Another Way to View Piriformis Problems

I work with a LOT of runners. I am very accustomed to the typical tight hamstring and/or tight external hip rotators (piriformis, superior gemellus, obturator internus, inferior gemellus, quadratus femoris and gluteus maximus). When I work on any of those muscles, I often follow the anatomy train (for a FANTASTIC anatomy read, check out Anatomy Trains by Myers) across the pelvis to the opposite side quadratus lumborum (QL).

This month’s moment of epiphany occurred thanks to working on a few dozen athletes at a regional USA Track and Field meet two weeks ago. So many of the athletes exhibited the typical tight external hip rotators and tight opposite side QL that I began to wonder: “How many hip patients have I seen over the years who had this same combination of hip and opposite side low back issues?”

Each one of those runners at the meet was shocked when, after performing ART on the symptomatic hip, I would then work on an equally tender QL on the opposing side. They would ask “Why does that hurt, too?” They were even more surprised to find that they could not hold a side bridge plank with that QL for more than a few moments.

My theory is that upward pull of the tight QL changes the orientation of the opposite femur relative to the pelvis. This altered positioning in turn leads to a tighter external rotator of the hip. The tightness eventually leads to pain that diminishes with therapy, but returns with activities.

Fast forward to today. While hanging out at a local bike shop between patient appointments, I watched a Retul road bike fitting taking place. With every stroke of the pedal, the customer’s left knee swung outward at the top of the pedal stroke. When the cyclist would rest in between computer measurements, I observed his right iliac crest (hip) approximately 1” higher than the left regardless of his position on the bike. And finally, the Retul system “detected” his LEFT leg as longer than his RIGHT leg---meaning my observation of a higher right iliac crest correct. Unfortunately, the “Retul” solution to this problem is to shim the “short” leg. The system isn’t intelligent enough to recognize the interconnectivity of muscle groups and anatomical regions.

Even though there is a supposed relationship between the glute medius and the opposite side QL (see Trendelenberg exam), I constantly find that hip external rotator problems travel with the opposite side QL. What this means is if you have a piriformis problem that never completely goes away, add a routine of QL stretching---especially on the opposite side.

The other take-home message is be careful when someone offers shims or orthotics to account for a “short” leg. If the leg actually is shorter, then an orthotic device is a great and necessary approach. But too much of the time there is a tight group of muscles pulling the pelvis and causing the “short” leg. Find a knowledgeable health care provider to give a thorough evaluation of the entire body before sticking devices beneath your feet.