Piriformis Syndrome

Piriformis syndrome

Piriformis syndrome is compression of the sciatic nerve. It causes pain deep in the buttocks which radiates down into the leg.

Piriformis syndrome symptoms

  • Symptoms of Piriformis syndrome consist of tenderness and pain deep in the buttock muscles.
  • Pain may radiate down the back of the leg into the hamstring muscles and sometimes even into the calf area.
  • Two tests which a professional therapist may use to identify sciatic pain include the straight leg raise test and the slump test.
  • Other signs of Piriformis syndrome include reduced range of motion of the hip joint, especially internal hip rotation (rotating the thigh inwards) is often seen.
Hip mobility pnf technique
Tight piriformis muscle on the right side

Sometimes people may confuse piriformis pain initially with hamstring origin tendinopathy. However, there will be no area in the hamstring muscles themselves which is tender to touch.


Piriformis syndrome causes & anatomy

Piriformis syndrome in detail

It is usually overuse which causes the piriformis muscle to go into spasm resulting in pressure on the sciatic nerve. The piriformis muscle is one of the small muscles deep in the buttocks that rotates the leg outwards. It runs from the sacrum bone at the bottom of the spine and attaches to the thigh bone or femur roughly near the outside crease of the buttocks.


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The sciatic nerve runs very close to this muscle and in around 10% of the population, it actually passes straight through the muscles fibers. If the piriformis muscle becomes tight it can compress the sciatic nerve and cause pain which can radiate down the leg, commonly known as sciatic pain.

It has been suggested that this condition would be better referred to as piriformis impingement due to the impingement of the sciatic nerve. A common cause of piriformis syndrome is tight adductor muscles on the inside of the thigh. This means the abductors on the outside cannot work properly and so put more strain on the piriformis muscle.


Piriformis syndrome Treatment

Treatment consists of two phases:

  • First reducing pain by relaxing the muscle through ice or heat, electrotherapy, massage, and stretching.
  • Then when pain allows strengthening the muscle to help prevent the injury recurring.

Reducing pain

  • Rest from any activities which make symptoms worse. This is likely to include running and other weight-bearing activities.
  • If Piriformis syndrome is acutely painful or inflamed then applying ice may help reduce muscle spasm.
  • More chronic or longer-term conditions may respond better to heat therapy to relax the muscle however, heat should not be applied if an acute injury, inflammation or recent tear of the muscle is suspected. In this case, heat will only increase swelling, inflammation, and bleeding.
  • For gradual onset or more chronic conditions, heat in the form of a hot bath or hot water bottle applied for approximately 20 minutes three times a day can help to release the muscle spasm and encourage blood flow through the muscle.
  • Applying heat before performing exercises, particularly stretching exercises may help increase the effectiveness of the exercises.
  • A doctor may prescribe anti-inflammatory medication such as ibuprofen to reduce pain and inflammation.
  • A professional therapist may use sports massage or electrotherapy such as ultrasound to relax the muscle.
  • Light massage at this stage may also be beneficial in releasing muscle spasm in the piriformis.
  • For more stubborn conditions Botox injections may be indicated and occasionally surgery is required.

Improving flexibility

  • Gentle piriformis stretching exercises should be done but only if pain allows as this should also reduce the pressure on the nerve causing the pain.
  • Stretches should be held for around 20 seconds and done in sets of 2 to 3, repeated at least three times a day.
  • The aim is to stretch and relax the piriformis muscle so in turn it will reduce pressure on the sciatic nerve and relieve symptoms.

Treatment and rehabilitation of piriformis syndrome focus on releasing muscle tension and correcting any muscle imbalances or biomechanical causes which may be contributing to the condition.


Piriformis syndrome exercises

Piriformis stretch in standing
  • As soon as comfortable to do so, piriformis syndrome stretches should begin.
  • Exercises to strengthen the piriformis muscle and other hip muscles can also begin. This will help to circulate blood through the muscle and strengthen it so it can cope with the future demands placed on it.
  • Muscle energy techniques are an excellent way of improving the stretch of the muscle. This involves repeatedly contracting and relaxing the muscle whilst it is being stretched by rotating the femur bone inwards.
  • In addition to the specific piriformis stretches it is important to stretch the hamstrings, groin, hip abductors and lower back.

Read more on piriformis syndrome exercises.

Foam roller exercises

Foam roller exercise for piriformis syndrome

Sports massage

  • Deep sports massage techniques can be used to release the tension in the Piriformis muscle.
  • Massage can be applied on alternate days. At the very least two to three sessions at the start of rehabilitation is a good idea.
  • As the condition improves massage can be performed deeper, but the deeper the massage the longer it should be left between sessions as the muscle will need to recover in the same way as it does with heavy strengthening exercises.

References

  • Rich BSE, McKeag D. When sciatica is not a disc disease. Detecting piriformis syndrome in active patients. Phys Sportsmed 1992:20(10):105-15
  • Cramp F, Bottrell O, Campbell H et al. Non-surgical management of piriformis syndrome: a systematic review. Phys Ther Rev 2007;12(1):66-72
This article has been written with reference to the bibliography.