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Piriformis Syndrome

“Piriformis syndrome” can be a vague diagnosis, as there can be varying symptoms associated with this syndrome. First, let us define the particular piriformis muscle. The piriformis muscle is located in the gluteal region and it originates on the front of the sacrum, which is the lowest part of the spine before the coccyx (tailbone), and the greater sciatic notch. The piriformis muscle then runs laterally and outwards toward the hip to insert on the greater trochanter of the femur (top of the thigh bone). The bulk of the muscle lies in the midway region of the buttocks and basically divides the region into an inferior and superior part. The job of this muscle is to rotate the hip laterally when the hip is extended, and there are several other muscles that perform this same motion. When the hip is flexed, the piriformis abducts the thigh.

The symptoms associated with piriformis syndrome can be varied. A person may experience pain in the buttocks or abnormal sensations like numbness or tingling in the buttocks or down the leg. When a person feels pain in the piriformis muscle, it may mean that this area is tight, in spasm, or inflamed. If it is determined that the muscle is tight, then stretching and releasing of that muscle will help to decrease the pain. If the area is inflamed, one would need to control the swelling and decrease the irritation to that site. If the symptoms are related to the abnormal sensations, then often it is because the sciatic nerve is involved. The sciatic nerve runs just beneath the piriformis muscle and exits below it, and even divides the muscle in a certain population of people. This nerve can get irritated by the piriformis muscle, and thus cause numbness, tingling or pain either locally at the buttocks or down the back of the leg.

So what causes piriformis syndrome? One reason could be that the person has experienced a trauma to this region and thus producing the spasm, inflammation and pain. An example of this would be a fall onto the buttocks. Often, there is not a particular incident that causes this syndrome and it develops over time with no particular mechanism of injury. Prolonged sitting can also be a precursor to this syndrome, especially if one sits on a hard surface or sits on their wallet in the back pocket. The wallet often puts pressure directly on the muscle and causes pain and inflammation. Extensive walking or stair climbing can also be a cause of piriformis syndrome.

Piriformis syndrome creates similar symptoms that can be caused by or associated with other diagnoses as well, therefore it is important to rule out other issues to make a correct diagnosis of piriformis syndrome. There are other structures that can create pain in the buttocks, such as the other muscles that are located in that region or radiating pain from the lumbar spine or sacroiliac joint. The sciatic nerve can also get impinged or irritated by other structures, such as when it exits the spine above the gluteal region or by the lumbar discs. One should not assume that pain in the buttocks or sciatic nerve symptoms are always piriformis syndrome. An X-ray or diagnostic studies like an MRI are not indicated in piriformis syndrome, as these will not show if the piriformis is irritated or in spasm. An X-ray would show the bones, and an MRI would show if there are significant tears to the muscles, tendons or ligaments or possibly inflammation. However, these diagnostics may be helpful to rule out other structures from being involved, as noted above.

A proper diagnosis is often based on a combination of ruling in and ruling out other diagnoses. A full and extensive subjective report of symptoms and a medical history review are very important. A thorough objective examination by a medical professional such as a medical doctor or a physical therapist is warranted. This would include assessments of the lumbar spine, sacroiliac joint, the hips, as well as specific palpation of the gluteal region. Often, a person will have decreased hip range of motion noted and may have increased pain with hip flexion, internal rotation, or other motions that tense the muscle. There is also noted tenderness in the piriformis muscle with palpation. The sciatic nerve should also be assessed to determine where along the nerve it is being affected to produce the symptoms.

Each person is very individual, therefore a proper treatment plan has to be individualized for that particular person as well. An example of a physical therapy treatment plan may include stretching, strengthening, patient education, restoring proper movement patterns and manual therapy. The stretching would be for the actual piriformis muscle, as long as it does not cause increased symptoms or irritation to the sciatic nerve. The stretching should be gentle at first, and more progressive as tolerated. The stretches should be held for 30 seconds in order to have the maximum benefit and most release of the muscle. One example of a piriformis stretch is to lie on your back and bend both knees then cross the affected side foot over opposite knee and pull the knee up and across the body (with your hands) toward the opposite armpit. Stop when you feel a gentle stretch and hold for 30 seconds. There may be other muscles that are tight that are contributing to the pain as well and need stretched, such as the gluteal muscles and low back muscles.

The sciatic nerve can be “stretched” or un-tensioned as well, and this is called “nerve gliding.” At times, this may help free-up the nerve along its line of travel and thus decreasing the tension on the actual nerve. The idea is to un-do the “kink” in the nerve. Think about a water hose and if there is a kink then the water does not flow well below that area, then when you release the kink the water flows freely. When a nerve is being pinched or irritated, one develops numbness and tingling below that area as well.

The strengthening component is very important as well. An underlying weakness may be part of the cause of the syndrome. Your lower body and abdominal muscles should be tested for any weakness, and addressed as needed. Often, the gluteus maximus muscle and gluteus medius muscle are weak and thus not supporting the hips and pelvis correctly and therefore the piriformis overcompensates and spasms. These are the muscles that help with walking, running, stairs, and single leg tasks. An example of an effective gluteus medius exercise is called “hip abduction” or side leg raise. Begin by lying on your side with your top hip rolled a little bit forward. Then lift your top leg up/back at a 45 degree angle to engage this muscle. One should feel the buttocks region tighten, hold for five to ten seconds, then lower slowly and in a controlled manner.

Weakness in the core muscles may also be contributing, thus not supporting the proper posture in seated and standing positions. Core weakness can also contribute to low back issues, which affects the sciatic nerve and gluteal region. There are many core exercises out there, and one great example is called “dying bug.” Begin by lying on your back with legs at table-top position and arms straight up toward the ceiling. Extend your opposite arm and leg outward from your core or center of the body, then bring it back to the starting position and switch sides. Be sure to keep your abdominal muscles engaged and belly button pulled in toward your spine, as if you are zipping up tight pants.

Patient education about this particular syndrome and about their particular plan of care is crucial with piriformis syndrome. The contributing factors should be discussed so that the person knows what to avoid and what to continue to perform. They should be educated on proper posture, movement during the day, and their individualized treatment plan. It is also important that the person knows not to sit on hard surfaces and/or their wallet. Movement and an active lifestyle is important to maintain, so it is necessary to get proper education on what is safe to continue to perform in order to remain healthy. This may be on a case to case basis based on the particular person’s limitations, but often they are able to continue brisk walking on even surfaces.

If the person’s movement patterns are part of the issue, these should be discussed and remedied. For example, if they are walking with a limp or do not have proper trunk control with walking then they would benefit from gait training in order to improve this. If stairs are being performed improperly, then this should be addressed and they should be taught proper movement patterns. One common example is that people do not properly engage their core and gluteal muscles with stairs, therefore other structures get irritated.

Piriformis syndrome is likely treatable with physical therapy and proper exercises. It is very rare that any surgical intervention is necessary for this syndrome. The sooner you receive treatment the better outcome and quicker recovery you will experience.