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:
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.
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.
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.
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.
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
Phase II: four weeks. Do all phase I exercises, and add the following:
a. Standing mini-squats with a theraband
Phase III: 6 weeks. Do all phase I and II exercises, and add the following:
a. Front and diagonal lunges
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:
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.
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:
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.
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.
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