Piriformis Syndrome

Intro: What is Piriformis Syndrome?

It’s a pain in the butt - literally!

The piriformis muscle is a spitfire muscle - it likes to get fired up. It’s underneath the glute muscles and runs from the anterior (front) sacrum bone (above the tailbone) diagonally out to the hip bone.

Since the sciatic nerve runs through or right next to the muscle during its journey from the lumbar (lower back) region down to the toes, a tight and restricted piriformis muscle can cause nerve symptoms. And that’s exactly what the diagnosis of piriformis syndrome is. It’s sciatic nerve symptoms due to one or both piriformis pinching on the sciatic nerves.

Note: piriformis syndrome is also known as “deep gluteal syndrome”.

Symptoms of Piriformis Syndrome

What are nerve symptoms? They present as feelings of numbness, tingling, burning, electric shocks, the leg falling asleep, and sometimes weakness also.

Nerves have 2 functions: sensory (sensation) and motor (muscle contraction).

Therefore, if a nerve is being compressed or pinched on, you can lose one or both of those functions at varying levels of severity:

• The area the nerve innervates may feel a deep numb, tingly, or lack feeling

• The area the nerve innervates may become weak

My patients would often describe it as a “pain in the butt” but the worst symptoms were those symptoms that spread down the leg. They didn’t understand why I was massaging and mobilizing their glute region when their worst symptoms were down near the knee or ankle - but you have to address the cause of the pain which is that piriformis muscle. After some anatomy education, they began to understand that those leg symptoms were residual symptoms that stemmed back to the root of the cause - the piriformis.

Common Causes of Piriformis Syndrome

A person can develop piriformis syndrome many ways:

• A traumatic experience like a fall or accident

• Prolonged sitting (especially if a wallet is kept in the back pants pocket often)

• Excessive hip external rotation (or walking with the toes turned outward)

• Muscle spasms of the piriformis (due to fatigue, growth, or weakness)

I’ve never experienced piriformis syndrome, but my husband has. For him, the biggest aggravator is sitting for long periods at work, in the car on a road trip, or on a plane.

This brings me to an important lesson: if you sit for long periods for work, invest in a comfortable ergonomic chair. Oftentimes, you may have a chair that’s too hard and not set up for someone of your height. People who are tall and using a chair meant for someone short are going to have a ton of pressure through the glutes and piriformis while sitting. People who are short and using a chair meant for someone tall are going to have a ton of pressure through the hamstrings and sciatic nerve region while sitting.

What is proper ergonomic sitting posture? The best way to explain this is through an image. Focus on attained 90-degree angles at the hip, knee, and ankles. Be sure the chair is padded and supportive - not hard. A good chair is worth every penny, especially if you suffer from piriformis syndrome. If you can’t invest in a new chair, consider investing in a pad and lumbar roll for your existing chair then. I’ll share some shopping links below for ideas.

Photo Credit: Ergonomic Trends

Location and Muscles Affected by Piriformis Syndrome

The main structures affected by piriformis syndrome are the piriformis muscle(s) and the sciatic nerve. Let’s take a closer look at their anatomy so you can visualize the areas that are most impacted by this injury.

Photo credit: SpineUniverse

As you can see in the photo above, the nerve runs through the muscle (in a small percentage of people ~10%) or right directly next to it. So any inflammation or restriction of the piriformis muscle will directly impact that bundle of nerves. 

The sciatic nerve runs down the leg all the way to the toes and it provides sensation and motor control so you can feel and move your legs. This is what makes a diagnosis of piriformis syndrome or sciatic tricky because someone may say they have hip pain, outer thigh pain, knee pain, ankle pain, etc and think that’s where the pain is starting… but it may truly be starting up at the piriformis instead.

The piriformis muscle itself has 4 actions: hip extension, hip abduction, and hip rotation (internal and external). It’s an important muscle for stabilizing the head of the femur into the greater trochanter - it stabilizes the entire hip!

The piriformis can have trigger points or little knotted up muscle fibers that can cause radiating symptoms in various pathways. See the photo below to see where the piriformis typically shoots pain to: usually the outer thigh and outer shin region.

Photo credit: Muscle joint pain

Pretty cool, right? Well, not if you’re feeling this pain and symptoms. But it’s cool to see how the body works and a good reminder that it’s very, very complicated. A trained Physician or Physical therapist is always best to see ASAP if you’re struggling with symptoms similar to what I’m describing here.

Testing for Piriformis Syndrome

Piriformis syndrome can be tested by your Physician or Physical therapist in a number of ways. The best signal is your lifestyle and occupation requiring a lot of sitting… or a traumatic accident. 

They’d first want to rule out other causes of the sciatic symptoms by assessing the lumbar spine, SI joints, and hip joints.

Muscle length tests, range of motion tests, and joint mobility tests would be done to assess your lumbar spine and hip mobility (including a side-lying FAIR test). Sciatic nerve tension tests would be done to test for nerve symptoms (like a straight leg raise test). A palpation (feeling) of the piriformis will of course be done to test for tenderness and tightness. Imaging like an MRI may be used to rule out other causes of nerve compression - possibly coming from higher up in the lumbar region. 

Conservative Treatment for Piriformis Syndrome

Disclaimer: The information provided is not intended to be a substitute for professional medical advice, diagnosis or treatment.  Never disregard professional medical advice, or delay in seeking it, because of something you have read on this website.  Never rely on information on this website in place of seeking professional medical advice.

Most of the time, piriformis syndrome can be resolved with Physical therapy. However if conservative treatment does not resolve it, the next step is to try an injection (often lidocaine or cortisone) to reduce the pain and/or inflammation. Or a nerve block may be done.

Physical therapy for piriformis syndrome pain is hugely successful to help with mobilizing the guarded muscles, mobilizing the nerve, and strengthening the weakened muscles.

Treatments for Piriformis Syndrome Pain (from basic to advanced):

• Reduce the activity that may be aggravating it

• Fix ergonomic sitting posture and possibly invest in a better chair

• Joint mobilization (level depends on stage of injury; especially of the hip or sacrum)

• Range of motion exercise (within a pain-free range) 

• Stretching (plus contract-relax technique)

• Nerve mobilizations (flossing of the sciatic nerve)

• Strengthening exercise (including isometrics and neuromuscular stimulation) to load the ligaments and muscles progressively

• Cardio (to help vascularization or bring blood flow to the area for healing)

• Functional exercise (form training)

• Manual/Massage: soft tissue massage (especially of the guarded muscles and potential trigger points)

• Modalities: Ice

Below are some Amazon links to Piriformis Syndrome pain related products that may be helpful:

Physical Therapy Exercises for Piriformis Syndrome

In the videos below, I’ve compiled the best physical therapy based exercises for piriformis syndrome. Watch and practice!

To fix piriformis syndrome, stretching alone is not ENOUGH. You’ve got to strengthen the piriformis plus the muscles around it also so the piriformis doesn’t have to work as hard.

Mobility & Strethching for Piriformis Syndrome

Strengthening for Piriformis Syndrome

Mission: Mobilize, Modify, Move

In the videos above, you learned how to mobilize and move when diagnosed with piriformis syndrome.

Now let’s talk about how to modify your daily life and workouts while you’re recovering from it.

1. Avoid prolonged sitting! If you work sitting at a desk all day, set an alarm every hour to remind you to get up and walk around or stretch for a few minutes. Get a better chair and maybe even pad it better for more support.

2. When walking, ensure that the toes are facing forward and there’s not too much turn out of the toes (with the hip externally rotated too much which will overfire the piriformis)

3. Keep the pelvis level and squared off with all movements and activities throughout the day. Holding your baby? Keep the hips centered. Bending down to grab a golf ball off the green? Keep the hips square.

4. When working out, some lower body exercises may aggravate your pain. So consider working out the core and upper body more frequently temporarily. Then for lower body exercises, if it’s >4/10 pain consider modifying the exercise by using a smaller, more comfortable range of motion, using less load, or doing less volume. If that still doesn’t help, sub out the exercise for a different one.

Well, that's it!

Did you find this blog helpful!? If so, comment below your biggest take home point. Have any questions? Email me and let’s chat!

I hope you’re able to say BYE to that pain in the butt soon. Stay well!

Thanks for reading!

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