Decoding Leg Pain: Part 1 - The Truth About Piriformis Syndrome

In this episode of Ask the Chiropractor, Dr. Brant Hulsebus, a chiropractor from Rockford, Illinois, explores the common misconceptions between sciatica and piriformis syndrome. He starts by explaining the structure, function, and irritation of the sciatic nerve, and how it is often confused with piriformis syndrome. Dr. Hulsebus covers the symptoms, causes, and diagnosis of piriformis syndrome, including tests and x-ray evaluations. He further distinguishes the two conditions and emphasizes the role of chiropractic care in diagnosing and treating these issues.

www.rockforddc.com

Transcript

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Hello, Dr. Brant Hulsebus here and welcome to another edition of Ask the Chiropractor. Ask the Chiropractor is my little podcast that I do when someone has a question about chiropractic or chiropractic care, I try to answer. I'm a chiropractor here in Rockford, Illinois. I'm a proud graduate of Palmer College of Chiropractic and I'm happy to be the team chiropractor of the Rockford Icehogs. Let's dive into it. Hi there welcome back to another edition of Ask the Chiropractor. Today we're going to talk about something that most people come in the office pretty confident they know their diagnosis and then really what it is most of the time versus what it isn't. So we have a lot of, and by the way, this is going to be a two part episode because I'm going to talk about usually what people come in with versus what they think they come in with. I'm going to do an episode on each one. What are these two things? Sciatica and piriformis syndrome. We have a lot of people that come in and said, hey, I looked this up on the internet. I know exactly what I have. What I have going on is a thing called sciatica. I said, really? And we take a look at them and we start to do different tests and different x rays and different examinations and we quickly realize it's not sciatica at all. It's Piriformis syndrome. So for this week, I want to tell you a little bit what pure formless syndrome is and why so many people think it's sciatica. And then next week I'm going to tell you about sciatica, this way you can help differentiate the two and if you're watching this somewhere else and you're not in the Rockford area and I'm not your chiropractor, you can check with your chiropractor about these two things. They're very similar, so to think that one's one and one's not the other one, it's not that weird, but I like to go over the differences. First thing we have to do is understand what the sciatic nerve is and what it does. The sciatic nerve comes out of your lower S1. And they come together to form one big nerve. It's usually about the diameter of your thumb. This nerve travels through your pelvis, underneath your glutes, and then starts to innervate the back of your leg, innervates everything then from the knee down. It doesn't innervate your front thigh. That is done by a different nerve called the femoral nerve. So the sciatic nerve is the widest, biggest nerve in your body. Maybe not the longest, there's arguments on that. But it's definitely one of the biggest nerves. Like I said, it's about the size of your thumb. It goes all the way down. It controls all the motor functions of everything knee down and behind the legs. It controls the sensation. That's where you would go to a doctor and they would take a cotton ball and a pinwheel and go up and down and tell you to stay soft or sharp. The dermatome, the skin area. Burning, itching, soreness, pain. These are all things when the sciatic nerve is irritated. So if you were to have sciatica, we would see the lower back be misaligned. But let's switch over now and talk about piriformis syndrome. Piriformis syndrome is a muscle, the piriformis muscle. It's underneath your gluteal muscles. And if your pelvic should rotate, And tailbone does not. Your piriformis muscle will become stretched. And when it's stretched, it gets inflamed. And when muscle tissue is inflamed, it becomes sticky. And you see the sciatic nerve is going above, below, or if you're really unlucky, right through this muscle belly. And this muscle belly is inflamed, it'll hit that sciatic nerve, and it'll mimic sciatica. You'll have the same things I just talked about. Weakness down your leg. possible foot drop, you could have sensation problems, you could have rotation, other issues. So how do we know that you're dealing with pure reformer syndrome and not sciatica if they're so similar? It's really easy. Most of the time with the pure reformer syndrome, you have a condition called torta pelvis. And what torta pelvis is that your sacrum stayed still, but your hip rotated. And this usually happens because of a problem further up. I said the sciatic nerve comes from your lower lumbars. But your upper lumbars, your L1, L2, have a muscle on the front side, or the anterior side. Called the SOAs, P-S-O-A-S. And what that muscle does is it goes from the front side and it goes behind your small intestines, through the pelvis to the front of your femurs or your leg bones. And if your L one L two gets upset by you bending and twisting or taking a load and you know you have to twist and bend or reach backwards, you overload the little joint in the back called the facet joint, the backside of the joint, facet joints, about the size of half a dime. If you irritate that, you will adaptively rotate and stay away from the inflammation. Now when the L1 and L2 rotate to stay away from the inflammation, they move. And when they rotate and they move, they grab that pure, excuse me, that psoas muscle and they pull it. Because what's moving away from one side to the other side, so if it's, the inflammation is on your left side, you're going to rotate away from that left side. And that left psoas muscle now is being pulled and stretched. That's going to grab the femur, lift it, and twist it. And rotate your pelvis. But see, your tailbone didn't want to move. And because your tailbone didn't move, that piriformis muscle that we talked about is underneath all your glutes, gets really mad and angry and gets scratched and gets inflamed. And that's what can hit your sciatic nerve. So often people will come in and tell me they have sciatica, and they'll point right at their SI joint and say it's right here. I'm like, that's not your lower lumbars. That's your SI joint. And that's giant si. Joint means sacral. Iliac. So sacro is your tailbone and iliac is your pelvis bone, right? So that's where they come together. That's called your SI joint. So the moment someone says they have sciatica and they point right there, I'm already thinking it's not sciatica, it's probably piriformis syndrome. And how do we check this? We can lay you on your back and when you're laying on your back, we can grab one of your legs and try to bend that knee towards the opposite shoulder. Because if your pelvis is rotated, that's not going to want to move one way or the other. It's going to lock up on us because that muscle is already being stretched. It won't go as far. And if I put pressure on that knee as I do it, you're going to be like, Oh yeah, that's the sweet spot right there. Now we know we're on the piriformis. How else do we know it? We lay you face down. And we have you lift one leg but not bend the knee and do the other side. Because if that tailbone's not moving, that hip is moved, it's going to jam that joint. And it's not going to let one leg go up as high as the other leg. We call that a sacral leg check. We can also take your feet and bend them all the way towards your Towards the gluteus maximus muscle, right? And if your feet, one foot was close to the other side and there's been no history of knee injury, we can go again and think it's toward a pelvis and it's piriform syndrome that's interfering with this. And so now we've confronted the sacral misalignment. We can already, you already told us that your SI joints hurt. What we'll do is we'll go up to the SI joints and we'll take our fingertips and we'll palate up feeling, feeling your musculature. And what we'll do is we'll get up to your back and we'll see that the musculature, the tightness ends around L one L two. And that's what we find. So we find you need a good L1, L2 adjustment. You need a good SI adjustment, or sacrum adjustment. And then you'll get up and tell me how much better you feel. Now what's another clue to this? If your hip flexor muscles are already being stretched, you would tell me maybe you have worse pain when you go to lift your leg. Like when I go to stand up and walk it bothers me. That would be all clues that this is probably piriformis syndrome caused by torta pelvis. And that you really need a good lower back adjustment and you need a really good pelvic adjustment. More than you need your lower lumbar adjusted for traditional sciatica. Now, the best Test to confirm this bar none, is an x ray. Boy, if I have an x ray up, I can see it crystal clear. I can see that your L4, L5, and sacrum are totally lined up perfectly. And your L1 and L2 is twisted and your pelvic is rotated. It's clear as day. It's very little guesswork on an x ray. But again, your family doctor might have taken x rays of your lower back and told you don't have any issues. But remember, when we are trained to look at x rays, analyze x rays, we know to look for deformities, fractures, growth, abnormalities. But that's where the chiropractic and the medical education matches. But where the chiropractic education goes further, maybe a different direction, is we're also taught how to look for alignment issues. Where they're not. It's just not part of their curriculum. No more is me understanding the chemical compound of a cortisone shot part of my curriculum. I don't do medicine, so I don't study medicine. They don't do chiropractic, they don't study chiropractic. So don't let a medical doctor tell you there's nothing in your x rays that a chiropractor could help, because the chiropractor, they don't have a chiropractic education. It's happened here several times. Someone told me my doctor looked at the x rays and told me I had normal alignment. We get rad reports from radiologists that there's a total alignment as they describe the differences in the pelvis being rotated. You can't have your pelvis rotated and be in perfect alignment. It's crazy talk. It's just ridiculous. So your chiropractor is trained to look at that x ray and exactly see what's going on. Now the good news is, the images we take and the images your medical doctor takes, today in 2025, 90 percent of the time are the same x ray. Those are just backwards. We put the left and the left, the right and the right. They put the left and the right and the left. So their x rays are backwards in a chiropractic clinic. You take a chiropractor's x rays to a medical clinic, our x rays are backwards. But when you're in our home field, it's our rules. Okay? We can look at their x rays. So if you've already had an x ray, bring it to the chiropractor. Please bring it to the chiropractor. Not the x ray report. We don't care about the x ray report. We want to see the actual x ray because they don't know how to look for alignment like we look for alignment. So the report is, it's neat. It tells us that there's nothing you're safe to take care of, but it doesn't really tell us how to take care of you the best way. So if you've had an x ray, bring it. If you have an MRI report, bring those too. Those are fine. We like the MRI reports, honestly. Because looking at an MRI, usually it's a whole bunch of screens. Now it's very possible that you had an MRI of this area and they said they found a disc bulge in your L4 L5. And they say you got sciatica. Well, disc job is the bulge. Disc jobs are shock absorbers, so if there's too much stress on the left, they bulge the other way. That's their job. I've very rarely ever seen an MRI report come back without a disc bulge. So don't let the disc bulge thing freak you out. I'm going to talk more about that next week when I dive more into sciatica where the disc is a key player. But for the most part, for piriformis syndrome and for this lower back issue, the care plan is simple. We get you adjusted. Once you started getting adjusted frequently and we noticed that you're starting to hold your adjustment, you're starting to stay where you are in alignment, they were going to give you those stabilization exercises. I've talked about this a billion times. The muscles of your spine, you cannot consciously move them. You can't like, I can't move my fifth cervical right now. There's no way to do it, okay? So they're only reacting to how my eyes stay with the horizon. So their job is always to keep my eyes level with the horizon. So what happens is, The only way to make these muscles stronger is by stabilization exercises. So we can get the adjustment, we can help you get lined back up again, and we can teach you stabilization exercises to complement the chiropractic care so you can do your best healing. A lot of times, if it's really bad, we might even work with a physical therapist or a strength conditioning coach. I know I do a lot of this with my friends down the street at Movement Fitness, it's a return to play place, we have people that get injured, they want to go back to playing their sport, we'll get them adjusted, I'll tell them what I found, I'll tell them which hip flexor it was, they know how to stretch those hip flexors, they know the contralateral muscles, it's a great friendship. So those are all available to you to make you feel better. So there you have it, sciatica or piriformis syndrome. Now you understand piriformis syndrome, I'm going to invite you to come back next week and I'm going to dive into sciatica. I want to do piriformis syndrome first because I think that's actually, in today's world, more common. Now, I think in my grandpa's time, it was less common. I think sciatica was more common. But I think we've come a long ways in the way we design chairs, right? Grandpa started practice in 1949, and I don't think the chairs were very good back then. If you ever want to try this out, get an old car and go for a long car ride. Get a new car and go for a long car ride. You tell me which chair is better. All right. The exception to this, of course, is always airplanes. Just kidding. But yeah, so the chairs are better. We know more about it. We know how to do things better. So that's why I think this piriformis syndrome is more common today than sciatica. All right. Come back next week. Learn about sciatica. This is part one of part two. Talk to you again. And remember, like I talked earlier, if you have questions about chiropractic or chiropractic care, can chiropractic help this? Can chiropractic not help this? There's only one qualified profession that can answer that question, and that would be a chiropractor. Alright, thank you.