Piriformis syndrome is a condition in which the piriformis muscle becomes tight, resulting in sciatic nerve compression and symptoms of ‘sciatica’.
The classic symptoms of piriformis syndrome are known as sciatica. In fact, patients will often arrive at my clinic complaining of sciatica. However, this is just a group of symptoms which can be caused by a few different conditions including lumbar disc herniation.
Sciatica symptoms include pain which radiates through the buttocks and into the leg, usually at the back of the leg, sometimes down the outside. The pain may radiate as far down as the calf. There may also be associated feeling of weakness, tingling or numbness in the same areas.
Other symptoms of piriformis syndrome include a dull ache in the buttock which is made worse by long periods of sitting, as well as long periods of walking or running. All of these symptoms may also be due to other injuries such as a prolapsed lumbar disc or spinal canal stenosis, but if there is no history of back pain and there is full pain-free range of motion in the back then this is unlikely. In cases of piriformis syndrome, there is also usually a reduced range of motion into internal (medial) hip rotation and tenderness and tension can be felt when pressing into the bum muscles.
What is it?
Piriformis syndrome is a compression of the sciatic nerve by the piriformis muscle. The piriformis is a relatively small muscle found deep in the buttock. Its job is to help with lateral (aka external) rotation and abduction of the thigh.The problem with this muscle is that it lies very close to the course of the sciatic nerve – the main nerve which runs from the lumbar and sacral spine into the back of the legs. In fact, in some people (estimated to be around 20%) the sciatic nerve actually passes directly through the piriformis muscle.
If the piriformis muscle becomes tight due to overuse or injury then it can impinge (press on) on the sciatic nerve resulting in the symptoms of referred pain, tingling, numbness and weakness. The exact proximity of the nerve to the piriformis in each individual has a direct relationship with how likely you are to suffer from piriformis syndrome. Some people (including myself!) are just more prone to it!
Piriformis syndrome is a common problem in runners. We have established that the cause is a tight piriformis muscle, but why is this muscle tight? Here are the main causes:
- Weakness of other hip abductors
- Leg length discrepancy
- Running on cambered roads
- Increasing training mileage too quickly
- An impact to the buttock
The primary reason for piriformis syndrome developing is a weakness in other hip abducting muscles, especially the gluteus medius. This muscle is found in the buttock, higher up than the Piriformis, just below the iliac crest. If this muscle (and other hip abductors) aren’t strong enough, then more strain is placed on the relatively weak Piriformis muscle, resulting in overuse and muscle tension.
A leg length difference can have a similar effect whereby the pelvis on one side is lower than the other side, meaning the hip muscles such as gluteus medius have to work harder to stabilise the pelvis. Again leading to more work for piriformis, increased muscle tension and the development of piriformis syndrome. Running on cambered (banked) roads has the same effect as a leg length difference.
Increasing running training too quickly without giving the body sufficient time to adjust and adapt is another cause of piriformis syndrome which can also cause many other injuries! Think of it this way – if you suddenly decided to take up a new sport, the first few times you feel pretty sore and tight for a few days afterwards because you put your body under strains which it is not accustomed to. The same happens to the glute muscles when you start running, or increase your mileage suddenly.
Finally, an impact to the glute muscles can cause piriformis syndrome. Falling and landing on the buttocks is the most common example. This causes bleeding within the muscles – known as a haematoma. This increases the pressure within the muscle compartment and puts pressure on the sciatic nerve.
Treatment of Piriformis Syndrome
As with all running injuries, the first thing to do is to stop running altogether! Try to also avoid excessive walking and long periods of sitting for the time being.
As there is no muscle injury as such (unless your case is due to an impact), it is ok to apply a heat pack to the buttock muscles which will help with reducing muscle tension. Apply for 15 minutes at a time, repeating every 2-4 hours where possible. If your case of piriformis syndrome was caused by an impact, apply ice for the first 3 days (10-15 minutes at a time, every 2-4 hours). Then you may be able to switch to heat.
At the same time, start stretching the glute muscles. The best stretch to target the piriformis muscle is performed as follows:
- Lay flat on your back with the knees bent and feet on the floor.
- To stretch the right buttock, place the right ankle on the front of the left knee.
- Reach behind the left thigh with both hands and pull the leg in towards you.
- Hold when you feel a stretch in the right buttock.
- Hold this position for 20-30 seconds, switch legs and repeat 2-3 times per leg.
- Do this 3-5 times per day.
Massage is a great tool in the treatment of piriformis syndrome. This can be performed by a qualified sports massage therapist, directly to the buttock muscles to ease tension in the piriformis muscle.
Massage can also be performed at home, using either a foam roller or a tennis ball. If using a roller, sit on the roller with it going across both buttocks, knees bent and feet on the floor. Keep the unaffected foot on the floor and place the foot of the affected leg on the top of the other knee. Shift your weight onto the affected buttock and slowly roll across the glute muscles, stopping at any particular tender spots for a few seconds. Start off doing this for just 2-3 minutes a day and increase up to 5.
Using a tennis ball to massage the glutes is very similar. Simply sit with one bum cheek on the ball and slowly rotate your pelvis to move the ball around the entire buttock. You cn adjust the amount of your weight you apply by placing more weight on the hands and feet.
Give your body a few days to adjust to the rest and stretching exercises and once comfortable to do so, try to start strengthening the other hip abductor muscles. To do this, the clam execise is my all-time favorite:
- Lay on the unaffected side, with both knees bent, feet in-line with the spine and the top hip directly over the bottom one (ensure you aren’t leaning backwards).
- Keeping the feet in contact, slowly raise the top knee up, away from the bottom one.
- Make sure you don’t allow the top hip to fall backwards and keep the lower back and pelvis still.
- Isolate all movement to the hip joint.
- This doesn’t have to be a particularly big movement. It is better you concentrate on performing it correctly.
- Slowly lower the knee and repeat this 10-15 times initially.
- Stop if you feel any pain.
Perform this exercise once every other day initially and then increase this to every day once you are sure it doesn not flare up your pain (this can be the case if performed too early). After a week or two, start to increase the number of reps, aiming eventually for 2 sets of 20.
Take a look back at your training programme. Look at the increase in distance and intensity and see if this is excessive. If you’re not sure ask a running coach or more experience runner. Look at where you’ve been running, are the roads flat or cambered?
Also consider running shoes – do you need a different type or are yours worn out. All of this can contribute to developing piriformis syndrome.
Returning to running
When pain has gone, you may consider going back to running. Don’t be tempted to go bck too soon or to do too much too soon or you’ll end up back at square one. Once pain has gone on a daily basis, my advice would be to try other forms of exercise which involve less impact first. Try cross training, swimming and cycling. Also try going on a couple of long walks to ensure this doesn’t stir up the problem.
Once you are happy with this, try a gentle 10 minute jog. Don’t be tempted to go any further than this on the first couple of attempts. Partly because your body needs time to adapt again and secondly if you do feel pain you need to be able to rest again as soon as possible and not have to walk miles home!
For the first couple of weeks have at least 2 full days recovery in between your runs and don’t increase by more than 5 minutes at a time. Continue stretching, strengthening and massaging every day. Continue to gradually increase mileage until back to your normal distances.