Low back pain (LBP), is ubiquitous. LBP most commonly involves one of the following conditions: sciatic nerve entrapment, herniated nucleus pulposus, direct trauma, muscle spasm due to chronic or overuse injury, or piriformis syndrome.
Piriformis syndrome is characterized by pain and instability.
The location of the pain is often imprecise, but it is often present in the hip, coccyx, buttock, groin, or distal part of the leg.
Piriformis syndrome is compression of the sciatic nerve. It causes pain deep in the buttocks which radiate down into the leg. Here we explain the symptoms, causes, treatment, and exercises for preventing and treating Piriformis syndrome.
What Is Piriformis Syndrome?
Piriformis syndrome is a group of symptoms that are believed to be due to the piriformis muscle. The piriformis is a muscle located deep in our gluteal region. It’s a thick pear-shaped muscle which is actually where it gets its name.
Purim for pair and Forma meaning shape in Latin.
This muscle originates on the anterior surface of the sacrum, and sacrotuberous ligaments. It then runs lateral and across the greater sciatic foramen and inserts on the inner surface of the superior portion of the greater trochanter also known as our femur bone.
It’s one of six external rotators in the deep gluteal region. One key difference between the piriformis muscle and the other external rotators is that anterior origination, and then passing posterior to the sciatic nerve.
The piriformis plays an important role in rotating the leg out to the side particularly when the hip is extended such as during walking and running. It also works in abducting the leg, moving the leg further away from our body when the hip is in flexion.
People will often say the piriformis does the internal rotation of the hip when the hip is flexed calling this the inversion of action. When we discuss piriformis syndrome the reason the piriformis is often pointed to is that anatomical detail that we discussed previously where it passes posterior to the sciatic nerve.
Due to this, it’s often believed that if it’s inflamed, irritated, or for a range of other reasons, it could compress the sciatic nerve. Giving off this host of symptoms people experience.
How to test for piriformis syndrome?
To test if it’s the piriformis, the first thing is to rule out anything of more concern. If there are no red flags present (Trauma, Unexplained Weight Loss, Neurologic Symptoms, Age>50, Fever, IVDU, Steroid Use, History of Cancer), a few ways you can test for that, then we can move on to ruling in and rolling out performance syndrome.
There are a few different special tests that have been suggested to be used, such as the fair test.
Instead of on our back or our side, we flex our hip, adduct our leg, and then internally rotate the hip, which should tense the piriformis.
If the person reports pain or increased symptoms on the back of their hip at the piriformis, it’s a positive test. For this, it helps to rule in piriformis syndrome.
There have been other tests, such as the active piriformis test. The BD and paste tests have been examined, but none inherently provide any more clinical utility than just the fair test.
In contrast, we can just use four signs and symptoms clustered together for a relatively accurate indication.
These are buttock pain, pain aggravated with sitting, external tenderness near the greater sciatic notch, and pain with tensioning the piriformis muscle.
Given that this condition is theoretically an entrapment of the sciatic nerve, it’s expected that the straight leg raise is used to help differentiate piriformis syndrome and Discogenic pain.
The challenge is that this is quite a flawed test for piriformis syndrome. It could help to a degree in ruling discogenic pain, but it doesn’t necessarily rule out puriform syndrome.
This means it doesn’t provide a lot more clinical utility than just the fair test or those signs and symptoms we just discussed.
Various types of imaging can also be done, most of which are used to rule out other conditions, such as an MRI for discogenic-related pain. Ultrasound has also recently been gaining more attention, but it doesn’t seem to provide any greater accuracy than the cluster of symptoms we discussed.
One last key thing when diagnosing piriformis syndrome is that not all pain in the butt is piriformis syndrome. Even in situations that point to this trend of symptoms, we don’t know if it’s the piriformis for sure our ability to honestly point to the piriformis muscle as the cause of entrapment or cause of symptoms is questionable and not established.
It is possible that it could be other structures or a combination of many structures, and thus would be better to utilize the term deep gluteal syndrome, which is what our current research is pointing towards.
Symptoms of Piriformis Syndrome
Most patients describe acute tenderness in the buttock and sciatica-like pain down the back of the thigh, calf and foot. Typical piriformis syndrome symptoms may include:
- A dull ache in the buttock
- Pain down the back of the thigh, calf and foot (sciatica)
- Pain when walking up stairs or inclines
- Increased pain after prolonged sitting
- Reduced range of motion of the hip joint
These symptoms often worsen after prolonged sitting, walking or running, and may feel better after lying down on the back.
What treatments are piriformis syndrome?
We have a few different treatment options that we can consider for puriform syndrome.
- Conservative management such as stretches, strengthening, etc.
When it comes to conservative management, a range of treatments have been examined in the research. Stretching, strengthening, muscle energy techniques, dry needling, deep friction massage, and neuromobilizations as the main ones. in general, we don’t see significantly different results for pain between any of these treatments.
Some people may respond better to some of these than others, likely based on their expectations of results. It appears that for many people, as long as they’re doing something and taking the initiative towards their health, they’ll likely see some degree of improvement.
While these don’t necessarily have distinct differences in pain management. We see differences across these treatments for changes in function, strength, and cost. Stretching, strengthening, and muscle energy techniques are specific types of support.
They generally have superior results for change and function; these are the most cost-effective since people can generally do them by themselves.
The best-recommended interventions for piriformis syndrome when it comes to conservative management will be stretching and strengthening.
After we look at the other treatment options, we’ll go through some stretches and strengthening opportunities you can do at home.
In regards to injections, some recent research has been dug into this, examining different kinds and comparing them to see which generally has the best effect. It appears that botox-used injections are generally the most supported by current research.
When they look at the effectiveness of various kinds, a botox-based injection often results in the longest-lasting pain relief and improved function.
If an injection is done, it should be followed up with exercise-based care. A recent study specifically looked at this and demonstrated that if an exercise-based program was used following a botox injection in those experiencing performance syndrome, it significantly reduced the recurrence of symptoms and the need for follow-up regarding surgery. It’s a bit of a mixed bag.
Firstly in most studies looking at those experiencing performance syndrome, very few require surgery.
Secondly, we have minimal research with long-term follow-ups for those who get surgery. It appears that in those who get surgery for piriformis syndrome, it is effective for pain management, at least in the short term.
There isn’t any research comparing non-surgical and surgical options, so it is hard to make some good recommendations in this area, and we will have to wait for further research to come out.
Let’s discuss what you can do for yourself.
When it comes to navigating piriformis syndrome, we want to start thinking about our tolerance, our capacity, and our progression. Our tolerance is how much load we can handle before having symptoms or before your symptoms are too much. Our capacity is how much we can handle if we don’t have symptoms you’re sealing, and our progression is how we improve both of those things based on need.
In the case of piriformis syndrome, people are often irritable with longer durations of sitting, walking, standing, and possibly running.
For many of these, we’re dealing with our tolerance not being enough to handle the tasks that we’re asking of our piriformis or our deep gluteal region in general to manage this, and we can look at it from a few different angles.
First, start thinking about maximizing your recovery and general adaptive reserves. This often means checking your sleep, nutrition, hydration, and overall stress.
The next thing is to start thinking about positional changes and activity modifications that might be needed to allow the area some time to calm down and hopefully increase its tolerance. If you’re constantly poking out the area metaphorically, you won’t have time to take a break and recalibrate.
In the first while of trying to manage it, consider playing around with your positions in sitting, standing, and other activities where you can control them to not put the piriformis on a lot of tension; that way, it has some time to calm down.
In loaded activities, such as running, you may need to temporarily reduce your volume and intensity to support the area’s recalibration and then gradually ramp up over time. Then supplementing it with various stretches and strengthening options can be helpful.
Physiotherapy for Piriformis Syndrome
Physiotherapy can isolate the origin of the piriformis syndrome pain, help relieve pain and restore normal movement and range of motion in the affected area.
The physical therapist performs a thorough evaluation, assessing pain and functional status, hip joint examination, muscle strength and biomechanical assessment. Based on the evaluation, the therapist designs a customized treatment program tailored to the patient’s specific condition. Most patients regain full function following 4-6 weeks of physical therapy.
Physical therapy treatment for piriformis syndrome can include:
- Pain management using heat, ice, and ultrasound
- Targeted stretching, particularly of the hamstrings
- Manual therapy soft tissue and joint mobilizations to increase blood flow to the area, reduce muscle spasms in the piriformis, and improve mobility and range of motion
- Myofascial release to relieve tightness in the piriformis and surrounding soft tissues
- Targeted hip-strengthening exercises, particularly the hip abductors, extensors, and external rotators
- Movement reeducation minimizes stress on the piriformis muscle and the subgluteal area and restores stability to the lower extremity.
If you’re experiencing piriformis syndrome pain and sciatica, give your physical therapist a call to relieve your pain and help you regain function and ease of movement!