Introduction

Do you have a pain in the buttocks during when running or exercising that refers down the back of your leg? This is a common sign of an injury to the piriformis muscle deep within the buttocks that can duplicate the sensation of a sciatic nerve-related injury..

This injury can often be left as a back burner during the early stage as a pin-point ache and tightness. If left untreated, however, the symptoms can often become my significant and resulting in extensive aches and pains during exercise and even during extended periods of sitting..

What is the Piriformis?

The piriformis is a short muscle buried deep within the hips. In each hip, it runs from the back of your pelvis (sacrum) to the top of your femur. Because of its positioning, the piriformis muscle helps rotate your leg outward (external rotation) which plays a key role for lower extremity biomechanics to prevent excessive internal rotation at the hip and knee valgus (the knee falling in) and further down the kinetic chain, it plays a key role in preventing a fallen arch (some refer to flat feet).

When running which is where we see most of these injuries, the piriformis is most active during the “stance” phase, where your foot is planted on the ground and whilst the other leg is in the swing phase. Here, it acts as an external rotator of the leg to maintain stability..

Why is it painful?

Despite the importance of this piriformis muscle, it plays a key role in an injury known as piriformis syndrome. The piriformis is positioned directly next to or in some cases, around the sciatic nerve. Which can leave these individuals more susceptible to piriformis syndrome..

The sciatic nerve is the main nerve that supplies the lower body which runs from the base of your spine, along your hips and down the back of your legs. This nerve supplies the muscle groups and function that allow all the muscles on the backside of your lower body to fire when needed.

What’s the difference between Sciatica and Piriformis Syndrome?

It is very important to distinguish piriformis syndrome from sciatica 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, as it leaves out the nerve root from the spinal column. This compression can cause the same type of pain that radiates down the backside of your leg but tends to originate at the lower back.

When the piriformis muscle is irritated by being tight, strained or spasming, the sciatic nerve can get irritated which is often described as a deep ache, burning, tingling, loss of sensation or pain in the buttock down the back of the leg.

Symptoms of Piriformis Syndrome:

  • Pain in the buttocks and back of legs.
  • Tenderness at a specific spot in the pelvis between the sacrum (above the tailbone) and the top of the femur (ball-like bone on the side of the hips – the area the piriformis muscle runs through.
  • Worsening of the buttock and sciatica-like pain with prolonged sitting or exercise.

How to test for Piriformis Syndrome

Straight Leg Raise

Lay in a supine position (on your back), keep your leg straight, foot pointing up towards your face and then slowly raise. Pain or nerve-like symptoms will shoot down the back of your leg when your leg is raised straight. This is suggestive of sciatic nerve irritation. Although it is not specific to piriformis syndrome you may feel an ache or sharp pain in the buttocks which will confirm the Piriformis Syndrome.

Resisted Abduction

Start in a prone position and place a belt or tied rope around your knees. Focus on pulling the knees apart and squeezing the buttocks for 10 seconds. Pain may occur which is suggestive of Piriformis Syndrome as the muscle activated and compresses the sciatic nerve.

Piriformis Stretch Test

Stretching the piriformis can elicit pain if you have tightness of the Piriformis muscle which can compresses the sciatic nerve.

How to treat Piriformis Syndrome

Treatment for piriformis syndrome is mainly focused on addressing the painful or irritated piriformis muscle that’s seemingly the cause of the buttock and referral leg pain.

Strengthening Exercises

As the piriformis works as an abductor and external rotator of the hip, strengthening both the piriformis itself and the other hip muscles that surround it is a primary goal of treatment. By doing so, it is recommended to progress the exercises from isolated attention to a fully functional strength phase in line with the training or sport-specific needs.

To address this, we use a three-step approach for hip muscle rehabilitation. The first phase consists of body-weight only such as glute bridges and clamshell leg lifts. Phase two includes using a Theraband or resistance band for resistance. Phase 3 includes additional external load and single-leg variations. Here is an example of the Side Plank Clam which is great for building hip and core strength.

Stretching

Based on the anatomy of the piriformis muscle, we can come up with ways to stretch it if the muscle is tight. When the hip is in flexion, the piriformis acts as an abductor (moving away from the body by shortening in length). Therefore, you can stretch it by putting the hip into adduction (moving towards the midline of the body).

Nerve Glides

To treat the sciatic nerve pain, a technique call nerve glides allows the nerve to glide through its natural path and reduce the compression on the nerve, improve range of motion and reduce pain.

Combining these strength exercises with the stretches and nerve glides provides a comprehensive approach to treating not only the injured site but also the contributing factors to the injury.

Other ways to treat and prevent Piriformis Syndrome

  • Having a regular massage or foam rolling the piriformis muscle and reduce tightness.
  • Avoid doing things that irritate the piriformis muscle: prolonged sitting, in particular, can be very irritating, so modifying your routine, taking regular breaks so you don’t need to sit.
  • Reduce training or running intensity and volume to work within a pain-free state whilst the injured site heels.
  • If you are still able to do some running, avoiding workouts or conditions which irritate your piriformis will also help—common culprits include high speeds, uphills and downhills, and tight turns.
  • Warm-up the hip muscles before exercise and stretch at the end of each training session

Can I train/run with Piriformis Syndrome?

Piriformis syndrome can be a chronic, long-lasting injury. Your ability to return to high-intensity training will be slow as you become stronger and rehabilitate the injured site. As your hip strength gradually improves, the piriformis will get less irritated over time, and your tolerance training gradually increase.

Take-Home Message

If you find yourself unable to make progress, it likely means there is an underlying problem that has not yet been addressed. Working with a sports therapist or physiotherapist to plan and action an individual programme to return to your usual training routine is the fastest way. To rehabilitate the injury completely, reduce the training intensity/volume ad follow a structured progressive rehabilitation programme.

If you are struggling to progress with this injury, we have space for you within our online coaching platform in which one of our therapists will take you through an injury assessment and consultation to understand the problematic issues and work with your to build a programme that works around your lifestyle to ensure you get back to moving more, pain-free. Simply head to the booking calendar HERE to book your consultation now.

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