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Piriformis Syndrome: How to detect it and strengthening and stretching programs to help you heal

Posted Jan 10 2014 6:00am

Pain associated with piriformis syndrome most often follows the borders of the piriformis muscle (red)

The piriformis is a small, relatively short, and little-known muscle buried deep within the muscle tissue in your hips.

In each hip, it runs from the back of your pelvis to the top of your femur. Because of its unique positioning, the piriformis muscle helps rotate your leg outward when your hip is extended, but rotates your leg inward and into abduction when your hip is flexed.

When running, the piriformis is most active during the “ stance” phase , where your foot is planted on the ground. Here, it acts as an external rotator of the leg, but it is neither the primary nor the most powerful muscle which acts in that role.

Despite its seemingly insignificant function in the muscular support of your body while running, it plays a central role in a complicated and frustrating injury known as piriformis syndrome.

Epidemiology: Causes, what makes it worse, what’s going on

The reason this unassuming muscle can be so problematic is likely because it is positioned immediately adjacent to the sciatic nerve, a very thick nerve which runs from the base of your spine along your glute muscles and down the back of your legs, providing the nerve signals that allow all of the muscles on the back side of your lower body to fire when needed.

When the piriformis muscle is irritated, the sciatic nerve can get irritated too. In around fifteen percent of people, the sciatic nerve actually passes through the piriformis, which, according to some researchers, leaves these individuals more susceptible to piriformis syndrome.

Classically, piriformis syndrome feels like an aching soreness or tightness in your butt, between the back of your pelvis (the sacrum, specifically) and the top of your femur.

  • Pain, tightness, tingling, weakness, or numbness can also radiate into your lower back and down the back side of your leg, through your hamstrings and calves.
  • Buttock pain and tightness with prolonged sitting is also a common occurrence with piriformis syndrome.
  • When you run, you will probably feel pain in your butt throughout the stance phase of your stride; the pain might get worse when you run fast, go up and down hills, or go around tight turns.

Piriformis syndrome is related to sciatica, a painful irritation which also involves pain, tightness, weakness, and a numb or tingling sensation than courses down from your lower back into your butt, hamstring, and calves or even feet. How the piriformis muscle and the sciatic nerve relate to piriformis syndrome and sciatica-like pain is something that even doctors and researchers can’t quite agree on.

Their interactions are complicated, as there can be many causes of buttock pain and sciatic nerve pain. The mere existence of a “piriformis syndrome” has even been questioned, but the most current research and review papers accept that piriformis syndrome represents a real phenomenon that is responsible for buttock and lower leg pain.

Because of its proximity to the sciatic nerve, an injury to the piriformis muscle can cause sciatica-like pain that radiates down the leg

Regardless, it is very important to distinguish piriformis syndrome from other problems that can cause similar symptoms in the buttock and leg. A herniated disc in your lower back, for example, can put pressure on the sciatic nerve, causing the same type of pain that radiates down the back side of your leg, as can spinal stenosis (a narrowing of the canal where your spinal cord passes through) and a host of other pelvic and lower back issues.

Though there are no universally agreed-upon criteria for piriformis syndrome, a comprehensive review paper published in 2010 by Kevork Hopayian and other doctors at the University of East Anglia in the UK provides useful criteria. In their study, they defined piriformis syndrome as “sciatica [i.e. musculoskeletal pain in the leg] arising from pressure on the sciatic nerve trunk or its branches by the PM [piriformis muscle] or disorders involving the muscle.”

This definition is useful as it encompasses both sciatica-like pain radiating down through the hamstrings that is likely the result of pressure on the sciatic nerve, as well as localized pain and soreness in the piriformis muscle itself. Hopayian et al. also outlined the four most common findings in patients with piriformis syndrome among the 55 studies they examined:

  • Pain in the buttock/piriformis region
  • Tenderness at a specific spot in the pelvis between the sacrum and the top of the femur—the area the piriformis muscle runs through.
  • Worsening of buttock and sciatica-like pain with prolonged sitting
  • Aggravation or alteration of the pain when the hip and leg are positioned to put tension on the piriformis muscle

While these symptoms are definitely evident in people with piriformis syndrome, it’s unclear how common they are in people with non-piriformis-related sciatica, so its diagnostic usefulness is somewhat limited.Fortunately though, other conditions that can cause similar symptoms can be identified by objective medical tests like an MRI or a CT scan—these can check for herniated discs or other low back and pelvis issues. If these tests come back clean, piriformis syndrome can be considered as a cause.

There are also a few specific tests for piriformis syndrome that have been highlighted in scientific studies.

  • In the straight-leg raise test, pain shooting down the back of your leg when your leg is raised straight (typically by a partner) while you lie on your back is indicative of irritation of the sciatic nerve, though it is not specific to piriformis syndrome.
  • Another test can be performed while sitting: attempting to push your knees out against resistance (provided by a partner or rope) can cause pain in some people with piriformis syndrome.
  • Finally, two maneuvers which put a stretch on the piriformis muscle can also be used to test for piriformis pain. Having a partner rotate your hip and leg inwards while you lie on your back with your knees straight can produce pain, as can lying on your unaffected side and rotating the painful side across your body with your knee bent.

straight leg
The straight-leg raise test can cause sciatica-like pain if you have piriformis syndrome, but might also indicate the presence of low back problems

pirif_test_one_redded
One test which can produce piriformis-specific pain is a supine internal leg rotation, assisted by either by a partner or a rope, as illustrated here.


Stretching the piriformis in this position can elicit pain (red area) if you have piriformis syndrome

sitting_test_pirif_
Pain might also occur if you attempt to abduct your hips from a sitting position against resistance provided by a partner or a rope.

Though these piriformis-specific tests can help confirm the presence of piriformis syndrome, they are not accurate enough to rule it out. Hopayian et al.’s review study found no one technique to be reliable or accurate enough to endorse; rather, they cited the more general symptom of aggravation or modulation of piriformis pain when you stretch or tension the piriformis muscle.

You might also be able to feel a thickening in the piriformis muscle itself, deep within your glutes, but this is also not enough by itself to definitively diagnose piriformis syndrome.

Research-backed treatment options

As you might have been able to guess from the ambiguity of the symptoms and diagnosis criteria, piriformis syndrome is not a heavily-studied injury, in runners or even in the population at large. Even case studies of piriformis syndrome in athletes are extremely difficult to come by, so our approach to treatments will have to rely more heavily on a theoretical approach versus one backed by high-quality clinical trials.

Most treatments for piriformis syndrome that are recommended in scientific literature are focused on addressing the painful or irritated piriformis muscle that’s (presumably) the cause of the buttock and leg pain. This largely consists of stretching and strengthening exercises.

Case studies and case series articles from the scientific literature recommend using several different stretches for the piriformis. Based on what we know about the anatomy of the piriformis muscle, we can come up with ways to stretch it—if, when the hip is in flexion, the piriformis acts as an internal rotator and abductor, we can stretch it by putting our hip into external rotation and adducting it.

This is exactly what is accomplished in the stretches recommended by Douglas Keskula and Michael Tamburello in a 1992 article on treatments for piriformis syndrome.

crossover_stretch
Supine piriformis stretch with a crossover (moving left knee towards right shoulder)

supine_stretch_not_crossed_over,
Supine piriformis stretch without a crossover (moving heel towards right shoulder)

opposite_assisted_stretch
Supine piriformis stretch assisted by opposite leg (moving right knee towards right shoulder)

Keskula and Tamburello recommend starting with three sets of five to ten repetitions of each stretch two or three times per day.

Though Keskula and Tamburello only vaguely describe how long each stretch should be held (progressing “as tolerated” by the athlete), another paper by Pamela Barton at the University of Western Ontario in Canada recommends beginning with holding stretches for five seconds and gradually progressing over time to 60 seconds. You should be gentle with the stretches, not overly aggressive—this may put too much stress on the already-irritated piriformis.

Strengthening exercises are also recommended in several different scientific papers. As the piriformis works as an abductor and rotator of the hip, strengthening both the piriformis itself and the other hip muscles that surround it is a primary goal of treatment.

A 2010 case report by Jason Tonley and a group of fellow physical therapists describes in detail a strengthening protocol used to successfully treat piriformis syndrome in a 30-year-old recreational athlete who displayed many of the classic signs of poor hip muscle coordination: inward knee rotation during single-leg squats and poor hip abduction and external rotation strength.

To address this, the authors prescribed a 14-week, three step program for hip muscle rehabilitation.

  • The first phase consisted only of glute bridges and clamshell leg lifts, both using a theraband for resistance.
  • After four weeks, the patient progressed to weight bearing exercises: standing mini-squats (with a theraband), “monster walk” side steps (also with a band), a “sit-to-stand” exercise, and single-leg mini-squats.
  • Following four weeks of the second phase, the patient progressed to lunges, deep squats, and even plyometric-style hops and landings (with the intent to prepare him to return to basketball and tennis, his principle sports).

In all phases of rehab, the patient progressed over time to three sets of fifteen repeats of each exercise.

A similar program designed for runners is illustrated below. Start gradually, but build up over time to three sets of 15 repeats of each exercise.

Phase I: four weeks

a. Clamshell exercise, adding resistance with theraband
clamshell_with_band-resized

b. Glute bridge with theraband (hold, for up to two minutes)
glute_bridge_with_band-resized

c. Side leg lift
side_leg_lift-resized

Phase II: four weeks. Do all phase I exercises, and add the following:

a. Standing mini-squats with a theraband
minisquats_with_band-resized

b. “Monster walk” side steps (continuously moving in one direction, then moving back the other), also with a band
monster_walk_with_band-resized

c. Single-leg “sit-to-stand” from chair
single leg sit

d. Single-leg mini-squats off a step
mini_squat_off_step-resized

Phase III: 6 weeks. Do all phase I and II exercises, and add the following:

a. Front and diagonal lunges
front_lunge-resized

diagonal_lunge-resized

 

While the rehab program in Tonley et al. was immensely successful with their patient, a case report obviously isn’t as useful as a randomized clinical trial. It’s unclear how useful this program would be for other athletes with piriformis syndrome, but given the lack of high-quality studies, and the dearth of research on treatments specifically for athletes, Tonley et al.’s program is still a pretty good place to start.

Combining these strength exercises with the stretches described above should address both muscular weakness and tightness.

Other research on piriformis syndrome has focused on treatments for more stubborn cases.

Some isolated studies describe injections into the piriformis muscle, either of a local anesthetic like lidocane or of a corticosteroid . Studies indicate that pain relief from injections is highly variable, with some patients experiencing long-lasting relief, and others getting none at all. Some newer trials have even investigated BOTOX injections (the muscle-paralyzing drug better-known for its use in cosmetic surgery) for treating recalcitrant piriformis syndrome.

Given how little is known about injectable treatments for piriformis syndrome, especially considering that none of the studies on this topic involved athletes, it’s hard to draw any concrete recommendations—these options are something you should discuss with your doctor.

Surgical release of the piriformis muscle has also been described in multiple papers as a last-resort treatment for piriformis syndrome. As with injectable treatments, studies on surgical patients invariably focus on sedentary people, often with additional existing back or spine problems, so it’s nearly impossible to extract any information useful to a runner. Again, talk to a trusted doctor if you are considering surgery.

Other possible treatment options

Though there’s not much in the literature about treating piriformis syndrome in runners, it occurs commonly enough for several “folk treatments” and workarounds to have emerged. Among these are:

  1. Having a massage or stretching out the piriformis muscle and reduce tightness. One way many runners do so is by rolling their glute muscles on a tennis ball or a lacrosse ball (perfectly shaped to put controlled pressure on the glute area).
  2. Deep tissue massage techniques like Active Release Technique (ART) and Graston Technique are also popular, and they may well accomplish the same goal as the “myofascial release” massage techniques that are described in some case studies by physical therapists.
  3. Another popular method to address piriformis syndrome is to simply avoid doing things that irritate the piriformis muscle: prolonged sitting in particular can be very irritating, so modifying your routine so you don’t need to sit as often or for as long can be helpful.
  4. Standing desks are becoming more popular, and taking a short break every hour or so allows you to get your piriformis stretches in, too. If nothing else, experimenting with different sitting surfaces (harder, softer, flatter, or more contoured) might also reduce irritation.
  5. If you are still able to do some running, avoiding workouts or conditions which irritate your piriformis will also help—common culprits include high speeds, uphills and downhills, and tight turns.

Of course, it goes without saying that none of this is supported by scientific research, so you’ll have to experiment with what works for you and what does not.

Conservative treatments: these are methods that are fairly simple, inexpensive, and can be done on your own at home.

Before jumping right in to treatment, it is important to emphasize that these treatments have been developed specifically with piriformis syndrome in mind, not buttock or sciatic pain in general. If you’re not sure whether you have piriformis syndrome, you should see a doctor to get a proper diagnosis. Other injuries which cause similar symptoms will require different treatments.

  1. Stretching routine incorporating the following exercises. Begin by stretching very gently, building up over time to three sets of 5-10 individual stretches, each held for five seconds. Over time, you can build up to 60 seconds for each stretch.
  2. Hip strengthening exercises per Tonley et al.’s paper, with a few minor modifications to make the exercises more relevant for runners. Start gradually, but build up over time to three sets of 15 repeats of each exercise.
  3. Phase I: four weeksa. Clamshell exercise, adding resistance with theraband
    b. Glute bridge with theraband (hold for up to two minutes)
    c. Side leg lift

Phase II: four weeks. Do all phase I exercises, and add the following:

a. Standing mini-squats with a theraband
b. “Monster walk” side steps, also with a band
c. Single-leg “sit-to-stand” from chair
d. Single-leg mini-squats off a step

Phase III: 6 weeks. Do all phase I and II exercises, and add the following:
a. Front and diagonal lunges

Gentle daily rolling with a foam roller, tennis ball, or lacrosse ball to loosen up the piriformis muscle and glutes.

Aggressive treatments: These are treatments with more cost and less certainty about outcomes, but may prove useful in recalcitrant cases.

  1. Working with a physical therapist to develop a specialized rehab program.  Because the literature is so sparse on appropriate exercises for treating piriformis syndrome in runners, it might make sense to see a PT if your case is particularly troublesome or long-lasting.  That way, you can address any aspects of your own individual muscular tightness or weakness that might contribute to your injury.
  2. Active Release Technique or Graston Technique.  These soft tissue mobilization exercises don’t have any support in the scientific literature, but have been praised anecdotally by some, though not all, runners with piriformis syndrome.
  3. Injections of a local anesthetic, corticosteroid, or BOTOX.  If you have a recalcitrant case of piriformis syndrome that has not responded to many months of conservative rehab, you can talk to your doctor about an injectable treatment.
  4. If all else fails, surgery is a final alternative.  This is also something you should consult with a trusted doctor about.

Return to running

Piriformis syndrome can be a chronic, long-lasting injury.  Your ability to return to training will likely not come all at once.  Rather, as your hip strength gradually improves and your piriformis gets less irritated over time, your tolerance for running should gradually increase.

It is wise to strive to keep your running volume and intensity within your tolerance range, so you don’t re-aggravate your piriformis.

If you find yourself unable to make progress, it likely means there is an underlying problem that has not yet been addressed.  Beyond this, the lack of scientific research on piriformis syndrome makes it very difficult to recommend any specifics on a return-to-running program.  Working with a doctor or physical therapist to return to your usual training routine is an excellent idea if you have a stubborn case of piriformis syndrome.

 

 

References

1. Fishman, L. M.; Andersen, C.; Rosner, B., BOTOX and Physical Therapy in the Treatment of Piriformis Syndrome. American Journal of Physical Medicine & Rehabilitation 2002, 81 (12), 936-942.
2. Anderson, K.; Strickland, S. M.; Warren, R., Hip and groin injuries in athletes. American Journal of Sports Medicine 2001, 29 (4), 521-533.
3. Papadopoulos, E. C.; Khan, S. N., Piriformis syndrome and low back pain: a new classification and review of the literature. Orthopedic Clinics of North America 2004, 35 (1), 65-71.
4. Hopayian, K.; Song, F.; Riera, R.; Sambandam, S. The piriformis syndrome:  a report of a systematic review of its clinical features and the methodology developed for a review of case studies; University of East Anglia: 2010; pp 1-53.
5. Barton, P. M., Piriformis syndrome: a rational approach to management. Pain 1991, 47, 345-352.
6. Fishman, L. M.; Dombi, G. W.; Michaelsen, C.; Ringel, S.; Rozbruch, J.; Rosner, B.; Weber, C., Piriformis syndrome: Diagnosis, treatment, and outcome—a 10-year study. Archives of Physical Medicine and Rehabilitation 2002, 83 (3), 295-301.
7. Beatty, R. A., The piriformis muscle syndrome: a simple diagnostic maneuver. Neurosurgery 1994, 34 (3), 512-514.
8. Hopayian, K.; Song, F.; Sambandam, S., The clinical features of piriformis syndrome: a systematic review. European Spine Journal 2010, 19 (12), 2095-2109.
9. Keskula, D. R.; Tamburello, M., Conservative management of piriformis syndrome. Journal of Athletic Training 1992, 27 (2), 102-110.
10. Tonley, S. C.; Yun, S. M.; Kochevar, R. J.; Dye, J. A.; Farrokhi, S.; Powers, C. M., Treatment of an Individual With Piriformis Syndrome Focusing on Hip Muscle Strengthening and Movement Reeducation: A Case Report. Journal of Orthopaedic & Sports Physical Therapy 2010, 40 (2), 103-111.
11. Benzon, H. T.; Katz, J. A.; Benzon, H. A.; Iqbal, M. S., Piriformis Syndrome. Anatomic Considerations, a New Injection Technique, and a Review of the Literature. Anesthesiology 2003, 98 (6), 1442-1448.12.       Childers, M. K.; Wilson, D. J.; Gnatz, S. M.; Conway, R. R.; Sherman, A. K., Botulinum Toxin Type A Use in Piriformis Muscle Syndrome A Pilot Study. American Journal of Physical Medicine & Rehabilitation 2002, 81 (10), 751-759.
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