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I have a client whom is obesed and had an accident a few months ago, she feel down and didn't think anything of it.  At first, she just let the irriation she was having set, it would go away.  Now that it has sat her cc is pain in hip, sciatic that radiated to her posterior IT band,  pose. lateral side of calf , then down to the malleous.   We have done some stretching and that seems to help for half a day, then she has also being coming in for spinal manipulation.  She was using a cane which was not appropriate for her body, and that was throwing her off balance and out of alignment, so she dc'd this, and seemed to do somewhat better, but now she is gone back to work and it has flared up again.  She is seditary all day long. Myofascial seems to open up muscle, and she get some relief from that, and some relief from stretching-ROM.     ANy suggestion or advice would be valuable right now.  I feel that she is not benefiting from treatment, and she is looking for a way to avoid and MRI that her GP wishes her to do.  

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How long have you been treating this client? How often has she been seeing you and getting treatment done? In some cases what you have been doing, i.e. Myofascial, stretching, or ROM, will work, but just needs a few more sessions and maybe a longer time frame for it...
I agree with Abbie. I would try to see her 2-3x a week for several weeks, maybe for longer sessions (90 mins) before she gives up and goes with more invasive treatment. And ultimately, she is going to have to take the responsibility to do some self-care at home with the stretching...I'm overweight and at my desk a lot myself but I get in the floor and do stretches every day.
I agree with others that she needs to do her stretches. The low back and glutes are the main focus. I use my elbow for deep tissue relief for sciatica. Also MFR on the thigh and back. I just worked on two the past week. Generally three to four sessions has them back to full speed.

One stretch I have them doing is; standing hang over as if touching the toes. Just hang loosely not trying to reach. Breath in deeply, hold a moment then exhale fully. Hang a few moments, and repeat the breath. This is slowly repeated three or four times. It is an excellant back stretch from the self therapy techniques of Korean Martial Therapy (Hwal Bup Do). Make sure they understand not to use their back to straighten up. Use the hands for support by walking them up the legs.

Good luck with your client. Obesity does hamper recovery from sciatica.
Thank you for all your helpful input! My client states she is doing stretching when she is not here, and icing down twice a day, and trying not to take pain pills for relief. She is only coming in maybe twice a week spartacially due to her work schedule. Again, thank you!
Hi Jen,

I want to give another avenue to try. I made the same mistake with one of my clients. Because of the location of referal pain, especially when seated, I think you should try to address glute minimus and tensor fascial latae more so than piriformis. It seems as soon as a clients pain is radiating down the leg we automatically assume sciatic nerve issues. In most cases this is correct, but when the pain is more lateral a lot of times superior gluteal nerve is involved. This nerve controls glute med and min. The exact referal pattern you described comes from TrP's in TFL. It might be best to work these in a side lying position for ease of palpation and pressure. Once in side lying work the area between the iliac crest and greater trochanter and slightly anterior as well. she will most likely have some burning sensations from the TrP in TFL. That response is normal for this area. Doing some traction with the femur out laterally from the acetabulum could also help alleviate some of the discomfort.
Ahhhhh...is it true that 'massage therapists' cannot 'diagnose? If that is the case then I would 'assess' for coccygeal displacement. Massage of the glutes is hardly worth just 'deep tissue'. What tissue? Suggest revision of the ligaments of the pelvic bowl.
Piriformis treatment for sciatic pain is only beneficial if the pain is actually sciatic Nv in origin. A fall and Mm guarding may have affected piriformis or any other Mm but surely subsequent treatment should have ameliorated.
I would just try stacking vectors looking for positions of ease a'la strain/counterstrain.
Continual stretching maybe be counterproductive, and in fact may exacerbate, what could already be a 'false' pain signal.
Cheers
AJ
And further to that the interspinous ligament recieves an innervation from the medial branches of the lumbar dorsal rami, and experimantal stimulation of the interspinous ligament produces low back pain and referred pain to the lower limb/limbs. There are numerous clinical studies to suggest that even with proven ligamentous strain, and treatment by anaesthetisation only 10% of patients report relief.
Ligaments are poorly vascularied and take time (6 mths) to begin to heal. In the meantime it's important to understand the role of peizo-electric fields in healing of these tissues.

Allan J Jones said:
Ahhhhh...is it true that 'massage therapists' cannot 'diagnose? If that is the case then I would 'assess' for coccygeal displacement. Massage of the glutes is hardly worth just 'deep tissue'. What tissue? Suggest revision of the ligaments of the pelvic bowl.
Piriformis treatment for sciatic pain is only beneficial if the pain is actually sciatic Nv in origin. A fall and Mm guarding may have affected piriformis or any other Mm but surely subsequent treatment should have ameliorated.
I would just try stacking vectors looking for positions of ease a'la strain/counterstrain.
Continual stretching maybe be counterproductive, and in fact may exacerbate, what could already be a 'false' pain signal.
Cheers
AJ
Reiki. Reiki heals on all levels, physical..emotional...and spiritual. Sounds like she needs healing on a level deeper than muscular. She seems to be holding emotional pain in her muscles. Reiki will heal your client
Hello Jen,
This may be a little late to help and never to late to consider incorporating in your day to day assessment.
I agree with positioning your client a la "strain counter strain". All modalities and post graduate studies have something good to offer us and our clients. And we do need to be able to assess our client's needs to best serve them with our knowledge of various techniques and approaches. They are all great, and understanding the philosophy and laws of NMT, Myoskeletal, MFR, Cranial Sacral, will make you an artist, not just a therapist when it comes to treating your client. In other words not every muscle needs to be stretched, not every muscle should be released, some need to be activated, etc. Learn the approach(laws/philosophies) and apply them to create/research new techniques of your own to add to your ever expanding base. But what I notice in your discussion is the lack of a plan in your approach. You need a target...
So, I would definitely look into assessing your client (learn postural assessment) in weight bearing and non weight bearing- especially ASIS and PSIS positions(angles) (distance between ASIS to midline R/L), also look for any torsion & flexion/extension in her sacrum before doing anything. The body was designed to move freely. So,I also look at gate, and assess the body in motion as well as ROM & the other common forms of assessment, even in sitting. See if she is "locked up" on one side of her SI jnt. Have her standing, position your thumbs underneath her PSIS(keep your thumbs there-hold on in other words) and have her flex(bend forward as if to touch her toes). Both PSIS should track equally R vs L (horizontally), You might notice one side will continue to follow the motion and the other side stop. See if one ASIS is lower than the other, then note the PSIS levels and their relative ASIS to PSIS angles and compare. I wouldn't doubt if she has an "up-slip" on one side (R or L SI jnt- ASIS and PSIS are both higher on one side then the other side. I know about leg length also, but we have to start somewhere) and as a result, some torsion may be going on in her sacrum, thereby affecting her piriformis and many of the 27 muscles that attach in the area. Pressure receptors in her joints, tendons, ligaments, etc are firing off while in motion and in static positions and affecting the whole area which is why she is still complaining. Sometimes, just rolling up a (2) towel very tight and positioning it under her ASIS to prop both of the ASIS up to let gravity help you (while lying face down) and gently rocking her "sacrum) (very gently from time to time during treatment) and with gentle contract /relax traction on her legs(one leg at a time, again at various times during treatment, and then a downward pressure with palm of your hand (palm close to L5/fingers towards feet) on her sacrum towards the table and feet-pumping motion) will diminish the firing of the receptors in her SI (and other joints) enough for the body to position itself into a more anatomically correct position. Too much is like not enough, correct? Think relax the pressure receptors in her joints, relax the muscle guarding, don't stretch muscles that are already longer (stretched out) by faulty posture-activate them... etc. You know the rest... :) AND thank you to all that post information on this site, i am always pleasantly reminded of things I forgot, and enthused to learn new approaches or ideas. Imagine, if she has an "up-slip" or shorter leg, every step she takes is like walking off a 2" plank, jarring her SI, knee, heel/ankle and hip which would affect all you mentioned above. The IT band is like a shock absorber for the leg. And, there's probably ant. rotation (or bilateral). Figure which side it is and tell her to lay on her couch and let the leg (bent) hang off the couch (anterior rotated side) so that her knee is as close to her shoulder as it can be while remaining on the floor or pillow-the other leg stretch out straight... and relax. Always tell her to get up slowly. Look up Mr. Dalton and Mr. Paul St-John for Cont. ed.

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