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Piriformis Syndrome (aka. Pain in the Butt)

What is it?

The piriformis syndrome is a condition in which the piriformis muscle irritates the sciatic nerve, causing pain in the buttocks and referring pain along the the path of the sciatic nerve.  The nerve pain, called "sciatica", often goes down the back of the thigh and/or into the lower back.  The pains is deep in the buttocks, which is made worse by sitting, climbing stairs or performing squats.  The affected leg is often externally rotated (toes point out) when relaxed, such as when lying face down on the bed with your feet over the end of the mattress.  Some reports suggest a 6:1 female to male predominance.

The piriformis muscle assists in abducting the and laterally rotating the thigh.  It lies deep in the gluteal muscles and originates from he sacral spine and attaches to the greater trochanter of the femur.  The sciatic nerve usually passes underneath the piriformis muscle, but in approximately 10%  of the population, travels through the muscle.  It is thought that acute or chronic injury causes swelling of the muscle and irritates the sciatic nerve, resulting in sciatica.   Patients with an aberrant course of the nerve through the muscle are particularly predisposed to this condition.

Contributing Factors

There are several factors that can contribute to piriformis syndrome, including:

• If the leg is externally rotated for an extended period of time (such as when driving) the piriformis muscle can shorten.

• Faulty foot mechanics.

• Faulty spinal mechanics.

• Gait disturbances.

• Poor posture or sitting habits.

Treatment Strategies

There are several treatment strategies to help heal this common injury, the key is to find the right combination that works for you so experiment with each and see what works:

• Stretching the piriformis

• Piriformis stretch (see http://www.trackcoach.com/tips/tips_piriformis.htm)
• Pretzel Stretch (start off by lying on your back, bend your knees and cross your right leg over your left so that your right ankle rest on your left knee in a figure four position. Then bring your left leg towards your chest by bending at the hip. Reach through and grab your left thigh to help pull things toward your chest.)
• Standing active stretch (lift injured leg, rotate leg inward, pointing toward other leg, and hold for 10 seconds, repeat).
• Lying down active stretch (lying down face down, bend your knee at a right angle so that your lower leg is pointing straight up, now rotate your leg so that your foot moves outward, away from you, when you reach maximum stretch hold for 10 seconds, repeat).
• Lie on back, flex injured hip and knee, grasp injured knee with uninjured-side hand, pull knee towards uninjured-side shoulder, grasp just above right ankle with injured-side hand, and rotate ankle outwards.
• Stand on your uninjured foot, place injured foot on chair such that injured knee and hip are flexed at about 90 degrees. Now, using injured side hand, press the injured knee across towards the other side of the body while keeping the ball of the injured foot on the same spot of the chair.
• Other: Important to stretch iliopsoas (rest on bent knee, injured side, and slowly roll forward).

• Massage piriformis, gluteals, psoas.

• Strengthen the piriformis and gluteals.

• Cut back your training volume, and then return to running pre-injury training volume and intensity gradually.

• Cut back your speed work and hill running

• Ice after training

• Avoid long car drives, or take short breaks to loosen up.

• Electrical stimulation (microcurrent, HVGS)

• Ultrasound therapy

• Improve your posture

• Address faulty pelvic mechanics

• Orthotics or new running shoes

Best of luck!

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