Unfortunately, a patient who arrives with a "diagnosis" of sciatica is likely to have no idea as to the actual origins of their pain. Diagnoses can superficially seem reassuring. It seems that having a latin term assigned to one's pain by an expert tends to make everyone feel better. Diagnoses can also foster hidden (and incorrect) assumptions about the origins of a pain pattern. For example, when presented with the term "sciatica" most people would assume that the patient has some form of nerve compression at the spine. Some more insightful practitioners may recognize that the sciatic nerve could be compressed at various muscular sites as well. Few would trace the origins of the pain to muscular referral from myofascial trigger points.
Sciatica is a symptom, not a diagnosis; its cause should be identified. a
Most cases of sciatic pain pattern are due not to nerve involvement, but to a very common referral pattern from the gluteus minimus muscle. Trigger points in the anterior gluteus minimus often refer pain in a lateral leg distribution, not uncommonly being felt more strongly below the knee than above.
The Myth of the "Tight IT Band"
Lateral leg pain may trigger other misguided diagnoses. The situation is equally confusing when the patient, perhaps in concert with a doctor or therapist, interprets their combination of poor adduction, tight hips and a sciatic distribution down the lateral leg as a "tight IT band" that requires stretching. This misinformed view, very popular in the sports and workout worlds, is unfortunately supported by nearly every personal trainer, running partner, massage therapist, yoga instructor and movement professional that the patient may choose to communicate with.
...the IT Band is some dense connective tissue and probably can’t be permanently deformed. While it may be stretched in the short term this is due to its viscoelastic properties (i.e. adding a bit of grease or shaking out the cobwebs) rather than any means where it is actually permanently lengthened. Actual lengthening would require you to damage your IT Band to get it into a lengthened state. 5 minutes on a foam roller or 10 minutes of daily stretching would not be able to do it. b
There is a much-debated "IT Band Syndrome" that involves lateral and local inflammation near the knee. It tends to occur with anatomical variations such as a bowlegged stance and hyperpronation of the foot which increase the pressure of the IT band across the lateral structures of the lateral epicondyle of the femur. It is popular, but not medically supportable, to describe this condition as a "friction syndrome".
We would thus suggest that the ITB cannot create frictional forces by moving forwards and backwards over the epicondyle during flexion and extension of the knee...Our view is that ITB syndrome is related to impaired function of the hip musculature and that its resolution can only be properly achieved when the biomechanics of hip muscle function are properly addressed. c
Many practitioners overlook the contribution of trigger points in the gluteus maximus and TFL toward increased tension in the IT band.
The occurrence of pain over the palpable IT band is very misleading. This is generally the case with referred pain, which is likely to occur very convincingly over joints and other structures that are then blamed as the source of the pain, particularly if the structure is demonstrably imperfect via imaging. Attempts to "roll out the IT band" in an attempt to "stretch" it may bring some temporary relief, but the pain returns after a short time. Rolling the lateral leg on a foam roller has little impact on the IT tract, but may influence myofascial trigger points in the vastus lateralis. VL trigger points can cause localized lateral knee pain that is very similar to that caused by IT band syndrome. If the VL is itself a satellite referral target of the minimus, the pain will remain until the minimus is dealt with directly. There could be a referral contribution in the upper leg from the TFL as well.
You Can't Stretch the IT Band - Nor Would You Want To
The web is replete with thousands of images of "the best IT band stretches". Given that the iliotibial tract is an extremely tough body of connective tissue that provides the TFL and gluteus maximus a strong lever to move the leg and stabilize the knee, stretching the IT band itself would be a very bad idea -- if it were even possible. The iliotibial tract has extensive fascial attachments to the femur along its length, and is essentially just the lateral, thickened portion of the fascia lata, which is a fascial bag that envelops the thigh. The IT band itself does not and cannot limit adduction, which is often evaluated via a test known as Ober's sign.
Ober's sign assesses the ability of the femur to adduct and drop to the floor in side position. The abductor muscles of the hip are in a position to limit this test, and taut fibers due to trigger points in those muscles will keep the muscle short, cause referred pain in the glutes, hip, low back and down the leg, and will resist stretch unless the tender points are treated.
Treating Lateral Sciatica Pain Patterns
All of this points to treating trigger points in the hip muscles as a sensible treatment approach for lateral leg pain, one that we include in our CTB classes dealing with Hip, Thigh, Knee and Groin pain. It is often useful to initially compress tender points in the gluteus medius, gluteus minimus and TFL with these muscles in a relatively shortened position (see the lead image for this article). Hips tend to get taut and hardened in people with these complaints, making the muscles difficult to treat under stretch and also likely to contract on the short. Mechanical pressure during shortening followed by post-isometric relaxation is excellent therapy for these muscles. For an excellent real-life example, see Doug Ringwald's case study on treating sciatica in a single session by addressing gluteal trigger points.
By treating the hip and VL muscles first, followed by progressive stretching, the client is likely to see a rather quick reduction in lateral leg pain along with increased adduction, all without any attempt to stretch or foam roll the IT band. While foam rolling at home may help address trigger points in the vastus lateralis muscle, that muscle is a satellite referral target for the gluteus minimus and as such is unlikely to be the sole source of the pain. Rolling the hips with a lacrosse ball followed by adduction stretching is likely to be a far better use of the client's precious time if it comes down to a choice.
This is not the end of the story of lateral leg pain. Some patients do indeed have sciatic nerve involvement, although in my clinical experience that number is far less than the number of misdiagnosed cases of trigger point referral. The quadratus lumborum muscle is frequently a key muscle that sets up a chain of referral all the way down the leg, and is very sensitive to lateral asymmetries such as effective leg-length discrepancy. That's a topic for another article.
- Travell and Simons, The Trigger Point Manual - The Lower Extremities p. 191 (back)
- Greg Lehman, DC - The mechanical case against rolling your IT Band. It can not lengthen and it is NOT tight. http://www.thebodymechanic.ca/2012/03/17/stop-foam-rolling-your-it-band-it-can-not-lengthen-and-it-is-not-tight/ (back)
- Fairclough, et. al., Is iliotibial band syndrome really a friction syndrom? -- http://www.ncbi.nlm.nih.gov/pubmed/16996312 (back)