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Teaching Clients With Sciatica

Have you ever had a client who seemed to be advancing nicely, then sciatica strikes? This condition- which is irritation or pinching of the sciatic nerve—often includes pain radiating from the lower back down the back of the leg, tingling in the toes or feet and numbness along the track of the nerve. Sciatica is a symptom of another problem in the body, such as a herniated disk, lumbar spinal stenosis, disc degeneration, pelvic instabilities, or Piriformis Syndrome. It is important to remember that, while Pilates work can increase sciatica symptoms, it is not a cause of the condition.

Luckily, the practice can be modified to make irritation of the sciatic nerve less likely. In working with clients and in my own battle with the condition, I’ve found that certain positions, practices and cues can actually cause an increase in irritation, but a few subtle changes can help deter flare-ups. Below I’ve listed some easy to avoid situations that can contribute to discomfort in sciatica sufferers. Usually, when one of these root causes is found and eliminated early, the sciatica will decrease or disappear.

CAUSE: Squeezing the sitz bones
Among my clients, this is the most common irritant of sciatica. It’s also one of the most challenging areas to release because students usually don’t realize how much tension they’re holding.

As soon as a client comes in complaining of sciatica, I have them lay on their back, knees bent and feet flat. I begin with some pelvic tilting and watch how they release the pelvis back to the mat after each tilt. You may see that they are not releasing the sitz bones all the way—instead they’re probably using their glutes to gently “hold onto” the sitz bones the whole time.

After the last pelvic tilt, when they should be resting in neutral pelvis, instruct your client to “drop the sitz bones.” You should be able to see the sitz bones fall toward the mat. It may take a few minutes of practice for the sitz bones to drop.

The student most likely will feel like they did nothing—the tension is so subtle that they don’t know the difference between squeezing and relaxing. Focus on continuously telling them to drop the sitz bones throughout the remainder of the session. Some cues I use are “pretend you have a wide butt,” “widen the backs of the thighs” and “give weight to the sitz bones.” Also, check the wrinkles on the back of their pants for a visual cue: these wrinkles will flatten as the bones are dropped.

CAUSE: Spring Tension
If leg springs on the tower are too heavy, it could cause the student to brace against the tension by pushing down the low back, or tightening up the neck and shoulders, thereby creating muscle tension around the sciatic nerve. We want to the abdominals to work during leg springs, so its good to encourage neutral pelvis.

When you notice this tensing of the torso and upper body, change to lighter springs and remind your client the goal is to lengthen the spine and connect the abs in at the same time. If your client is unable to “drop the sitz bones” the springs are too heavy. Try using lighter springs or teach the exercise without springs.

CAUSE: Extreme External Rotation
As instructors, we know to leave a space around the width of one fist between the big toes when externally rotating the legs. If the client is too rotated I’ve noticed they often pull tension into the low back and piriformis muscles, as if the front body is very open and the back body is tightened. All of this squeezing around the sciatic nerve will irritate sciatica.

If you notice extreme external rotation, have your client imagine just a “fist’s width” between the big toes. Use kind and gentle images of swirls, such as “imagine candy cane stripes swirling around your legs and meeting in the back”.

CAUSE: Lost Abdominal Connection
Notice if your client is able to maintain neutral pelvis throughout most of the exercises. If, for examples, they start to push the low back down during the Stomach Series on the mat, or Back Stroke on the reformer, that is a sign that they’re allowing too much pressure into the sciatic nerve region.

If you generally teach these exercises in a flat back position, keep in mind that this position may not be suitable for some bodies. Since sciatica is often a symptom of a pre-existing condition in the low back, a flat back position for some exercises may irritate the sciatic nerve. Try slowly teaching a client with sciatica to lengthen the spine into neutral during these exercises.

To lengthen the low back and abdominals in a neutral spine position, focus cueing around the pubic bone. Ask the student to “drop the pubic bone through the inner thighs.” This will rock the pelvis slightly forward, lengthen the spine and engage the abs without tension in the low back. It can also help students “drop the sitz bones,” which was mentioned earlier as another sciatica irritant. The goal is essentially the same, but here you are approaching the position from the anterior rather than the posterior.

CAUSE: Pushing the Hips and Thighs Forward
When the front hip bones and thighs are thrust forward, the low back is shortened into a forward direction and the sciatic nerve region is tightened and stressed. Muscularly, this is a similar problem as holding onto the sitz bones, and the effect on the nerve is just the same.

Not surprisingly, this is most common and easiest to observe when the client is standing or kneeling. To help retrain the body, ask clients to “bring the hips inside the body” or “draw the hips back below the shoulders.”

If this doesn’t work, have them begin to drop the head forward, and start rolling down over the legs. Stop them just after the head and first few vertebrae have rolled forward. At this point, their hips and legs have probably adjusted to the proper place. Tell them to leave the hips right where they are, and roll back up.

Pilates Exercises to Try Leaving Out
Sometimes certain exercises just don’t work for people with sciatica. You can try modifications or take the exercise over to another piece of equipment. However, in most cases leaving the exercise in question out is the best way to know they will not be in pain the next day, or the next moment.

These exercises might be contraindicated for those with sciatica:
1. Climb a Tree
2. Side Sit-Ups, specifically on the Short Box
3. Teaser
4. Hamstring Stretches
5. Tower
6. Monkey
7. Stomach Massage
8. Side Kicks

When you and your client discover which habits are contributing to their sciatica, it is important that you discuss the fact that they are probably following this same movement pattern all day long, not just in Pilates. Pilates does not cause sciatica, it only reveals what is already there. Talk to your client about moving mindfully throughout the day. You can help them learn how to change their habits, but it’s up to them to actually do the work, inside and outside of the studio, so they can live pain-free and healthfully!