Sciatica is one of the most common diagnoses that we see at our clinic. 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.
However, diagnoses can also foster hidden (and incorrect) assumptions about the origins of a pain pattern. For example, upon hearing 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. (Travell and Simons, The Trigger Point Manual - The Lower Extremities p. 191)
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 invite other misguided "diagnoses". Not uncommonly, 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. However,
...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. (Greg Lehman, DC - The mechanical case against rolling your IT Band. It can not lengthen and it is NOT tight.)
Some therapists very much believe in an "IT Band Syndrome" that involves lateral and local inflammation near the knee. It is popular, but not medically supportable, to describe this condition as a "friction syndrome". But more in-depth investigation reveals this as a fantasy:
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. (Fairclough, et. al., Is iliotibial band syndrome really a friction syndrome?)
Most practitioners overlook the muscular realities. The hip abductor fibers of muscles like the gluteals and TFL are very likely to limit adduction of the leg on stretch, with painful referral down the leg.
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The experience of pain over the palpable IT band is very misleading. Most people (including medical practitioners) tend to assume that pain is "in the local tissues". Trigger points can create a profound illusion regarding where pain originates. Referred pain is prone 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 the symptoms associated with IT band syndrome. If the VL is itself a satellite referral target of the minimus, the pain will remain or return 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 Your IT Band - Nor Would You Want To
The web is full of many examples of "the best IT band stretches". Unfortunately, this is complete nonsense. 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 clinically evaluated via a test known as Ober's test.
Ober's test 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.
Because muscles under stretch tend to refer pain if they have trigger points, when you do this stretch you are likely to feel pain radiating down your leg over the area of your IT band. This of course reinforces the illusion that it's the IT band that you are stretching - but it isn't.
Treating Lateral Sciatica Pain Patterns
Treating trigger points in the hip muscles is a much more sensible treatment approach for lateral leg 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.
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