Piriformis syndrome is a neuromuscular disorder that is caused when the piriformis muscle compresses the sciatic nerve. The piriformis orginates from the sacrum and attaches to the femur. The sciatic nerve is the largest nerve in the body (L4-S3) and usually emerges below the piriformis muscle, however variations have been shown in many studies (see Figure 1).
Figure 1, anatomical variations in the relationship of the sciatic nerve to the piriformis muscle.–
The patient may complain of a deep aching pain in the buttock or a radiating sharp pain that extends along the middle of the rear thigh. Sometime numbness and tingling can continue to the calf and toes. These symptoms can be accompanied by low back pain and worsen after prolonged sitting. However a thorough exam by a physician should be conducted to exclude a more serious origin such as an herniated disc pressing upon the sciatic nerve, which could mimic those symptoms.
Several factors can predispose patients to developing this conditions. Some of these factors are:
• Joint stiffness (hip, lower back, SIJ)
• Worn shoes
• Muscle tightness(especially piriformis and adductor muscle) and muscle weakness.
• Leg length discrepancy
• Feet problems
• Inappropriate or excessive training
• Poor biomechanics
• Inadequate warm up
• Poor pelvic or core stability
• Poor posture
Piriformis syndrome is more common in activities such as running, sprinting, jumping, squatting or lunging, that require repeated use of this muscle. Possible because as the primary muscles of the hip become fatigued, smaller muscles such as the piriformis must work harder to maintain form. However there are many other external factors that may lead to an overuse injury such as advancing mileage too quickly, excessive mileage, wearing work shoes (or with poor support), terrain, poor running technique, etc.
There is no definitive test for the piriformis syndrome. Often there is a history of repetitive and vigorous activity such as running for long-distance. Diagnosis of piriformis syndrome is made thanks to a combination of the patient’s report of symptoms, tests to reproduce symptoms (FAIR, SLR with internal/external hip rotation, Freiberg, Pace, etc) and finding of a tender point over the piriformis muscle, which may be felt as a sausage-shaped mass.Occasionally MRI may be required to assist diagnosis.
Many techniques could be used to release the piriformis and varies among osteopaths, physiotherapists and chiropractors. Treatment may comprise a combination of:
• Joint manipulation
• Dry needling
• Electrotherapy (e.g. ultrasound)
• Soft tissue massage
• Stretching exercises
• Muscle energy techniques
• Biomechanical correction
• Exercises to improve flexibility, core stability,strenght.
• Technique correction
• Plan to return to sport
• Shoe lift or foot orthoses
Warm up properly before activity and increase intensity gradually.
Stretch the piriformis, hip muscles (the gluteal group, the lateral rotator group, the adductor group and the iliopsoas group), hamstrings, quadriceps in order to adequately reduce pain and increase range of motion.
Strenght the hip extensor, hip abductors and external rotators to reduce strain on the piriformis. As a matter of fact as the primary muscles of the hip become fatigued, the smaller accessory muscles, such as the piriformis, must work harder to maintain form. Trying to compensate for stronger muscles is how the piriformis becomes strained.
Figure 2 shows piriformis stretch and strengthening of the hip external rotators and abductors.
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen help reduce the pain and inflammation. Return to running Weeks it takes to return to normal form:
• 2 weeks off=4 weeks to recover
• 3 weeks off=6 weeks to recover
• 4 weeks off=8 weeks to recover
Before start running again you should be able to walk 1 hour without pain. Aerobic conditioning can be maintained in the swimming pool or cycling.
Gradually add Hill runs.
4 weeks schedule(2 weeks off running):
- 1st week 50% of preinjury distance 75% of preinjury pace
- 2nd week 75% of preinjury distance 75% of preinjury pace
- 3rd week 85% of preinjury distance 85% of preinjury pace
- 4th week 100% of preinjury distance 85% of preinjury pace
6 weeks schedule(3 weeks off running):
- 1st week 50% of preinjury distance 75% of preinjury pace
- 2nd week 60% of preinjury distance 75% of preinjury pace
- 3rd week 70% of preinjury distance 75% of preinjury pace
- 4th week 80% of preinjury distance 85% of preinjury pace
- 5th week 90% of preinjury distance 85% of preinjury pace
- 6th week 90% of preinjury distance 90% of preinjury pace
8 weeks schedule(4 weeks off running):
- 1st week 35% of preinjury distance 50% of preinjury pace
- 2nd week 40% of preinjury distance 50% of preinjury pace
- 3rd week 50% of preinjury distance 60% of preinjury pace
- 4th week 60% of preinjury distance 75% of preinjury pace
- 5th week 70% of preinjury distance 75% of preinjury pace
- 6th week 80% of preinjury distance 85% of preinjury pace
- 7th week 90% of preinjury distance 85% of preinjury pace
- 8th week 90% of preinjury distance 90% of preinjury pace
Acupuncture works very well on the piriformis. You may need to see a doctor to rule out a herniated disc or (If you feel pain on both sides) to rule out stenosis of the central canal (narrowing of the hole the spinal cord goes through). The sacroiliac joint must be treated simultaneously with the piriformis if the joint is a factor. See a chiropractor or osteopath to be evaluated for lumbar and sacroiliac joint dysfunction.
Don’t drive and do not sit for long periods. If you are being advised to have surgery for “piriformis syndrome,” be sure to try trigger point therapy and sacroiliac joint release first
Dott. Emanuele Luciani
Osteopath, physiotherapist, hatha yoga teacher
Osteopath registered with the General Osteopathic Council (GOsC)
"Centro Studi Tre Fontane"
Via Luigi Perna 51, Rome