0:04 This is Brent of the Brookbush Institute and in 0:06 this video we're going over static 0:07 manual release of the piriformis. Now, if 0:10 you're watching this video, I'm assuming 0:11 you're watching it for educational 0:13 purposes and that you are a manual 0:15 therapist, and in your state it 0:18 specifies that manual release techniques 0:20 are within your scope. Now, this probably 0:22 goes for all athletic trainers, physical 0:24 therapist, chiropractors, osteopaths, 0:26 licensed massage therapists. You're all in 0:28 the clear. However, personal trainers, 0:31 probably not. Now, before I have a patient 0:35 or a client on the table to do any 0:37 release technique, any manual work, I'm 0:39 going to be pretty sure from my 0:42 assessments that that technique is 0:44 necessary, especially when it comes to 0:46 things like the piriformis or adductors, 0:48 where we're getting into more sensitive 0:51 areas. Obviously, if somebody came in for 0:53 shoulder mobility issues or shoulder 0:55 pain and you start palpating their 0:57 backside, they're going to wonder what's 0:59 up. Make sure you have a good working 1:01 hypothesis before you're doing manual 1:03 techniques. I'm going to have my friend, 1:04 Brian, come out. He's going to help me 1:06 demonstrate this technique. Now, all of 1:09 these manual release techniques 1:11 basically come down to locate the muscle, 1:15 be able to palpate that muscle, and 1:16 compress that muscle. You get bonus 1:19 points if you know where the trigger 1:20 points are, because those are your common 1:23 points of tightness and having a general 1:26 idea of where to place your hands will 1:28 speed things up a little bit. I've 1:30 done the due diligence of marking out 1:32 some landmarks here that we need. I put 1:35 this piece of tape over the posterior 1:38 iliac spine, and then you can see it 1:40 curves down here. Well, I hope you guys 1:42 can see a little bit that it curves down 1:44 here over the sacrum. If you can't, you'll 1:46 get to see that in the close-up. And then 1:49 here, we have the greater trochanter. 1:52 The piriformis runs from anterior sacrum 1:57 to greater trochanter. The last thing we 1:59 need to consider, anatomically that is, is 2:01 the fact that the piriformis is actually 2:05 deeper than the glute max. So, we have to 2:08 find a way of differentiating between 2:10 glute max and piriformis fibers. 2:13 My glute max fibers generally run this way, 2:16 or vertical, whereas my piriformis is 2:20 horizontal. So you guys should be able to 2:22 notice that if you go this way, you can 2:26 strum some glute max fibers. They're 2:27 pretty thick. They're pretty broad- 2:30 that's a big, thick muscle. Now, the 2:32 piriformis fibers- if I go a little 2:34 deeper and I go superior to inferior 2:36 this way, then I start strumming. I have 2:40 to get pretty deep though. You guys can 2:42 tell if you go shallow and go superior 2:43 to inferior, you don't get any- you don't 2:45 feel fascicles, you don't feel strings of 2:49 muscle fibers. Now, as far as finding the 2:54 tense point, I'm going to go just below 2:56 my iliac crest here. I'm going to go 3:00 ahead and start around the sacrum. I 3:02 happen to know that the piriformis 3:04 trigger points are either generally very 3:07 close to the sacrum, or right in the 3:09 middle of the belly of the muscle. So if 3:12 I take this nice, broad thumb this way, 3:14 I can go from superior to inferior. 3:18 I'm going to start by looking for really 3:20 tight fascicles, because we're going to 3:22 assume that even if it's a tight trigger 3:25 point nodules, that they're still going to 3:27 pull the fascicles they're attached to 3:29 pretty tight. Once I found those tight 3:32 fascicles, I'm going to go ahead and move 3:34 maybe towards his greater trochanter if I 3:36 feel like that's where the more of the 3:38 tension is coming from. Once I find 3:40 that nodule, I would then compress. Or if 3:43 I feel like it's more towards the sacrum, 3:45 I could move back all the way to his 3:48 sacrum and see if pressing superior to 3:52 inferior, a little medial to 3:55 lateral there to find the most 3:58 dense tissue until I find that trigger 4:02 point, and then I could compress there. Now, 4:04 I'm showing you guys all of this on this 4:05 side so that you can see what I'm doing, 4:09 but the truth of the matter is that from a 4:11 technique standpoint, from a body 4:13 position standpoint, I'm going to want to 4:14 be on this side. I'm going to 4:17 want to do the piriformis that 4:18 is closer to me. I'm even going 4:20 to show you guys a little bit of a trick 4:22 here. If you have somebody in neutral 4:24 position, their piriformis is actually 4:28 not very 4:28 tight. It's actually kind of in a 4:30 neutral length, and if you just start 4:33 pressing down, you might start playing 4:35 that game of like trying to put your 4:37 finger on top of a marble, or you may 4:39 just press straight into mush. There's 4:41 not a whole lot of feedback. So what I 4:43 like to do, assuming that somebody has no 4:45 knee issues, is go ahead and take them 4:48 into knee flexion and then tuck their 4:50 foot into my arm here, right in my elbow, 4:54 on my armpit. And that way, as I'm 4:57 palpating his piriformis, here, I can pull 5:00 Brian into internal rotation, which is 5:05 going to lengthen his piriformis and 5:07 increase the tension a little bit, right 5:10 so that now those fibers are pulled just 5:13 a little taut. I'm not trying to stretch 5:15 his piriformis this way, but I want 5:18 those fibers pulled a little taut, so that 5:19 when I go to press on that trigger point 5:21 it doesn't do this to me. Alright, so I'll 5:24 pull down. Once again, broad strokes. I'm 5:28 going to go superior to inferior to find 5:30 those fascicles, and then I'm going 5:34 to go either proximally towards his 5:36 sacrum, or distally towards his greater 5:41 trochanter until I find the most tender 5:44 point. I'm going to use this hand as my 5:47 dummy thumb in this case. I'm 5:50 going to go ahead and put the other hand 5:52 to apply pressure. I'm going to try to 5:54 straighten out my arms to get as much 5:56 tension as I need here, and then I'm just 5:59 going to lean in with my body weight 6:01 until I feel that point where the tissue 6:04 density really starts ramping up. I don't 6:07 want to go all the way to the tissue end 6:10 point. I don't want to go all the way to 6:11 an end feel. I don't want so much pain 6:14 that I actually get the muscle 6:15 contracting under my fingers. Then I'll never 6:17 get a release. But if I go right up to 6:19 the point where I feel that increase in 6:21 tissue density, and I lean until I feel a 6:25 release underneath my fingers, that is a 6:27 decrease in tissue density, or Brian 6:30 tells me. You still feeling that? Alright, 6:33 he's still feeling that. I'm going to 6:34 hold for a few more seconds. If he 6:36 says that 6:37 he no longer feels the soreness, he 6:42 no longer feels the uncomfortableness, 6:43 the discomfort, then we can go ahead and 6:47 move on. It's starting to let go, right? Yes, it's a lot looser now. 6:51 Your piriformis was pretty 6:54 jacked up. Alright, next up we'll do 7:01 our close-up recap, guys, but I hope from 7:03 this position you guys can see my 7:06 body position. Manual therapists, you 7:09 always have to be thinking about you 7:11 first, and I know that sounds crazy. But 7:14 notice once I had him in position, my 7:16 arms were straight, I pulled him into 7:19 as much internal rotation as I needed, 7:21 and all I'm using is body weight. 7:23 Specifically, this hand is pressing over 7:26 this hand which is totally relaxed, so 7:29 that I'm not wearing out joints. I'm not 7:31 putting myself in a compromised position. 7:32 Okay, guys, here's our close-up recap. You 7:35 can see I've marked out the posterior 7:38 ilium. I've marked out the sacrum, here, it's 7:41 where this tape turns down. And then I've 7:43 marked out the greater trochanter. We 7:45 know his piriformis goes from anterior 7:47 sacrum to greater trochanter, deep to 7:50 those vertical glute fibers. To add 7:53 tension to his piriformis so that I'm 7:56 not playing the "try to put my finger 7:57 down on a marble," or I'm not just pushing 8:01 into mush because all of these muscles 8:03 are relaxed in this position, I can add 8:06 tension by pulling Brian into internal 8:09 rotation here. So, I'm going to tuck his 8:11 foot up in my arm. I'm going to strum 8:14 superior to inferior to find those 8:16 horizontal fibers. Once I find the 8:19 tightest fascicles- it helps to know that 8:22 most of your trigger points are going to 8:23 be located either closer to the sacrum or 8:25 in the middle of the belly of the muscle- 8:27 so once I find those tightest fascicles, I'm 8:30 going to move in one direction or the 8:31 other until I find a nodule or acute 8:35 point of increased tissue density. I'm 8:37 then going to apply pressure by letting 8:41 this hand relax and placing the other 8:44 hand over top, straightening out my arms 8:47 and leaning in. 8:49 I'm then going to hold that until I feel a 8:51 release or I can do the other protocol, 8:54 which would be five seconds on, two 8:56 seconds off, five seconds on, two seconds 9:01 off. I think I've mentioned in previous 9:02 videos that I do tend to gear towards 9:05 the the static hold, and usually 30 seconds 9:08 to 2 minutes does the trick. I hope you 9:12 guys enjoyed this video. I hope you add 9:14 static piriformis manual release to your 9:18 repertoire and use it when necessary. 9:20 Let's talk a second about what 9:22 assessments would lead me to believe 9:24 that the piriformis needs to be released. 9:26 If we're talking about the overhead 9:28 squat assessment, we're talking about 9:30 knees bow out, an inadequate forward lean, 9:33 a posterior pelvic tilt, or an 9:36 asymmetrical weight shift, that would be 9:38 the piriformis opposite the side of the 9:40 shift. If we're looking at goniometry, 9:42 we're looking at either a lack of 9:45 internal rotation in prone, or if we're 9:48 doing those supine tests, piriformis will 9:51 actually cause a reduction in range of 9:54 motion in either direction. That has to 9:56 do with that weird action of the 9:59 piriformis where if you get closer and 10:01 closer to 90 degrees, it starts to become 10:04 more and more of an internal rotator 10:06 rather than external rotator. If you don't 10:08 know what I'm talking about, look up the 10:10 piriformis article in www.brentbrookbush.com 10:11 and you guys will see. You could 10:15 possibly consider something like the 10:18 FABER test or the hip impingement test, 10:22 which are both special tests for the hip, 10:24 as also indications that this may be 10:28 tight. From a pathology perspective, 10:31 although I don't like to go from 10:32 pathology to technique, if somebody had 10:35 gotten diagnosed with piriformis 10:37 syndrome or a sciatica, I would also 10:39 definitely put this technique in my 10:44 repertoire just to see if we could get 10:46 any abatement from symptoms. Now, mind 10:50 your scope, mind your technique as far as 10:55 your body position, and, of course, stay 10:58 specific to your assessments. I look 11:01 forward to hearing your 11:02 comments. Please leave your comments 11:04 below. If you have any questions, if you 11:06 think I left anything out, please let me 11:09 know. I'll talk with you guys soon. 11:18 you
