Do you experience a deep pain in your buttock region that sometimes radiates down the back of your leg, often referred to as Piriformis Syndrome?
In this blog, I’m going to discuss piriformis syndrome, dispel the most common myths about the diagnosis, and teach you everything you need to know about managing symptoms.
Be sure to also check out our Hip Resilience Program!
Piriformis & Sciatic Nerve Anatomy
The piriformis is a small, pear-shaped muscle that attaches from the front of your sacrum, the triangle-shaped bone at the base of your spine, to the greater trochanter of your femur.
The sciatic nerve, the largest nerve in the human body, typically travels in front of the piriformis (anterior), but it can also travel behind it (posterior), through it, or some combination of the three as it splits into its two primary branches, the tibial nerve and common peroneal nerve.
These structures, among many others, are found deep to the gluteus maximus.
Piriformis Syndrome
Coined by Dr. Daniel Robinson in 1947, piriformis syndrome is usually described as an entrapment of the sciatic nerve by the piriformis muscle that causes a deep pain locally, as well as symptoms down the back of the leg.
However, since there are a variety of structures that may encroach on the sciatic nerve in this region, many researchers and clinicians have started referring to the diagnosis as “deep gluteal syndrome” as a way to encompass all possible culprits. Plus, research by Bartret et al in 2018 found no relationship between the sciatic nerve variations I just mentioned and piriformis syndrome, which is contrary to previous beliefs.
With that being said, except in very rare cases, piriformis syndrome and deep gluteal syndrome probably don’t exist in the way that most people think they do. This is extremely important to understand.
True compression of the sciatic nerve by the piriformis would present similar to sitting on the toilet for too long, mainly resulting in numbness, tingling, or burning down your leg along the path of the sciatic nerve and its branches.
What’s actually happening then?
The best analogy I can provide is one that I first heard from Tom Jesson, a leading expert in this area.
If you’ve watched our video about “rhomboid pain”, which happens to be the most watched video on our YouTube channel, you’ll know that pain in this area of the upper back typically stems from irritation of a nerve or structure in your neck.
In most cases, this is actually what’s happening in people who have been diagnosed with piriformis syndrome – there is irritation of a nerve or structure in the lower back contributing to symptoms in your butt, thigh, or down the back of your leg. There are different medical terms for this, such as referred pain, radicular pain, and radiculopathy.
If not the lower back, the second most common culprit would be the hip joint itself. For example, a study by Khan et al in 2004 discovered that although the groin and buttock regions are the most common locations of pain for individuals with hip osteoarthritis, people can report a distribution of symptoms into their thigh, knee, and even shin or calf.
Piriformis Syndrome Rehab Overview
Why does any of this matter for physical therapy or rehab?
Because as I discussed in the rhomboid pain video, rolling a lacrosse ball on that area might feel good temporarily, but it’s probably not a long-term solution. The same thought process applies here.
If the issue is originating in your lower back, you don’t have to focus your efforts on the piriformis. However, if massaging or stretching the area feels good and provides short-term relief, it’s usually fine to do.
Now, I don’t have a quick fix and I’d be wary of anyone who offers one, but I can provide you with strategies to help. Since everyone’s situation is unique, my goal is to provide you with options so you can find what works best for you.
Activity Modifications & Stretches
Whether the issue is stemming from your hip or lower back, the first thing you want to do is identify and temporarily modify contributing factors and aggravating activities. For example, if you notice that your symptoms always worsen after 45 minutes of sitting at the computer, that’s something you’d want to address. You could change your chair, the height of the chair, the surface you’re sitting on, or even how you’re sitting, but the easiest thing to do in this scenario would be to get up and move before the 45 minute mark.
You would apply this rationale to any positions, movements, or activities contributing to your symptoms. Part of this process can also include positions, movements, or activities that help relieve your symptoms.
For instance, someone who describes a worsening of symptoms with prolonged sitting may report an improvement in symptoms with repetitive back extensions in standing or on their stomach. This is something that can easily be performed periodically throughout the day.
On the other hand, some individuals may notice relief with flexion of their lower back, whether that’s bringing two knees to their chest, one knee to their chest, or a similar movement.
You can also do side-to-side rotations on your back, cat-cows on your hands and knees, or any other comfortable movements for the hips and low back.
The point here is that there is not a one-size-fits-all approach. As I already mentioned, you can even do the classic figure 4 stretches, but you don’t have to perform them with the intention of trying to “release” the piriformis.
For those wondering about nerve glides, there’s no convincing evidence that they are significantly better than anything else. Some individuals might report feeling better, some might report feeling worse, and others might report no effect. You can perform them if they help, but regular exercise and movement also glide your nerves.
Strengthening & Aerobic Exercises
What about strengthening and aerobic exercise? I encourage both, but the mindset for all of this information should be about trying to achieve a healthier lifestyle to create a better environment for recovery with a focus on things that are actually within your control. This includes modifying aggravating activities, regular exercise, managing stressors, prioritizing sleep, etc. Taking care of your overall well-being is far more important than any singular muscle.
For most people, I recommend dedicated walking breaks. I understand that it’s not always possible, but setting a goal of 2-3, 5-20 minute walks per day is a great start.
Just like with everything else, options are good here. If walking is currently problematic but riding a stationary bike feels great, lean into that.
For strengthening exercises, you can work on any tolerable movements that train the hips and low back.
Sit-to-stands from a chair are convenient for most people. If you want to make them easier, you can elevate the height of the seat or use your hands for assistance. If you want to make them harder, you can do bodyweight squats. From there, you can progress to holding a weight in your hands.
If you’re struggling with stairs, putting weight on one leg, or just want to train one leg at a time, step ups and step downs are useful.
You can use actual stairs or a small, sturdy object and progress the height over time. You can also use your hands for assistance here.
To train the glutes and low back, bridges can be used. Depending on what’s comfortable, you can either do an isometric, in which you just hold the top position, or perform actual repetitions. Some people like to add a band around the knees or squeeze an object between the knees. To make bridges harder, do the holds or repetitions one leg at a time.
Another option for training the muscles of the low back is the back extension exercise, which can be done on an exercise ball, Roman Chair, or on the floor.
To train the sides of the trunk and hips, you can perform a side plank.
To make it easier, do a short side plank on your forearm and knees or a shoulder elevated side plank.
If side planks are uncomfortable or difficult for your shoulder, you can do hip abduction in side lying or standing, with or without added resistance.
To train the front of the trunk and hips, planks can be performed.
To make them easier, do them on your knees or elevate your forearms.
To make them more difficult, you can perform alternating hip extensions.
Any of these exercises can be performed for 2-3 sets of 10-15 repetitions or 30-45 second holds, 2-3 times per week.
No matter what you do, start easy and build slowly. Rehab takes time, patience, and consistency, so find what works best for you.
Do you want a structured plan that’s going to provide you with the knowledge and tools to feel more confident, capable, and resilient than ever before?
Check out our Hip Resilience Program!
Want to learn more? Check out some of our other similar blogs:
Rhomboid Pain, Sciatica, Core Stability
Thanks for reading. Check out the video and please leave any questions or comments below.
