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Structural Yoga Therapy for Piriformis Syndrome and "Fa

timfm2010-07-05 04:27:33 +0000 #1
Hi Mukunda,

As I mentioned I recently received your wonderful book, Structural Yoga Therapy. I want to document my history and process here on the forum so that it may of help to others.

GENERAL INFO

Gender: Male

Age: 37

Height: 6'3"

Weight: 164 lbs.

Birth Info: 04/09/1969, 8:13 AM, Arlington, MA

Location: Maui, Hawaii

Prakruti: Pitta-Vata (45%/35%)

Vikruti: aggravated pitta and vata (6/06 diagnoses by Dr. Suhas Kshirsagar BAMS, M.D.: www.hawaiiholisticme...suhas_kshirsagar.php ). I think I have kapha in the lungs as well, as evidenced by constant mucous and smoking in a "former life" (see HISTORY)

Diet: Lacto-vegetarian. Very occasional egg and fish. Following seasonal Ayurvedic guidelines for Pitta-Vata

Energy level and sleep are generally good/sound

PRESENTING/SYMPTOMS (Since March 2004)

1. Constant, dull, hot (dry?) pain deep in left buttock

2. A feeling of chronic muscle spasm/contraction, toxins (scaring?) deep in left buttock

3. Acute, chronic sciatic pain in left upper hamstring/glute area. Aggravated by forward bending, stretching, and standing/walking/running. For the most part the pain stays in the upper hamstring area although I do recall it creeping down the leg and sometimes numbness in the sole of the foot when forcing (himsa) forward bends (a thing of the past)

4. "tugging" pain in L4-L5-S1 area, becomes aggravated and more "nueralgic" when probing around intervertebral spaces

5. Stiffness, pain, and cracking in knees (I've always had cracking, vata joints), aggravated by prolonged sitting.

6. Occasional refereed throbbing pain to the inside of the left calf

7. Numbness in tip of left big toe (much older symptom, see HISTORY)

Pain is worse in the morning. Spasm/nueralgia seems to be aggravated by standing and stretching.

Emotional/Mental: Indecisive, ambivalent, "feeling stuck," sad, depressed (because of pain), somewhat angry/resentful

HISTORY

My history of back pain goes back 13 years, perhaps further. In college (UCSD) I was very active/athletic. I rowed crew for university (2 years) and then got into triathlon and distance running. On average, I ran 25-40 miles/week, biked 150-200 miles, swam 6-10 miles, and lifted weight 3-4x/week. I did this for three years. I also dabbled in various martial arts. In high school (Boston) I swam and played basketball.

I always had decent flexibility (as measured by the ease of touching one's toes), average strength and above average endurance. My first remembrance of back pain was at age 20 (1989/90) -- in the weight room while performing oblique twist with a 45 lb. barbell. I felt a sudden pinching pain in my lower back and immediately stopped. Nothing further became of it to my knowledge.

My real problems with lower back pain started in graduate school (London) after a car crash (1993/4). While in a cab, we crashed directly into a car that ran a red light. I saw it coming, and braced my body by extending my left leg straight in front of me, bracing it against the floor/back of cab drivers "wall." We made impact at about 25mph. I took the shock up into the left hip.

Symptoms started in the months after the accident. Mainly involving pain in the spine and neck. My middle back and neck would "go out" frequently, requiring and osteopath's adjustment. I had pain and stiffness in my lower back, aggravated by heavy lifting.

I started doing "The Five Tibetans" around this time, but found that upward dog and camel really compressed my lumbar spine. It is also worth noting that I became a vegetarian around this time.

Also during this time, I lost control of my studies, became more sedentary and was not doing much good for my body in general (smoking, etc.). The numbness in the tip of my left big toe started around this time. I think it was directly related to stimulant drug use coupled with a prolonged (5-6 hour) sexual encounter. I had discovered and been practicing (probably incorrctly) Toaist "sexual kung fu," and perhaps ran too big a charge through my unprepared circuits.

I returned to the states (1996) seeking a resolution to my pain. Uninsured, unemployed, and disinterested in the allopathic establishment, I sought out alternative care. I happened across ashtanga yoga and felt better than I could recollect after one, one-hour class. I jumped into it full bore, like a typical vata, pushing my body too hard and doing himsa in the name of the ego (very typical in ashtanga circles).

It was during this time, studying with my teachers (regina and sri patthabi joyce's newphew: vishwanath) and attending workshops (birch, freeman, swenson, habbermann, campbell), and doing my best to practice primary series 6 days/week, that I realized the sciatic pain. I thought it was muscle pain, but my teacher told me it was a nerve. David Swenson's assistant gave me a modified Gomukhasa in a workshop, which cured it almost instantly.

Now it was just the matter of the lower back pain. I attended a 6 day workshop with Karen Habbermann who put my through vigorous back-bending, immediately followed by a week in Boulder at Richard Freeman's studio where I continued to "abuse" myself. Being at altitude and practicing multiple times each day was the end of it -- both my back pain and my stamina. So my after roughly eight months of practice my pain was gone and I was totally burnt out. I took 3-4 months off, without pain and then tried to reestablish my practice without much success. My teacher had moved to NYC and the practice group had diffused. Sometime over the next months I managed to get back to it, but never really back to doing the full primary series. The pain started to creep back. 7 session of acupuncture worked wonders.

In 2001, I moved to Hawaii, planning to study Ashtanga intensively. I never really got there. I've practiced regularly, but for the most part just sun salutations, standing and closing sequences. For the most part without a teacher's guidance as I (naively) thought I had a good foundation and understanding of yoga.

My acute symptoms started in March 2004, after a 3-week (15+ hour/day) stint at the computer developing a website for a client. At that time I was sitting on a swiss ball, vacillating between extreme lumbar/pelvic flexion (holding stress) and extreme lumbar/pelvic thrust and sinking chest. I also had a tendency to bring my left foot up onto the ball and then let the knee fall out and down. I think these patterns contributed to much of the imbalance and problems I'm still dealing with. I now sit on meditation cushion on the floor cross-legged at my computer. I'm considering purchasing a proper ergonomic office chair because of the knee problems...

I injured my right MCL when squatting down too fast and putting too much weight on the right leg. Since I've been over compensating for pain in the left leg, by shifting more weight to the right. This was about 18 months ago and has healed, but I know have cracking in my right inner knee when binding. When the right knee was injured I had to put more weight on the left leg and then I injured the left MCL when squatting (I can't bend over forward). The left knee is much better now, I can sit in Hero again, but I can't squat (fully) or bind without discomfort.

All along, I've been trying to stick with my ashtanga practice, but it hasn't helped. My teacher started me on second series, but by the time got through warmups and standing, my piriformis and sciatic nerve were so aggravated that I couldn't relax them even in gentle backbends. Furthermore, I had to discontinue second series when the knee problems began. I have to bend my legs SO MUCH in sun salutations and downward dog as well as thrust my pelvis forward that the asanas are not even recognizable. I always had a tendency to over extend myself in asanas -- that is -- extreme lumbar flexion and pushing the ribs up and out as well as over flexing the middle/lower back. I've corrected this now, partly because flexion is not even approachable.

I been to several chiropractors, ayurvedic massage, lomi lomi, and acupuncture. The lomi was helpful with the trigger points, but I didn't commit to the acupuncture ($) long enough to have an impact.

An xray about 8 months ago, Showed normal intervertebral space and was "suspicious" for "mild disc disease" -- a good thing. I forgot to look at how level the pelvis/SI joint was. A chiropractor said it probably wasn't a disc problem as well as the MD who read the xray and another MD I consulted.

I've tried all sorts of anti-inflammatory herbs, topicals, etc. Dr. Suhas managed to bring down my Pitta with pitta tea, gotu-kolu "herbal wine," and a pitta diet, and helped me put on some weight with ashwaganda jam and Bala/Ashwaganda oil. But as far as fixing the structural problem, there was really no recommendation except "build up the body."

On my own and with lomi, I've managed to work through a number of trigger points (one the size of a walnut) in the gluteal region (medius, minimus, maximus). Now that they have subsided I have more direct access to the points on the piriformis.

I've now resigned to taking it on myself to correct the problems and end this pain. I'm no longer attached to any particular form of yoga. I just want to be able to move through life normally and use my body without constant pain.

BODY READ

Underweight

Tendency to shift weight to right leg

Left leg is extremely externally rotated

Left hip/pelvis is twisted anteriorly

Left hip/pelvis is tilted lower than right

Left leg is slightly atrophied

Lordosis AND Khyphosis

Head titled forward

When bending over/forward and in downward dog (view from back), left hip dips dramatically, left leg bends, and knee floats inward to prevent rotator (piriformis) muscle from pinching nerve

Shortened gate (left leg)

Left hip pops when extending leg while lying on back and when squatting (pops into place -- greater trochanter not sitting properly in socket?)

Pavanmuktasana Observations

I don't have a goniometer, but my range of motion seems to be normal except for (can't sit in dandasana, so I lean back to open hip/leg angle or bend the knees):

4. Can't achieve full let leg knee extension (est. ~30 degrees)

6. Internal hip rotation on left leg is less than average

8. Hip adduction going to my left is less than average, but feels kind of good if I'm gentle

14. Shoulder internal rotation is somewhat less than average and even when I drop the elbows a bit

15. Shoulder extension is maybe a tiny bit less than ideal

16. Scapula abduction can cause a bit of a pinch in the sciatic unless VERY slow/careful/present. To clarify, it's not the scapula abduction but the rolling back (thrust) the lumbar/pelvis with crossed legs.

17. Cross legged and seated spinal rotation feel good if I don't move the pelvis as well. It usually causes a pop or two in mid-lower back which seems to release some pain

GOALS

Stop the muscle spasms, allow the muscle to release toxins regain normal blood flow. Work through trigger points. Correct the structural imbalances by building strength in the appropriate muscles groups. Regaining normal range of movement. To be able to move about freely without pain in order to live a normal life.

Longer term goals are to reestablish a regular asana practice and build strength, flexibility, and balance in my body, and to be able to sit comfortable for pranayama and meditation. Realization of Self.

SELF DIAGNOSIS

Dramatically shortened and weakened left piriformis muscle pinching the sciatic nerve and causing referred pain to sacrum, hamstring, and calf. Resulting in twisted/unlevel pelvis an compromised "foundation." Possible SI joint instability/hypermobility. Weakened surrounding musculature (hamstrings, glutes and other external rotators, quads, and abs) do to inability to be active. Weak scapula adductors. Asana practice to date has served to aggravate the problem.

Asanas and movements I think are needed:

SI Stabilizers

Cat-Camel

Sunbird

Cakravakasana

Pelvic Tilt/Thrust

Rolling Bridge

Squats

Mountain

Warrior I (II?)

Tree

Bridge

Shoulderstand

Energy Freeing

Child's Pose

Boat (Navasana)

Cobra and variations

Locust and variations

Hero

Camel

Corpse

Bound Angle

PRESCRIPTION/WHAT I'M DOING

As you mention in your book, stretching doesn't seem to help with chronic pain. So, I need to focus on strengthening the right (inferior/opposing) muscle groups and focus on relaxation, breath-work and meditation.

1. SI stabilizer movements 2x/day. Joint freeing series in the AM

2. Manually massaging the gluteal area several times a day with a homemade warming oil: bala/ashwgahnda in sesame base with EOs of pine, rosemary, marjoram, black pepper, oregano, chamomile, juniper, grapefriut, and bergamot. Also added some New Chapter Zyflammend to it and St. John's Wort extract.

3. Using a trigger point ball ( www.tpmassageball.com/productinfo.php?id=4 ) to release the piriformis 2x/day and for deeper massage

4. Only sitting at the computer for 20 minute intervals and then getting up to move around for 5 minutes

5. AM/PM 20 minute meditation

6. PM Asanas and Movements as noted above

QUESTIONS

1. INRE SI Stabilizer movements. The PDF you sent states "Inhale and lift your HIPS tensing the outer gluteus medius muscle. Exhale as you lower the HIP coming back facing forward." Are you supposed to lift both hips or just the hip of the leg folded back?

2. Should I be doing the entire joint freeing series?

3. Are the asanas/movements I noted appropriate?

4. How should I sequence the asanas/movements?

5. How long should I stay in the asanas/movements? Should I move into and out of them repeatedly, or hold for a # of breaths, or both? Should I do "sets" of asanas? I'm comfortable in most of them for at least 5-8 breaths.

6. Is there any more info I could provide that would be helpful?

Namaskar,

-t


timfm2010-07-05 04:33:21 +0000 #2
Hi Mukunda,

Since posting this, I've had a chance to rea through Max and Durga's Sciatica SYT Papers. It seems I may be a bit over zealous as to what I should be doing considering i'm in the "therapuetic/free of pain" phase.

A few things I forgot to mention:

+ I was born with both my feet pointing in one direction, to the left I think. I wore a brace when I was young (1-2yo) to correct this.

+ My right anterior hip has always been tighter then my left, e.g., binding on right is more difficult than left. This makes sense since I've always favored my right leg.

+ Sneezing, blowing nose, and coughing casue pain unless knees are bent and I'm "prepared"

+ I have tinnitus (severe at times), and with me pretty much all of the time

+ I'm experiencing anxiety

+ The Xray ruled out stenosis and spondylolithesis

Gomukhasana and Pigeon (variations) are a no go. The caused pain and a spasm.

Here's a reassesmant:

SI stabilizers on cushion

Pelvic Thrust/Tilt focusing more on tilt and less on flexion

Rolling Bridge

?Runners stretch with affected leg back (torso lifted)?

Groin stretch

JFS

1-2 limit dorsiflexion

3-4 eliminate

5 bend knee and drag leg (affected side)

6 move hands and pelvis forward (open the angle), limit flexion

7 move hands and pelvis forward limit flexion do twice as many on affected side

8 move hands and pelvis forward

9-21 sitting on chair, standing or on knees

16-21 pelvis "fixed" (please elaborate)

ASANAS

Warrior I with affected leg back

?Tree?

Bridge

Shoulderstand

?Enery freeing (hands behind knees)?

Cobra

Locust

Camel

Corpse

?Bound Angle?

Quite pared down, but probably smarter. Same questions from above still apply, as regards to sequencing, #s, # of times/day, etc.

Namaskar,

-t
timfm2010-07-05 05:01:18 +0000 #3
Hi,

Just wanted to post adjustments to my protocol as well as other insights.

Since I began, I've had a few instances where walking has felt good and not aggravated my symptoms. This is rare, however -- but progress nonetheless. I have also realized that if I walk up even the slightest incline that it triggers an "overstretch" and hence spasm. My supposition here is that walking up an incline requires additional dorsiflexion which cause too much stretch in the piriformis.

I've become conscious that I'm habitually in slight lordosis (pushing my cocccyx back). This causes an overstretch and pain and spasm of the affected muscles. If I imagine that a weight is attached to the tip of my coccyx and relax my lower back, slightly engaging the lower abs -- things "fall into" normal. Also, it helps, if I consciously tell myself that my piriformis is relaxed. Over time, with the streghtening excercises and asanas this should correct itslef.

So currently I'm doing the following:

Joint Freeing Series (with modifications from above) 2x/day with Sacroiliac Mobilization excercises beforehand. I also try to do the SI movements and shavaasna one other time during the day.

(My inner knee (left) felt torqued pain durng a long shavasana, so I'm now placing support under my knees during this pose.)

A bit of abdominal work each day: pilates "roll ups" and some crunches making sure to pres the back into the floor and not go into lumbar flexion.

Stregthening Movements & Asanas in th PM after SI/JFS:

Runners Stretch (affected leg back)

Groin Stretch (Supta Badha Konasana from Gary K's Viniyoga, as the stretch in Mukunda's SYT book isn't much of a stretch for me)

Pelvic Tilt/Thrust

Rolling Bridge

Warrior (affected leg back)

Bridge

Shoulderstand (full)

Apanasana (gently, more energy relaese than glute stretch)

Cobra (and variations)

Locust (and variations)

Camel (bothers the elbows a bit)

Corpse

I'm doing daily oil bath with sesame (bala/ashwagandha +EOs) where (if I position myself just so -- most weight on nonaffected leg, affected leg gently externally rotated, and glute max relaxed), I can access the piriformis trigger points near the greater trocantor and in the belly of the muscle. These are "exqusitly tender" and cause refered pain to the upper hamstring and sacrum. I can feel that this work is beneficial, however (although my right shoulder gets tired).

Rolling on a massage ball in the sacral gluteal and hamstring regions.

Minimizing extended sitting at compter and looking at better quality chairs

AM/PM mediation and affirmations/visualizations/thankfullness about already being healed. I'm visualizing myself as already healed and giving thanks from a state of grace for it.

I'm learning to really let the breath guide all the movements and not to strain.

Making an herbal tincture from herbs recommended for nueralgic pain and muscle spasm.

Considering maybe trying some swimming a couple of times/week.

It's up and donw. Some days are better than others. The painis always the worst in the morning. It's a real chaleenge to not do any movements that cause pain, since so many of one's daily movemennts do so (bending over the sink, etc.).

Namaste,

-t
Mukunda2010-07-05 05:06:08 +0000 #4
T -

It is nearly impossible to self diagnose. It is healthy to say what you feel and try to learn if that is correct understanding of your feelings. Most common is there is confusion in self assessment therefore recommendations go the wrong direction; as a result of this more confusion, ignorance and avidya (loss of wisdom) arise. You have given way too much information to be of use to me or others. If you were to be concise stating what is pain, discomfort and what are doing about it in one paragraph that could elicit a response from me that might be helpful. I not given recommendations via email except for those Q given in this terse format. Other than that you are welcome to search this forum for specific topics that may provide some insight for you.

namaste mukunda
timfm2010-07-05 05:32:32 +0000 #5
Hi Mukunda,

I understand what you mean about self diagnosis and providing too much info. I guess it was really more of a catharsis than anything.

To be terse: I have chronic sciatic pain (since 3/2004) on my left side, which seems to originate deep in the left buttock and is felt mostly severely in the upper left leg/hamstring. It is aggravated by even the slightest forward bending, walking, and walking up hill. There is both the feeling of nerve pain and muscle spasm. I also have pain and stiffness in my knees.

Over three weeks my therapy has been as follows (all with modifications for sciatica):

+ SI Stabilizers

+ JFS

+ runners/groin/pelvic tilt-thrust/rolling bridge

+ warrior(affected leg back)-bridge-shoulderstand-energy freeing-cobra-locust-camel-corpse.

+ trigger point (self) massage

+ focus on relaxation, meditation

+ daily oil baths and use of antispasmodic and nervine herbs

There has been some improvement. It seems the glutes muscles had a bit of release yesterday. Bridge seems to be aggravating the back of my right knee so I'm only doing rolling bridge and not going up as high as before.

Namaste,

-t

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