One of the most common reasons a pregnant woman seeks the nurturing care of a massage therapist is for the relief of lower back pain in general, and sciatica specifically.
Sciatica is defined as inflammation of the sciatic nerve that results in referred pain from the lower back to the buttocks and lower extremity. The pain is often felt on the back or lateral side of one leg, although both legs can be affected.
Massage for Moms: Sciatica
Within the general population, sciatica is caused by a herniated disc, direct or indirect trauma, spinal stenosis or a combination of any of these factors. Another contributing factor is a hypertonic piriformis muscle. This overly tight muscle compresses the sciatic nerve and causes pain.
During pregnancy, however, the sciatic neuropathy is rarely caused by nerve root compression, disc herniation or other pathological conditions. It is usually a result of poor posture or uterine pressure on the sciatic region or tight lateral hip rotators.
Regardless of its etiology, sciatica can be very painful—but often easily treated during pregnancy. One word of caution: If the flare-up is acute, the best treatment is to use an ice pack on the sciatic notch. It is safe to treat the acupuncture point on the crown of the head (Governing Vessel 20) and the reflex points on the heels, but all direct massage on the affected leg must be avoided until the inflammation subsides.
All and any massage on the lower extremities — legs and feet — must follow lymphatic protocol during the entire pregnancy and for up to three months postpartum when fibrinogenic activity normalizes. This is the most effective way to safely reduce edema and prevent dislodging blood clots.
The massage is very light—10 to 30 grams of pressure—and starts at the neck and then works proximally to distally on the leg. Very little lubrication is used, to ensure stretching and gentle pulling of the skin. All deep strokes and pressures are contraindicated during pregnancy and the first three months postpartum.
In early pregnancy, some women experience a hot spot in one of their buttocks or the sacroiliac joint. This sensation often occurs in the late first trimester/early second trimester (11 to 14 weeks) and is concurrent with the higher levels of relaxin they are producing.
Since relaxin functions to soften connective tissue to permit pelvic widening (along with rib expansion and increased uterine ligament elasticity), early pregnancy sciatica is caused by the loosening of the pelvic girdle, especially the sacroiliac joint. As a result of this softening, the SI joint becomes somewhat unstable and can compress the sciatic nerve. By repositioning the pelvis, particularly the sacrum and ilium, the sciatica disappears.
The treatment technique is simple: With both hands loosely clenched in a fist and your wrists neutral, press her hips medially just behind each ASIS (medial compression). Hold for a count of five and repeat a few more times. Since the hips are more flexible because of increased relaxin, we can use this essential hormone to our advantage and reposition the bones of her pelvis to reduce sciatic pain.
Massage for Moms: Exercises
In addition to the compression, the following exercises also help to stabilize her pelvis:
• While standing, the client squeezes her buttocks and holds for a count of 10. Repeat for a total of 10 reps. This helps to strengthen the gluteals and restore medial pelvic positioning.
• While standing, the client leans on the affected side and squeezes those gluteal muscles for a count of 10. Repeat for a total of 10 reps.
Most of the sciatica women feel in later pregnancy is directly related to the position of the uterus on the sciatic region, pulling of the broad and sacrouterine ligaments, weakened abdominal muscles, the diastasis recti and postural misalignment. An effective solution is to move the baby off the sciatic region.
This can be accomplished in several different ways. If you are lucky enough to have body support systems (modular cushions that are contoured to support the pregnant torso), place your client in the prone position for at least one half-hour. This position gives the fetus more room to move and get off the sciatic region.
Sometimes one session in this position is enough to solve the problem. This posture often addresses the sacral soreness experienced by women whose babies are occiput posterior — the back of the baby’s head is pressed against the mother’s sacrum. Side-lying with the top leg in front of the bottom leg and bolstered with pillows tilts the pelvis enough to give the baby a chance to shift off of her lower back.
In the absence of these cushions, other effective alternatives are four-point (hands and knees, or elbows and knees) pelvic tilts, with or without pelvic rocking, leaning over a table or bed for 15 to 20 minutes, or assuming any position that brings the gravid uterus off the sciatic region.
Another very effective technique to reduce sciatic pain is the sacral lift. This cannot be performed on anyone with a coccyx problem, such as hyperflexion of the coccyx or coccydynia. In these cases, press the ischial tuberosities as an alternative. Place the flat of your fist (wrist neutral) under the lower sacral segments and lift at an angle of 45 degrees toward her umbilicus. Place your other hand softly at her ASIS and gently traction toward your shoulder.
Hold this position for a count of six and release slowly. Repeat several more times. Your client should feel a lifting of her pelvic floor and relief from sciatic discomfort. For additional client comfort, fold a small towel over your fist so there is no bone-on-bone contact.
Massage for Moms: When it’s Not Sciatica
Sometimes the uterine ligaments stretch (from a growth spurt or sudden movement) and cause referred pain that masks as sciatica. In these instances, recruiting the transverse abdominis helps support the uterus and ligaments and relieves the pain.
It is highly recommended that all pregnant women learn to use their core abdominal muscles correctly throughout gestation and early postpartum recovery to reduce the severity of the diastasis recti, help stabilize the lumbar spine, and support a more upright posture. During pregnancy, poor posture is a major contributing factor to muscle aches, lower-back pain and sciatica.
Hips laterally rotate during pregnancy and the piriformis muscle is a lateral hip rotator. Its proximity to the sciatic nerve makes it a major player in sciatic pain. When either piriformis muscle becomes hypertonic, it may press directly on the nerve. In order to evaluate if the piriformis is the cause of your client’s pain, have her medially rotate the affected leg. If pain is present with this movement, chances are good that the piriformis is involved.
To treat a tight piriformis, have your client bring the knee of the affected leg toward the opposite shoulder. With her hand, she brings the knee as high as she can toward the opposite shoulder. This can be done either standing or sitting. This piriformis stretch will ease the pressure on the sciatic nerve and reduce the pain.
Trigger-point release on the piriformis can also release the muscle. Palpate for particular (or several) hypersensitive spots. Press on the nodule with a “good hurt” pressure until the pain subsides. You may also vibrate the area as you press. Connective tissue massage, such as pin and stretch, is also effective.
Another way to release the piriformis is to position your client on her unaffected side and flex the affected leg until the point of discomfort. Leave the leg in that position until the pain disappears and move her leg (knee) higher. This technique, positional (gravitational) release, can easily be done by the client in the comfort of her home. The piriformis can also be released using muscle energy technique (MET) or strain/counterstrain.
In the final weeks of pregnancy, women often experience sciatica as the baby engages within the pelvis. At this point, there is little relief from most techniques because there is limited room for the baby to move. Ice packs, the sciatic glide (flexing the foot back and forth), the acupuncture point on the crown of the head and the reflex point on the heel of the foot, and a general, relaxing massage may help, but birth will be curative.
Massage for Moms: After Baby is Born
It usually takes four to six months after the baby is born for the levels and effects of relaxin to normalize. Immediately after birth, the pelvis is hypermobile and unstable. Sciatica can be caused by pelvic or lumbar subluxations, long-held birthing positions, poor body mechanics when lifting or holding the baby, strain on the sacroiliac ligaments, a symphysis pubis separation, muscle tightness, and weakened abdominal muscles.
Medial compression and core muscle strength are beneficial at this time. Wearing certain baby carriers reintroduces the maladaptive posture of pregnancy by bringing the center of gravity forward again. This often results in anterior pelvic tilt which, as we know, compresses the lumbar spine. If possible, new mothers should use certain baby carriers splinting their abdomen first.
Until core strength has been restored, an abdominal splint offers her the best protection against the sequelae of an anterior pelvic tilt. Treatment for leg pain should continue as light lymphatic drainage for up to three months postpartum to safeguard against dislodging any blood clots.
Sciatica in extended postpartum can be caused by recurrent lumbar/pelvic/sacroiliac instability or tightness, a tight piriformis muscle, the presence of a diastasis recti, or a symphysis pubis separation that did not heal properly. After three months, leg massage can be as deep as the client can tolerate, although if the sciatica is acute, light work is preferred.
Massage for Moms: A Special Population
In order to effectively evaluate the possible causes of sciatica and learn the numerous techniques to treat it, specialized training in a live classroom setting, with the on-site presence of a qualified instructor, is highly suggested.
This special population deserves to be treated by skilled practitioners who understand the changes their bodies undergo, know how to treat their physical discomforts, and can impact this life-changing time of their lives for the better.
It is an honor and a privilege to work with expectant and new mothers. It also assigns us the essential responsibility of educating ourselves appropriately.
About the Author:
Elaine Stillerman, LMT, has been a licensed New York-state massage therapist since 1978 and began her prenatal massage practice in 1980. She developed the professional certification and online courses “MotherMassage: Massage during Pregnancy.” She is the author of MotherMassage, Prenatal massage: a textbook of pregnancy, labor, and postpartum bodywork and Modalities for massage and bodywork. In 2013 Stillerman was inducted into the Massage Therapy Hall of Fame.