Piriformis syndrome, a really pain….in the butt
Updated: Feb 24
Recently, I came across an Instagram post of a runner stretching out her glutes. The caption under the photo said how the pain in her butt was KILLING HER after her long run and she was stretching it every chance she got.
Can you relate?
But what is it?
Your butt? sciatica? or something else?
The most common culprit, piriformis syndrome.
This name is a misnomer, because it's not a syndrome exactly.
The piriformis is a small pizza slice shaped muscle that lies deep under the gluteus maximus and is responsible for external rotation of the hip and pelvic stabilization.
It can be a real pain in the butt.
It can cause symptoms such as pain, numbness, burning and tingling which may or may not extend down the length of the leg.
Many of the runners we see, who come in with this pain, have been told by their doctor (or self diagnose) they have sciatica, when more likely it's something called piriformis syndrome.
Because compression of the sciatic nerve can cause pain to radiate up to the low back or down the leg, most people, even doctors, associate this pain with sciatica.
The way to tell the difference between sciatica or piriformis syndrome is where the compression occurs.
Sciatica is a compression of the nerve at the lumbar vertebrae. This can be caused by spinal rotation, vertebral disc compression or asymetrical pelvic rotation and typically, but not always, sends pain, tingling and numbness down the entire length of the leg. In many cases of sciatica, there will also be pain in the buttocks.
The piriformis lies on top of the sciatic nerve, and in rare cases, innervates (passes through) the muscle belly. When the muscle gets too tight it spasms causing it to compress the sciatic nerve, like a kink in a garden hose. Pain is often centered in the middle of the glutes and can be tender to the touch and/or painful upon sitting. In some cases, the spasm will pulse in the glute.
What causes the piriformis to tighten up?
There are many reasons the piriformis will tighten and cause dysfunction.
Excessive amounts of sitting - This can cause the piriformis to stretch and compress the sciatic nerve. Also, it can cause pelvic instability because the glutes, piriformis and other muscles become underactive. This can lead to the piriformis going into spasm after running because you're asking it to perform under stress (running) when it's not prepared to. Think pop-quiz in high school.
Excessive internal rotation of the femur - When your foot turns out like a pigeon into internal rotation it causes the piriformis to lengthen. Remember the piriformis is an EX-ternal hip rotator so too much internal rotation will cause it to lengthen too much and over time become overactive trying to hold it's position. This often leads to trigger points or nodules of pain in a muscle.
Poor pelvic floor/core control - Having a strong pelvic floor and core stability is more than having 6 pack abs. And as a runner, core stability is a must in order to reduce the risk of many types of running injuries. If you have a weak core, it causes the other muscle groups to "pick up the slack" this causes them to work harder and will eventually lead to fatigue and overactivity.
Additionally, piriformis dysfunction often times also results in tight adductors, like adductor magnus, sartorius, gracillis, as well as the deep hip (a group of external hip rotators) and of course gluteus medius and tensor fascia lata (hip flexor).
Luckily there are simple tests a massage therapists can perform to differentiate between true sciatica and piriformis syndrome, but remember, we cannot diagnose so a true diagnosis would have to come from a physician.
Treating Piriformis syndrome - Luckily, piriformis syndrome is relatively easy to treat, in most cases. Here are 4 simple and effective ways you can get rid of piriformis syndrome.
Ice - sitting on a bag of frozen peas can help to reduce inflammation and swelling which in turn can take some pressure off the nerve. Just remember not to over do it. Inflammation is your body's way of healing so a little inflammation is a good thing.
Stretching - One of my favorite yoga stretches for the piriformis is pigeon pose. This effective pose will target not only the piriformis, but the glutes and deep hip rotators, however, if your piriformis is tight because of too much internal rotation, it’s far better to stretch the adductors to take some stress off the piriformis.
Foam rolling - Using a foam roller, ball or other tools to target trigger points the muscle or relieve stress on the attachment points at the sacrum or the greater trochanter of the femur can help relieve pressure on the nerve as well.
The mistake that many people make is either using the wrong tool. Many time clients will use the hardest tool they can find like a lacrosse ball when a tennis ball is more appropriate for your first time. They think the more pressure the better, right?
Like massage, you need to work within your body's pain tolerance level. You also only need 30-60 seconds of sustained pressure to get relief. More than that makes an already irritated muscle even more irritated and can cause more issues, including nerve damage.
You also want to be careful not to compress the nerve itself. If you're unsure of how to use a tool, just ask, I'll be happy to give you a demonstration.
Massage - If stretching and foam rolling isn’t enough or you just don't want to do the DIY method, it might be time to see a professional. A licensed massage therapist can get into areas a foam roller cannot or help stretch you in ways you cannot do alone to easy piriformis pain.
If you're ready to take that step, you can book your next appointment here
Once the soft tissue dysfunction is removed, strengthening the glutes, core and hip flexors is recommended for lasting results. I suggest a corrective exercise specialist, personal trainer or physical therapist for specific exercises to strengthen weak muscles will keep this problem from ruining your next run.