facts about piriformis syndrome

PIRIFORMIS SYNDROME
SEPARATING FACT FROM FICTION

FOR THIS MISERABLE PAIN IN THE BUTT

PIRIFORMIS SYNDROME is not only difficult to diagnose, it can be resistant to almost any form of therapy practitioners throw at it (CORTICOSTEROID INJECTIONS, BOTOX INJECTIONS, PRP INJECTIONS, massage, electric stim, acupuncture, ultrasound, chiropractic adjustments, etc, etc) .  Despite the fact that the vast majority of doctors have no real idea what PIRIFORMIS SYNDROME is, how to go about diagnosing it, or for that matter, how to effectively treat it, the internet has definitely increased the awareness of this ‘epidemic‘. 

Yes, I realize that some of you will say that using the word ‘epidemic‘ to describe Piriformis Syndrome is a bit over the top. I would strongly disagree.   I call it an epidemic because despite the fact that for years its very existence has been questioned, the evidence points to the contrary.  In fact, the most current research on the subject (from UCLA’s School of Medicine) shows that Piriformis Syndrome is actually the number one cause of Sciatica in America today — more common than disc (HERE).  Yes; Piriformis Syndrome is real alright.  For those who have suffered it’s effects, it’s a nightmare that’s as real as a proverbial heart attack.

Because the lowest Spinal Disc in your spine must withstand a great deal more mechanical pressure than the other discs in the spine, it is (in my experience) the most common place to see what I refer to as, “The Big Four” (DISC HERNIATIONS, DISC DEGENERATION, SPINAL STENOSIS, and FACET SYNDROME).  Because these all seem to occur most commonly at the L5 vertebral / disc level, and because the nerve supply to the Piriformis Muscle just happens to come from that same level, it is fairly easy to mistake Piriformis Syndrome for back problem.  I would love to tell you otherwise, but I’ve done it myself.  Oh, one more thing that can throw a wrench in the machine as far as making an accurate diagnosis, is that all of the above problems can cause SCIATICA.    We could even call this list the ‘Big Five’ because the Piriformis Muscle also happens to sit just below the SI Joint (it has attachment points to the joint capsule) and can be related to chronic Sacroilliac problems as well.  Fouling things up even more is the issue of ASYMPTOMATIC DISC HERNIATIONS.  I simple test to help give you some kind of idea about where your pain is arising from can be found HERE.

WHAT DOES THE PIRIFORMIS MUSCLE DO?

What does the Pirifomis Muscle do?  The Piriformis Muscle is one of the muscles that make up what some like to refer to as the ‘Hip Rotator Cuff’.  The Piriformis Muscle is responsible for External Rotation of the hip.  To understand what External Rotation of the hip is, lay on your belly with your knees bent at 90 degrees (the heels of your shoes should be pointing at the ceiling).  Now let your foot fall to the inside (toward the other leg).  This is External Rotation of the hip joint.  The other muscles that perform a similar function are the Superior Gemellus, Obturator Internus, Inferior Gemellus, and the Obturator Externus.  The difference though between these other External Rotators and the Piriformis is that the Sciatic Nerve runs through a tiny window just underneath the Piriformis Muscle —- or sometimes it actually goes through the Piriformis Muscle. 

STRETCHING & STRENGTHENING IS A GREAT
FRONT-LINE TREATMENT FOR PIRIFORMIS SYNDROME

I am all for stretching and strengthening the muscles of the hip girdle and pelvis in an attempt to ward off the symptoms of Piriformis Syndrome.  In fact, if you suspect that your problem might be Piriformis related (or full-blown Piriformis Syndrome), the very first thing you need to do is to stretch (OUR STRETCHING PAGES).  If your problem is not too severe, you might be able to work it out in this manner.  However, I am leery of having patients rush out and get an MRI.  This is because standard MRI imaging procedures do not show the presence of Piriformis Syndrome.  Since MRI is not really a valid diagnostic option, there are other things that I often look for when when dealing with patients suffering with Piriformis Symptoms.  Some of these include….

  • HIP FLEXOR TIGHTNESS / TENDINOSIS:   Problems with any muscles that attach directly to the pelvis can cause or contribute to Piriformis Syndrome.  I frequently find HIP FLEXOR TENDON ISSUES in people with Piriformis Syndrome.  These are usually, but not always related to overly tight Quads.

  • GROIN TIGHTNESS OR TENDINOSIS:  Problems with any muscles that attach directly to the pelvis can cause or contribute to Piriformis Syndrome.  I have seen case after case of Piriformis Syndrome that started with groin pulls or other GROIN PROBLEMS

  • TIGHTNESS OR SCAR TISSUE IN THE TENSOR FASCIA LATA OR ITS TENDON —- THE ILLIOTIBIAL BAND:  Problems with any muscles that attach directly to the pelvis can cause or contribute to Piriformis Syndrome.  ITB PROBLEMS are often related to Piriformis Syndrome.

  • HAMSTRING TIGHTNESS / TENDINOSIS:  Problems with any muscles that attach directly to the pelvis can cause or contribute to Piriformis Syndrome.  If you look at any anatomy book, you’ll notice that part of the hamstring attaches to the Sacrotuberous Ligament.  CHRONIC HAMSTRING PROBLEMS (even sub-clinical ones) are often found hand in hand with Piriformis Syndrome.


Look for reduced range of motion in the hip joint.  This is especially true of internal rotation.  Any of the problems above can ultimately contribute to diminished internal rotation of the hip.  This can cause or contribute to Piriformis Syndrome.

  • A WEAK CORE:  Core Strength affects virtually everything.  To learn more about strengthening your core, just go HERE.

  • HIGH OR LOW ARCHES:  This goes hand in hand with the next bullet point.   Your foot type is critical for determining what sort of shoe you need. High arches can cause supination of the feet as opposed to pronation.  This causes people to walk on the outsides of their feet, leading to undue stress on the Piriformis Muscle, which, in turn, can lead to Piriformis Syndrome.  HERE is more information on this subject.

  • WHAT KIND OF SHOES ARE YOU WEARING TO RUN IN?  I recently had a patient come to me for Piriformis Syndrome.  This woman is a workout machine.  She runs, she lifts weights, and she even leads fitness boot camps at her town’s local Y.  She had been told that she was a severe pronator (typically flat footed people pronate) and was wearing a ‘Stability Shoe (aka Dual Density Sole).  The shoe is built with the outside portion of the sole softer so that flat footed people (who tend to walk on the insides of their feet) are pushed onto the outsides of their feet.  As you might imagine, a supinator will have real problems in a Stability Shoe — despite the fact that they rarely relate their problem to their shoe.

  • WHAT KIND OF SURFACE ARE YOU RUNNING ON?  Too many hills?  Are you running on a sloped surface?  Is it too hard?  Is it too soft?  Any of these can contribute to the development of Piriformis Syndrome.

  • WHAT YOU EAT:  Although many will pooh pooh this point,for many of you it could be the most critical of the bunch.  If you want to understand how your diet could possibly be related to various CHRONIC PAIN SYNDROMES including Piriformis Syndrome, HERE and HERE are some posts for you to read.

PIRIFORMIS STRENGTHENING EXERCISES

ONCE YOU HAVE STRETCHED THE AFFECTED PELVIC MUSCLE(S), WHAT KIND
OF STRENGTHENING EXERCISES SHOULD BE UNDERTAKEN?

The first thing to remember about any muscles, but particularly muscles that attach to the pelvic girdle is that you cannot really completely isolate any muscle as far as strengthening is concerned.  Another thing to remember is that probably not all of these exercises will work.  Add them in one at a time so that if something does not work, you know what it is.  I deal with a lot of Piriformis Syndrome, and my experience is that these exercises should only be done once a person is essentially out of pain (post-stretching protocol).  These exercises will help a lot of people who have a lesser degree of symptoms.  Be cautious because it is my experience that they will not help most of the really hardcore Piriformis Syndrome sufferers, and like I insinuated a moment ago, can actually fire things up..

  • SLIDE WALKING / LATERAL WALKING: Using the appropriate gauge of Theraband rubber tubing for resistance, loop it around both legs just above the knees.   Now, get into a half-squat position (like you are playing defense in basketball).  Slide Walk laterally in each direction —- again; just like you were playing defense in basketball. This can be an especially valuable exercise for those with tight groin muscles.

  • PIROUETTES:   Lift your bad-side leg outward with the final positioning of your toes pointing towards the leg you are standing on.  The end position is going to look like a poor man’s pirouette.   Do reps and sets accordingly.

  • HIP ABBDUCTION / ADDUCTION:  While standing upright, use a cable machine attached to your leg to both abduct the leg (take it away from center line) and adduct the leg (bring it back to center).  You can accomplish the same thing using heavy Theraband materiel.  

  • THE SCISSOR:  Lay on your side on the floor.  Now raise both legs slightly off of the floor.  Then raise the top leg as high as you can and bring it back down to the other leg —- in a “scissor-like” motion. 

  • THE OYSTER:   Lay on your side on the floor just like you were going to do a Scissor.  You are going to do the exact same exercise while keeping your feet together.  Instead of the exercise looking like a scissor, it will look more like an oyster repeatedly opening and closing.
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