A Real Pain in the Butt
Piriformis Syndrome
What is it?
Piriformis syndrome occurs when there is excessive tension or irritation of the piriformis muscle in the glute/hip region. When this muscle gets tight it can compresses the sciatic nerve (the nerve that runs down the back of your leg). This pressure may cause decrease blood flow, congestion, local inflammation, and radicular (pain that radiates from your back and hips into your legs) complaints. Researchers believe that piriformis syndrome contributes up to one-third of all back-related pain.
The piriformis muscle originates at the sacrum and inserts on the outside of the hip bone. It acts as a primary hip external rotator along with assisted hip flexion.
In the majority of the population, the sciatic nerve travels deep to the piriformis muscle. However, up to one-fourth of the population is predisposed to piriformis syndrome because their sciatic nerve passes through the muscle, splits the muscle, or both.
Symptoms
Symptoms of piriformis syndrome may begin abruptly as the result of a traumatic event or develop slowly in response to repeated irritation. This can be a result of a strain from a fall onto the hip or trying to catch yourself from a “near fall”. Irritation to their area may be from a repetitive micro-trauma which includes long-distance walking, stair climbing, or chronic compression from sitting on a hard edge or a wallet.
Symptoms can include pain, paresthesia (abnormal “pins and needles” feeling), or numbness beginning in the glutes and radiating along the course of the sciatic nerve. Symptoms are usually worse with prolonged sitting or standing. Patients will report increasing issues when walking, running, stair climbing, riding in a car, or rising out of a seated position. Sitting in a cross-legged position may exacerbate symptoms. Patients with piriformis issues will usually present with an antalgic gate causing a limp when walking.
From the compensation that follows piriformis syndrome, there may be tenderness in the sacroiliac joint and associated hip muscles. Those that have piriformis syndrome will come to find that they may have sacroiliac joint dysfunction and/or reactions in the spine and lower extremities.
An issue that may cause piriformis syndrome is poor arches of the foot. Another issue that should be considered is a possible leg length discrepancy.
This condition is most prevalent in 40-60 year olds. It also affects women more frequently, possibly due to variations of the Q-angle (the angle of the hips to knees in women).
Diagnosis
The diagnosis of piriformis syndrome is based on an accurate history and physical exam. Radiographic images of a soft tissue disorder have limited benefit. Advanced imagery may be an appropriate way to rule out other issues such as those with radicular complaints.
Management
The foundation of piriformis syndrome treatment including stretching, myofascial release, and correction of underlying biomechanical dysfunctions. Stretching of the piriformis muscle is crucial. Stretching of other muscles associated with the piriformis is usually necessary as well.
Soft tissue release may be appropriate for any associated myofascial concerns in the glutes, obturator, tensor fascia lata, hamstring, lumbar erectors, and hip adductors. PIR stretching techniques have proven to be a way to decrease pain and improve flexibility in the piriformis muscle.
Manual manipulation may be necessary to correct lumbar, sacroiliac, and lower extremity joint dysfunctions. Studies show that heat and ice benefit when applied before manual treatments.
Dry needling has been shown to benefit for managing piriformis syndrome.
Strengthening exercises should target abductors, adductors, and gluteal muscles. Rehabilitation should plan to focus on any biomechanical dysfunctions.
Patients may need to temporarily limit some of their activities including hill or stair climbing, walking on uneven surfaces, intense downhill running or twisting and throwing objects backwards. Patients should avoid sitting on one foot under them. Taking frequent breaks from prolonged standing, sitting, or car rides will help alleviate pain in the piriformis.
Those who find that they have a leg length discrepancy may need to start wearing a heel lift in their shoes. If the patient’s problem is stemming from the arches in their feet then they may need to get arch supports or orthotics.
NSAIDs may be beneficial in the early stages of management.