Here is a unique case study of how we helped a client to successfully manage a very difficult hip problem. This client who still trains with us, has now trained with us for nearly 3 years. But it took a good 2 years of constantly changing the plan, going backwards and forwards and constantly using various tools and methods to find a way forward with certain movements that were continually aggravating her. It was a very bumpy road, and before we met her she had already tried many things from other health practitioners with little to varied success. We wanted to share this story to show how difficult working with chronic pain can be, and why you need to very patient with the approach and also be wise enough to make changes were needed. Sometimes going backwards in the plan is the best way forward. Keeping notes is vital and I cannot stress this enough for this helps you to see patterns and establish what is the source of the problem. Otherwise you just end up reacting and treating symptoms which never leads to a good long term result. This article was written in combination with trainer Nathan Fejes who spent a majority of the time with this client.

What Was The Original Injury & Why Did This Client Come To See Us?

We decided to keep this client's name anonymous for this article but I do suggest you take a look at our testimonials page to read success stories just like this.

This client came to see us after getting diagnosed with Piriformis syndrome from her doctor. She had been suffering with hip pain for several years by this stage already and the only relief she had found was from a therapist in QLD. But as she lived in Victoria it was not going to be an effective way of getting on top of the injury. She needed to strengthen her body but was not sure of what to do and that is how she found us via our You Tube videos on Piriformis syndrome.This is what we did.

Assessment

I won't go into detail of our whole assessment, but this takes a good 60 minutest to complete and we look at many things in an order of simpler to more complex. This includes:

• Posture - static and dynamic
• Flexibility & Mobility - looking at all key joints
• Stability & Breathing - pelvic stability, foot stability and hip centration
• Isolated Strength - gluteal and lower abdominal
• Movement - assessment of all key movement patterns

But even before we do the first test, it is important to ask - what causes the pain? The pain occurred the next day after vacuuming, excessive walking, and gardening. At the start of her journey with us no other therapeutic treatment would work to improve the pain in the long-term. All it was able to do was manage the symptoms after it happened. Evaluating the movements and body position in these daily activities led us to suspect problems within the movement pattern of bending and rotation would be the catalyst to her pain.

During the assessment, and continually over time in future sessions we found:

• That the piriformis muscle was in "tonic mode", basically it was working in overdrive. Every exercise that required hip action and glute involvement would fire this up and pain would kick in. The reason behind this was not easy to establish but we had to find a way to shut this down as it was greatly inhibiting any of the muscles surrounding the hip that were essential for her to move.
• Static Posture assessment showing common hunched shoulders but it also showed more of a posterior tilt of the pelvis which was opposite to what we see with 90% of females who present with anterior tilt. From a front on analysis it did not show too much in a standing position, however when we asked her to move we did see many things appear that were not there when standing still.
• Mobility and flexibility assessment all appeared reasonably normal, if anything possibly too flexible except for the rotational stretch of the hips. This at first would bring on severe pain but later on would be the key to the correction process and be used to alleviate her pain!
• Stability assessment she passed easily. This along with the unusual posterior tilt suggested to me this might be more of a herniated disc problem for this is common traits to this injury. The only problem with this was that extension which usually relieves this person gave her pain. Very confusing!
• During the movement assessment the big problems as we suspected were proved correct. Bending and twisting were virtually impossible. But also squats and lunges would bring on symptoms of pain also. And single leg showed many problems we did not see in the static assessment.

The most difficult thing with all of this was that the pain was not always instant! At the time of doing it she was fine, so we would continue and keep asking, "are you okay" and she would be fine. It would be the next day or two later that immense pain would follow. This made things very difficult for us to know if we were doing too much or not enough. This was a very frustrating time for her, as we constantly went back and forth between pain and no pain.

Weakness in lower body was noticeably present and the longer this remained the piriformis muscle was continuing to work too hard to create the stability at the hip she was lacking.

We had to find a way to teach her body how to stabilize more efficiently and strengthen muscles without the piriformis muscle taking over.

The Plan

The exercises we knew we needed to do that would have all the solutions within them were also going to be the ones that would make matters worse. These key patterns were:

• Deadlift or bending movement pattern
• Lunge and single leg stance
• Woodchop or rotational movement pattern
• Squat

These exercises related closely to the real world movement tasks she was having trouble with (vacuuming, picking things up from the floor, walking for long duration and kneeling up and down from the floor.) The more we could improve and correct these movement skills, the easier it would be to strengthen the body in those tasks making her more efficient and stable resulting in no more compensatory stiffness from the hips.

This all sounds good in theory, but as I briefly mentioned we could not go straight to doing these which we found out the hard way.

When we prescribed these exercises within the session it gave her pain the next day. At the time within the sessions there was no pain, nor excessive effort performed with a bodyweight squats, lunges, light deadlifts & woodchops. Even after a couple of weeks of getting the movement technique to perfection without increasing any load, there was still pain the next day! We kept persisting, the client was very motivated to keep going, however, we had to change the program up through all of this trial and error, for her to improve, and not cause any pain the next day after the sessions.  

This is where things can get very frustrating as it makes no sense that pain would appear when things look good. We had to gradually regress movements and also come up with a relief strategy. We use this a lot with back pain by finding positions the person finds relief. This gives you clues as to what exercises you can use to help settle things down before trying the more risky movements again later when no pain is present.

We Had To Design A Relief Program

What we changed was working on only 1 of those 4 key exercises at a time within a session, as this would help us to be sure of which pattern was responsible for the pain. And we also spent considerable time testing her for exercises that provided relief and no pain. Some of these we were able to add significant loads to and they were fine. The key was to have period of time where she had no pain and we could build some reserve to be able to test the risky movements again later.

These were the relief exercises we used. We would use these between sets of the risky exercises and also during sessions when she was just not 100%.

Swissball Hip Extension

The video above gives you 2 of the exercises we used a lot at this stage. This was used to activate / strengthen the glute muscles and reinforce correct hip movement, without loading up the hips too greatly. This is always a problem with pirformis syndrome and this case was no different. Make sure you read our article How to strengthen the Glutes for more detail on how to do this and get a copy of our FREE Checklist below.

Forward Ball Roll:

This was used to strengthen core and reinforce correct hip movement without loading up the hips.

Upper Body Cable & Dumbbell Exercises:

Although these did little in correcting the problem physically, it achieved great mental strength. It is important to recognize the client needs to see progress and be able to "win" at something. These exercises we could progress with serious loads and this gave her the inner strength to be able to take on the more difficult parts of the program later. We did use exercises that promoted some single arm positions that recruited stabilizers of the trunk to help disengage the hip

Piriformis and glute massage:

This was completed using foam rolling and myofacial stretching techniques as seen above in the videos to relax the piriformis immediately before and after the more complex exercises to follow. As mentioned earlier this would become her key relief strategy as time went on. After a week or two of doing this we would then move to the key stage being Functional Movement. See article How Functional Movement Patterns Help You Live A Better Life for detailed explanation of this.

Functional Movement & The 4 Key Patterns

It was at this point after we had managed to let the pain settle that we had to introduce one of the following exercises.

• BODYWEIGHT SQUAT
• CABLE WOODCHOP
• BODYWEIGHT LUNGE
• KETTLEBELL DEADLIFT

Watch the video below of an overview of each of these patterns and how important they are to getting rid of pain and moving well in life.

It was vital to use only one of these exercises per session so we could be certain it was okay to do ongoing. This was similar to allergy testing with food. Technique was the major focus and we would use tools to assist her, along with various regressions at times, always working with extreme caution sometimes with only 5-6 reps at one time completed to prevent fatigue from ruining her form.

We were following this protocol for almost 2 years, gradually working on each movement at a time. For the first year we conquered the squat & woodchop without pain afterwards, the second year we conquered the lunge and deadlift without any pain afterwards.

Where Are We Today?

Today many of the things that were extremely frustrating are now a thing of the past. There is still some work to do and strength to gain, but the best news is the pain is rarely present and when it is, we are able to address it quite quickly. The four regressive "relief" exercises have helped us break that window where we can now perform the deadlift, lunge, woodchop and squat movements without pain and now can strengthen her body better by doing these with heavier loads. Instead of bodyweight squats, we are now doing them holding up to 12.5kg’s and even introducing unstable surfaces. The lunges are also done with a total of 10kg’s dumbbells now! The woodchops are comfortably completed with 20-24kg in a standing position.

The deadlift was the most difficult pattern of all to achieve and are now done between 20-35kg.

Most importantly outside of the gym, she is not in chronic pain and when she is she knows what her relief strategy is to reset her body back to normal. The daily tasks that caused all type of pain and suffering before are now pain free and completed with more ease than ever before. She still has more work to do, but things have become so much easier now and she no longer fears ending up disabled.

For More Information On Piriformis Syndrome

We have worked with hundreds of cases like this before and we also have a great online program complete with a 60 minute video and PDF book that has all the assessments, exercise instructions and step by step programs to guide you on the process of correcting this painful condition. Click here to see more about this program or on the image below to get your copy straight away.

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