility. Yes, we are all unique snowflakes, but let’s make sure our mobility and control are up to par before we blame our parents. To be sure you are setting yourself up for success, check and see if your foot placement is ideal for your bony make-up and mobility. This is best done on your hands and knees with a partner watching and preferably filming. Make sure that your hands are below your shoulders. Rock forward and backwards the finally settle at the center—ask your partner to confirm that you are actually centered. From here, slowly push your hips back as if moving to child’s pose.  Watch your pelvis; when you notice that is starts to rock backwards, this is where your butt wink starts when you are standing with this foot distance. Now widen your knees out a few more inches and repeat. Did the pelvic reversal look the same, better or worse? If better, a wider stance in the squat would work better for you. If worse, stay narrow. If the pelvic position was the same, check in with how your hips felt during each of the two foot positions. Say in the wider squat you felt a bit of pinching, then stay narrow. Top picture: no butt wink, so a good foot position. Bottom picture: butt wink, so I will likely have a pelvic reversal with a squat to this depth or deeper.   Going a step further, you can move to your forearms to mimic the forward inclination of the torso during a squat. Perform the same steps. In the picture below, this is right before I start to have a pelvic reversal, so this is my target depth with loaded squats.  After finding the correct foot placement, stand up and try a few more squats. Is the butt wink still there? Yes: if you are in the correct foot position and have ideal mobility, keep reading! Many of the athletes that I treat fall into these categories: Very flexible and can squat with their booty to their ankles Report feeling tightness in their hamstrings, even though they can bend forward and put their palms on the floor Have back pain with squats that increases at the bottom of the squat, often one-sided but not always Always sore in the quads after squats, rarely glutes or hammies Does this sound like you? Here are two of my favorite exercises to start working on motor control of the lumbar spine, hip and pelvis under load as well as posterior chain strengthening. The tempo goblet squat: This exercise forces anterior stabilization by adding a weight at the chest. The deep core must fire to offset the kettlebell. With a 3 second count lowering to the box, motor control of the lumbopelvic area is even more challenged. Additionally, squatting to a target allows the athlete to sit back more in the squat, engaging the glutes and hammies. This is often a new input for these athletes who are quad dominant. Check it out here: Goblet Box Squat The banded bird dog: Practicing moving your extremities while under the load of a small band is important before you try to move big weight. The bird dog requires hip and midline control with movement, made a bit harder by adding a band. Again, having a partner for a form check or performing this by a mirror is ideal. Many people will have a movement fault and not even realize! The goal is to keep the back and torso in the neutral position throughout. As soon as your form falters, take a break. Check it out here: Banded Bird Dog Add these exercises to your strength days and/or warm up a few times each week. Maintaining your core and pelvic control throughout the range of motion is the first step to easing back pain and improving your strength in the squat! If you try to self-manage for a few weeks and still see no change, let us know. We would love to help you here at Athletes’ Potential!
Dr. Jackie, PT, DPT, OCS, CSCS Whether you are looking to PR your squat, want to squat without pain or are just sick of nagging lower extremity pain—this is where the change needs to begin. This week I posted a picture on social media of a patient who started the session with a squat that deviated to the right and then after some mobility she was centered. This started a lot of conversation from athletes asking for help with this exact issue. First, check out your mobility. Remember: symmetry is important in a squat so be sure to check both sides and compare! Pain and dysfunction in the back, hip and lower extremity can absolutely be caused by a laundry list of issues, but sometimes we make it more complicated than it needs to be. The best way to begin to decrease pain and improve function is to find the low hanging fruit and start there. At Athletes’ Potential we use a group of movements to screen every patient with lower extremity complaints. The last movement is always a body weight squat. Not because every patient we treat is a weightlifter and wants to improve their squat, but because it is a foundational movement that everyone should have the requisite mobility and strength to perform. The first two places to look for a mobility restriction are the ankle and the hip. A few indicators of ankle restriction during the squat often comes in two forms: the people that feel like they will fall backwards if their chest is up any higher (pic 1) OR those who look like they have a solid squat but on closer look, their ankles are collapsed and spin outward (pic 2&3).    Ankle dorsiflexion is essential to have a deep squat with an upright torso. The best way to check your own ankle mobility: place your foot a hand width from a wall (in a lunge position), with the foot in that position drive your knee toward the wall making sure that your heel stays down. Can it touch the wall? If yes, move on to checking hip mobility. If no, your ankles are limiting your squat!   Our favorite ankle mobility drill uses a band to distract the ankle and then move it through range. Check it out-- Ankle distraction and dorsiflexion Ankles can be a frustrating joint to mobilize because they are slower to change. It is important to work ankle mobility into your warm up and/or cool down as much as possible! As you begin to chip away at ankle restrictions, check out this older blog post about the best way for you to modify a squat until your mobility is improved: Is squatting bad for my knees? Part II To self-check hip mobility there are a two hip movements that are important to check- hip flexion and hip internal rotation. When you are missing hip flexion and/or internal rotation, there may be a pinching sensation at the front of the hip during a squat or you have a “butt wink” at the bottom. To check hip flexion, lay on your back and pull your knee towards your chest. Ideally, you will be able to get your knee about a fists width from your chest. As you apply overpressure with your hand, you might notice your pelvis start to lift off of the floor. This is actually lumbar flexion, which is synonymous with a ‘butt wink’. The athlete below is experiencing this a bit, I think he was trying to show off for the camera. ☺  When checking internal rotation, sit on a table or box so that your feet are not in contact with the ground. Internal rotation is the motion when your foot moves outward from your body when your hips and knees are bent. We like to see 40-45 degrees, as in the picture below. Be sure that as you rotate your hip, you don’t bring your booty off the table and lean to make it go further!  Lacking hip flexion? Here is a great sequence to work through-- Hip Flexion Mobility
Is your internal rotation less than ideal? Is one side much less than the other? Give this a try-- Anterior Hip Opener with Internal Rotation Maybe you check all of these areas and you have the ideal mobility. What else could it be?? Really bendy athletes are on an opposite end of the spectrum from more immobile athletes. In fact, banded mobility and banded distractions won’t help you at all! If this is you—stay tuned for Part II that covers the limiting factor of the squat for flexible folks. Thanks for reading, Dr. Jackie, PT, DPT, OCS, CSCS |
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