Have you ever had a tight twinge of a pain deep in your butt muscles? And maybe "sciatic" pain that radiates down the back or side of your leg, in the absence of lower back pain?
If the answer is yes, you may well have had piriformis syndrome.
What is piriformis syndrome?
Piriformis is a muscle found in the buttock. It crosses almost horizontally from the sacrum (in the lower back) across the buttock to the head of the femur (thigh bone) on the outer hip. Its main job is to help laterally (aka externally) rotate the hip joint. In a flexed position, piriformis can also assist in abducting the hip joint (moving the thigh out to the side).
However, if the hip joint is flexed the angle of pull changes, the muscle becomes a medial (aka internal) rotator. Check out the helpful video above for a demonstration.
Piriformis syndrome is a condition whereby the muscle increases in tension, resulting in pain. Most commonly, this pain is located in the buttock area, as well as often being radiated down the leg. The cause of the pain is the tight muscle pressing on the sciatic nerve.
The sciatic nerve is the largest single nerve in the human body. It exists the spine between the L4/L5/S1 vertebrae and passes through the buttock and down the leg. It is this proximity to the piriformis muscle that makes impingement at this point a fairly common issue.
Sciatica is a symptom, rather than a condition. When someone says he has sciatica, it could be caused by a number of problems, one of which being piriformis syndrome.
The term sciatica basically refers to irritation of the sciatic nerve. This can occur anywhere along its course from the spine, through the buttock and down the posterior leg. Therefore, sciatic pain must be carefully examined to determine its cause.
Other issues which may cause sciatica include lumbar disc herniations ("slipped disc"), spinal stenosis (extra bony growths in the spine), spondylolisthesis (stress fractures in the spine), degenerative disc disease (wear and tear) and sacroiliac joint (SIJ) dysfunction (problems with the joint between the spine and pelvis).
In most cases, a physical therapist or doctor should be able to identify a case of piriformis syndrome and rule out spinal involvement without the need for medical imaging. Sciatic pain is most likely a symptom of piriformis syndrome if:
- There is no current lower back pain
- There is no history of lower back issues
- There is full, pain-free lower back movement
- There is tenderness when pressing the piriformis muscle
- An increase in muscle tone may also be felt
- The range of medial hip rotation is decreased (with the hip in neutral)
- The range of lateral hip rotation is decreased (with the hip flexed at 90 degrees)
- There may be pain on rotating the hip (either way) against resistance
Treating piriformis syndrome
Now we know what it is, how do we treat it?
As with most conditions, the first aim of treatment is to ease pain. This can be done with anti-inflammatory medications. Sometimes applying a heat pack will also help to ease muscle pain. Gentle stretching of the muscle is also recommended, as long as this does not aggravate the symptoms.
Once a medical professional has diagnosed piriformis syndrome, often the next step that will be taken is to decrease the tension in the muscle. It tends to respond well to soft-tissue treatments such as massage therapy and trigger point therapy. Acupuncture also often has a positive outcome and electrotherapies such as ultrasound may also be worth a try. Home treatments such as heat packs and using a "spiky ball" or foam roller for self-massage can also be effective.
Usually this combination of treatments is enough to ease the symptoms and get you moving again. However, symptom relief is not the end of the story and piriformis syndrome requires a thorough rehabilitation to prevent it reoccurring. For this, we need to know why the piriformis has tightened up and how to prevent this happening again.
The most common reason for a muscle to become tight is overwork. The most common reason for a muscle to be overworked is that it is compensating for a weakness somewhere else in the chain. If we look at the function of the muscle as covered earlier, we can see which other muscles do similar jobs and it seems logical to start there.
Runners in particular require really strong glutes to ensure an effective and efficient movement pattern. And this is actually true of most sports and even just daily tasks such as walking up hills and stairs.
The glutes really are the powerhouse of the body. Therefore, it stands to reason that if the main glutes (max, min, med) are not strong enough, other smaller muscles such as piriformis must work harder to assist.
While this may not be the entire problem, if the glutes are suspected to be weak, it is a good place to start. Other issues may include overpronation at the feet, leg length discrepancies, pelvic and core instability and pelvic misalignment.
Strengthening the glutes
There are copious exercises available to target the gluteal muscles, either as a unit or individually. Clam exercises, side-lying abduction, pelvic dips and single-leg squats are all ones I use regularly to hit gluteus medius and minimus with good effect.
The issue I often come across with gluteus maximus strengthening is that the muscle can become inhibited, meaning it isn't firing when it should. Instead, the hamstrings take the load. When working gluteus maximus, it is important to really focus on the muscle and squeezing it tight to ensure it is functioning when performing the exercises.
If you feel it more in the hamstrings than the bum muscles, chances are you're not using it sufficiently. Great glute max targeted exercises include bridges and hip extensions with external rotation (either lying or standing).
All of these exercises are pretty mainstream, so a quick online search should produce good video demonstrations to follow.
Other things to do if you're struck by this problem should include a gait analysis for runners to check your movement patterns, especially at the feet and to check you're in the right footwear. Also check your leg length — even a half-centimeter difference can have an impact.
Finally, address any training errors such as a sudden increase in frequency or intensity of training.
