Adhesion can from around the sciatic nerve. This can reduce mobility, blood supply and cause pain. It can be reduced with Manual Adhesion Release® or surgery. Proven since 1925!

Discussion Highlights:

0:50- Adhesion (fibrosis) can form around the sciatic nerve, throughout it’s course in the hip and thigh.

1:44- This is called a clinical diagnosis, which means it based on the skill of the person you see.

2:13- How do we know this?

5:50- Causes of sciatic nerve entrapment

14:17- Mobility in the nerve is important

35:27- Patients that suffer with chronic pain need to know this

[First 9:50 transcribed]

[Sitting at the table are: Dr. Brandon Cohen, Dr. Matthew Lytle, Dr. Carl Nottoli and Dr. William Brady.] 

 

Dr. William Brady: If you’re a healthcare provider, in a perfect world, you’re mad about the people you don’t understand and you look for a solution. So you come across a solution, go ‘maybe my guy had that’.

[Break for Title]

Dr. William Brady: Adhesion can form around the static nerve. So we treat this all the time. We diagnose it all the time and there’s still people who don’t seem to believe this thing happens. So this is just a brief review of sciatic nerve adhesion. On the right side of the slide here you see the sciatic nerve. That’s the back of the hip back of the thigh and then it splits into two other nerves. So, effectively from that piriformis muscle down to the back of the knee, that is the length of your sciatic nerve. 

So adhesion can form around the sciatic nerve throughout its entire course in the hip and thigh. This problem must be considered and ruled in or out for cases of low back pain, hip pain or thigh symptoms; pretty straightforward conceptually. If there is a list of things that can go wrong here, you need to consider all of the things that could be wrong in ruling in or out for cause. This is what everyone imagines their doctor does. Well, this is one more thing to add to that list that your doctor needs to be aware of. 

The hard part is there’s no single test to establish this. It’s not a blood test where it’s like, ‘Oh here’s your glucose level, you know, you’ve got diabetes. Here’s any number of other sort of routine medical things where [there is] usually a blood test or some definitive test.’ There’s not. This is what we call clinical diagnosis, which means it’s based on the skill of the person you see. So they have to be aware of it and they have to be looking for it and I have to have the skill or knowledge to assess it. That’s what makes this tricky. So the doctor must use all of the data: from the history, range of motion, palpation, which is feeling the tissues, to symptom-producing tests, etc. There’s a long list in order to diagnose this. So how do we know this and why isn’t this commonly considered?

It’s massively under-diagnosed. We know this compromises function, so this limits your straight leg raise test. We did another video on how the straight leg raise–there’s lots of reasons why it can be limited and almost none of those medical practitioners had any idea that sciatic nerve entrapment could limit this. And also, when you bring that leg up into that straight leg raise position and you also flex the ankle called dorsiflexion, that tells you it’s not the hamstring. It is somewhere along the track of the nerves and we’re from the low back down through the leg. Our additional skill other than a limited range here, is that we can feel this in the tissue. It takes up space, it reduces motion and there’s increases in tension. If you have the skill set to feel that with a high enough skill, those things start to become obvious. That’s what we look for. So sometimes doctors touch people to see if it elicits pain that can be an indicator of something, but we do this more to see where the adhesion is, looking for those specific things.

And furthermore–so that’s how we diagnose it mostly palpation and limited function–but that treatment fixes it. If we do the treatment, and then your straight leg raise goes up that’s successful treatment. And that means your hypothesis that this thing was there and that your treatment was effective. Well, if your outcome is the opposite of the reasons why you think it’s there, if your straight leg raise was limited and it’s not, and the tissue feels different, and also the patient feels better, and that’s repeatable, and that’s the next bullet point here. 

It’s reproducible. Over thirteen years of developing and teaching these procedures, we get a reproducible consistent result. I can do it, teach you to do it, you teach him to do it he teaches him to do it we’re like, ‘okay and I felt that’ and we can see as instructors the skill is absolutely essential to get the task accomplished. If you try it, but fail it just doesn’t work. It’s like missing the target in archery and we know the closer you get to a bull’s-eye the fewer visits it takes, the more success you have with treatment. So there’s things you can measure and things you can feel and when you do the right treatment with enough skill the things that you measure improve and the things you can feel improve. So that’s how we know it exists. 

However, there seems to be some disagreement regarding adhesion: Does it exist? Is it important? Can you break it down? There’s a lot of debate among conservative care providers. Where there isn’t debate is among surgeons. So is there debate, or a disagreement? There shouldn’t be. Period. Full stop.

If you google deep gluteal syndrome on Google Scholar 227 results come up and they routinely show adhesion is the most common cause for deep gluteal syndrome. So deep gluteal syndrome is, as the name syndrome implies, it’s a series of diagnoses that can happen deep to the glute. That’s where deep gluteal comes from, basically in the back of your bottom, the back of the hip. So underneath that glute, the number one problem you’ll have is sciatic nerve entrapment, secondary to fibrous adhesion. If you look down in that lower right corner, “causes of static nerve entrapment out of 24 surgical cases: thirteen fibrous and fibrovascular bands–”

Dr. Matthew Lytle: So 50% 

Dr. William Brady: Yes, right. [continues reading from the slide]…eight they thought was from the variations in the piriformis muscle. And we’ve all seen that, right? Piriformis syndrome–no one argues whether piriformis syndrome exists. What we’re saying here is this is far more common– 

Dr. Carl Nottoli: Yep 

Dr. William Brady:–than piriformis syndrome. And piriformis syndrome has been this–they’re actually renaming it because it’s one thing, but deep gluteal syndrome is a better label. It says it’s coming from somewhere in here, and under the deep gluteal syndrome umbrella you have: sciatic nerve entrapment and another step down from there can be fibrous adhesion or the piriformis muscle itself. And then there’s other things: mass affects from ganglions and schwannomas and those are far less common. But, in a surgical practice you’ll clearly see those.

Dr. Matthew Lytle: So interesting, I mean you know, [inteligible] you’d review all of them, but when they did the piriformis– thought was the cause– did they only address that or they have other fibrous bands? Because, arguably, you could say, right? If to truly–I mean you can’t do this to a patient– but it’d truly be scientific–I’d want to just cut the piriformis see what happens. I’d leave everything else because then you would go, ‘does that help? No?’ Because I would argue if they’re in there they’re gonna clean up whatever fibrous adhesion they find too– 

Dr. Carl Nottoli: Chances are if it’s piercing that muscle and creating tension and pressure and inflammation there’s also going to be adhesion, right?

Dr. William Brady: Yes, right 

Dr. Matthew Lytle: It isn’t weighted as high so it might need– I would almost say it’s thirteen plus eight, likely twenty-one.

Dr. Carl Nottoli and Dr. William Brady: Yeah 

Dr. Matthew Lytle: Which is going to be more like 90% of the cases of that. 

Dr. Carl Nottoli: Yeah 

Dr. William Brady: Couldn’t agree more that if you cut the piriformis and remove it or cut a good portion of it out you’re also separating tissue– 

Dr. Carl Nottoli: Right

Dr. William Brady:–from the sciatic nerve. So, yes, so what do we find when we feel the tissue? We routinely feel cases where the piriformis, you know, where the nerve goes through the piriformis or comes up over it instead of the traditional 85% of the time, [which] is that normal anatomical arrangement and there’s about three other ways to get the other 15%. At a very high skill level we can palpate that and what we generally find is as long as your straight leg raise isn’t limited, the idea that an anatomical variation of the piriformis matters… 

[crosstalk]

Dr. William Brady:..doesn’t say a whole lot. 

Dr. Carl Nottoli: By itself…caused the problem…is not the case

Dr. William Brady: Yes. And I think to your point an anatomical variation of the piriformis–so say the sciatic nerve goes right through it instead of under it, well that’s going to create a higher friction point than it does 

Dr. Matthew Lytle: a sharper turn

Dr. William Brady: against the superior malleolus. So, yeah I think you will get more adhesion there. I leave room for cases where– it’s– the anatomy is so tortured that the conservative care doesn’t work, you know, and you may need something. Again, the surgical cases versus the conservative care cases we see, they’re not a perfect overlap.

Dr. Matthew Lytle: Right

Dr. William Brady: You know, I also I don’t know how many times I’ve seen again a ganglion or schwannoma. And again, it’s a model where you have multiple pathologies that accumulate to cross a symptom threshold. 

Dr. Carl Nottoli: Right. 

Dr. Matthew Lytle: Right. 

Dr. William Brady: ..so who’s to say if any one of these things alone would create a symptom? 

Dr. Matthew Lytle: True.

Dr. William Brady: …and we find that when we reduce adhesion, boy, it wipes out a lot of things. So-but we just did the research on this where we took one-hundred and thirty-two low back pain patients. Thirteen of them had straight leg raise as their primary test. We identified adhesion in all thirteen of them and that was twenty sides as well thirteen patients but several had a bilateral. So out of twenty diagnoses we restored straight leg raise to an average of twenty degrees. So it works. We would need a larger sample group to start to see what would happen with some of these other aspects…

[End of 9:50 transcript. See the full video for more information]

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