Piriformis syndrome describes pain in the back of your hip and may be one of the culprits causing the extreme pain radiating down your buttock and the back of your leg. This path that the pain follows is known as sciatica.
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What is the piriformis muscle?
Piriformis is the Latin name for one of the 26 muscles in your buttock/hip area. The name Piriformis describes the pear shape of the muscle. You have one on either side of your hips. The pear lies horizontally, the fat end attaches to the sacrum (sitting bone) and the thin end attaches to the top of the thigh bone (femur).
Nerve roots L4 – S2 exit from the lumbar spine and merge to form the sciatic nerve. The sciatic nerve lies deep in the buttock and moves more superficial just underneath the Piriformis muscle. About 17% of people have a anatomic variation where the sciatic nerve runs through the Piriformis muscle, so this variation increases the risk for developing Piriformis syndrome.
What does the Piriformis muscle do?
The Piriformis muscle does:
- external rotation of the hip (that is rotating the hip that the thigh and toes face outwards)
- assists with abduction of the hip (leg moves away from the body)
- Stabilize the hip joint when you stand on one leg
How does Piriformis syndrome happen?
Any trauma to the Piriformis muscle, be it a direct fall, strain or repetitive activities (running, cycling, sitting, dancing) can lead to inflammation. This will cause a deep, dull ache in the back of the hip/buttock area. It will feel worse with contraction (moving the hip away from the body or turning the toes out) and stretch (moving the leg across the opposite leg or turning the toes in) of the piriformis muscle.
Inflammation is needed for healing, but excessive inflammation, together with muscle spasm can then compress the sciatic nerve. This compression will cause a burning type pain, which may be felt deep in the hip/buttock area. This burning sensation can start traveling down the back of the leg into the thigh.
All nerves are highly sensitive structures. Like a highly strung family member or colleague, irritation & change bugs them and make them act out. Compression of the sciatic nerve because of the inflammation and spasm, decreases the circulation to the nerve, almost like strangling the nerve. This will cause the nerve to act out to force you to seek help. Symptoms may include pins and needles, numbness, spasm of the hamstring or calf muscles. The symptoms are caused by this strangulation of the sciatic nerve, due to the piriformis muscle.
Causes of Piriformis Syndrome
Weakness of the Piriformis muscle as well as weakness of the entire pelvic girdle musculature may lead to adduction (moving closer to the midline) of the thigh, with a slight anterior tilt of the pelvis (standing with your butt stuck out backwards). This places the Piriformis muscle in a lengthened position the whole time you stand. This leads to trigger points forming in the muscle in an attempt to shorten it to decrease the effort to contract. These trigger points (knots) cause compression on the sciatic nerve.
Symptoms of Piriformis Syndrome
Symptoms of piriformis syndrome is due to compression of the sciatic nerve. Ischaemic symptoms (because of decreased circulation, think watering hose not watering the garden enough, plants wilt ect.) will be present. This includes:
- Calf, hamstring, buttock and back muscle spasms
- Pins & Needles (usually at the bottom of the foot or shin)
- Numbness or ‘dead’ feeling over the skin
- Sharp shooting pain in the back or buttock when bending forward
- Burning feeling in the buttock
- Pain radiating down the leg
- Weakness of the affected leg (unable to raise onto toe of affected leg)
What makes Piriformis syndrome worse?
- Driving (because of the position of the back and hip)
- At night (decrease in blood pressure when you sleep)
There are different types of tests that assesses each component of the problem. We must determine if the Piriformis muscle can stretch & contract without putting pressure on the Sciatic nerve. This test mimics the position you may take to put on your shoes and socks. If you get your symptoms or you are unable to get your ankle over your knee, your Piriformis muscle is contributing to your pain.
Length Tension Test & Stretch
If this position is painful or even going into it, the test is positive.
- Lie on our back, with both knees bent, soles of the feet on the floor
- Cross the unaffected leg’s ankle over the affected leg’s knee
- Push the unaffected leg’s knee away from you
- Note how far you can turn your hip out
- Now change sides and compare
- Stand with your feet hip width apart
- Twist your body over to the unaffected side, keeping the foot that you are twisting towards planted, the other foot can lift (almost like you are taking a golf swing)
- Repeat to the other side and compare the feeling between the two sides.
Contraction & Strength Test
If it is painful when trying to contract the muscle or move it through the range, the test is positive.
- Stand next to a chair or wall so you can hold on with one hand if necessary to balance
- Tighten the muscles in the front of your thigh by pushing your knee backwards
- You should feel your buttock muscles clench and tighten as well
Sideways lift in standing
- Stand with your feet hip width apart
- Shift weight onto the unaffected leg and lift affected leg sideways, 10 cm off the floor
- Repeat on the other side
This can cause symptoms in the standing and lifting positions if your piriformis muscle is affected.
Nerve Mobility test
This tests if the Sciatic nerve is able to slide and move freely around your hip.
Modified straight leg raise test
- Stand in front of a stair, facing the stair
- First place the unaffected heel on the stair, with the toes drawn up and the knee straight
- Now bend from your hip, aiming your chest to your shin, keep the standing (affected) leg straight
- Note how far you can bend forwards
- Now change sides and do the same
- Note how far you can bend
- Note any symptoms in your back, buttock and hamstring
If you experience your symptoms your sciatic nerve is affected.
- Wherever you are sitting reading this, move to the front of your seat, both legs straight in front of you
- Pull your toes up towards your knee caps
- Now hinge from your hips to fold towards your legs (straighten your lower back & collapse forward alternatively)
- Note how the sensation differs in the left and right sides
How bad is it?
Loss of power and numbness may not be as excruciating as the burning pain, but is more serious. If you experience a loss of sensation or inability to move the ankle, the sciatic nerve is suffocating and needs help ASAP.
The burning, pins and needles, electrical shock type pain is debilitating and extremely painful, but the nerve is still doing it’s job. That is, feeling, even though it is feeling pain.
Your physiotherapist will be able to diagnose the condition on the basis of your symptoms and physical examination. In some cases we will arrange for you to have X-rays or an MRI scan to rule out other causes of your hip & buttock pain.
X-rays enable us to see the bone, considering that the Piriformis muscle and Sciatic nerve is soft tissue, X-rays will not be helpfull. X-rays may be needed to rule out any other sites that may compress the Sciatic nerves higher up in your back.
Magnetic Resonance Imaging enable us to see bone and soft tissue (piriformis muscle and sciatic nerve). It is a costly scan to do and needs specialist referral.
How we test it
As mentioned before, the Piriformis muscle is one of the possible culprits that may cause sciatica. The other cause may be your lumbar discs. We are able to distinguish between the two causes and treat your pain.
We will do a thorough neurological conduction evaluation, including sensation, muscle power and reflex testing. This will show us if there is any nerve damage. We will also test the sciatic nerve’s ability to glide by performing a passive straight leg raise. Treatment will be custom made to fit your specific problem.
Why is my pain not going away?
If you experience repeated episodes of sciatica and the cause is diagnosed to be Piriformis syndrome, we need to establish why your pain keeps coming back. Mostly we identify the contributing factors to be habits that are difficult to break. Years of bad habits, poor posture will lead to weakness of the entire hip girdle. If you do not take the time to complete your rehabilitation, that is strengthening the hip after your symptoms are better, your pain will always return.
What makes Piriformis Syndrome worse
Even without doing any strenuous activities or exercise, habitual walking and standing posture can be the cause of your Piriformis syndrome. Continuously moving in these bad patterns will cause and the maintain your symptoms.
Your symptoms will get worse when you:
- climb stairs
- walk/jog steep slopes
- squats and lunges
Prolonged irritation of your piriformis muscle may cause the tendons to become scarred and lead to chronic symptoms, such as:
- constant pain
- limited hip movement (unable to give a big stride)
- numbness at the back of your thigh, knee or calf radiating into the foot
- difficulty walking up a small step
Physio treatment for Piriformis Syndrome
Consult your Physiotherapist first. We specialize in healthy movement. We will be able to correctly diagnosis you. If medication is needed we will advise you to consult with a GP to prescribe adequate pain medication. We will write a report to you your GP detailing the severity of your case.
Other treatment approaches include:
- Rest and activity modification (identify the movement or position causing the nerve irritation)
- rehabilitative exercises
- desk ergonomic advice
The first aim of Physiotherapy treatment will be to decrease the nerve compression and irritation by using electrotherapy (Ultrasound and Laser). We will also use Strapping to limit the range of movement of the affected leg, to avoid any further irritation on the Sciatic nerve.
Later during treatment Acupuncture or Dry Needling around the soft tissue of the nerve will be done to promote the inflammatory reaction and fast track healing. Soft tissue mobilization along the nerve pathway and will enable the nerve to move more freely and decrease your pain. Nerve tissue mobilizations are vital in regaining the normal glide action of the nerve. Dynamic, static and ballistic stretches together with eccentric loading exercises to condition the muscle fibers.
Using self-treatment methods can cause further harm or delay the appropriate treatment needed.
Phases of Rehabilitation & Treatment
Initial phase: Protection & initial Healing
The goal of treatment during the initial phase of healing is to decrease your pain. This will be done by controlling the inflammation, promoting scar tissue formation and unloading/complete immobilisation of the leg.
Intermediate phase: Regain Full Range of Movement
The goal of treatment during the intermediate phase is to regain normal movement while still controlling your pain. The strengthening exercises will also be introduced during this phase. During this stage you can expect to walk comfortably without crutches (if it was used during the initial phase), sit for longer periods, climb stairs, driving more comfortably.
Final phase: Return to normal activity & prevent recurrence
The goal of the final phase is to get you back to all the activities that you participate in, be it every day life or sports. Now is also the time to take your strengthening seriously as this will prevent recurrence in the future.
You can return to sports when you have regained normal, pain free movement of your legs and muscle power. If you have followed your prescribed physiotherapy program you will be fully fit within 4-8 weeks. If your symptoms are severe and persistent, even after non-surgical treatment you may require surgery. If so, your recovery time is likely to be at least 3 months.
Medication can help the process:
- Non steroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, may reduce swelling.
- Oral corticosteroids may be used to reduce swelling and pain. In more severe cases this will be prescribed by your doctor.
- At last resort – Steroid injections may reduce swelling and allow inflamed nerves to recover.
Surgery for Piriformis syndrome
If all treatment fail, your therapist may recommend surgery to loosen the sciatic nerve from the Piriformis muscle, in order to relieve the pressure of the sciatic nerve. Surgery will only be considered if there is progressive neurological disturbance that threatens permanent loss of function.
What else could the pain be?
There may be other conditions closely related to your pain, but not necessarily clear cut Piriformis Syndrome, so look at these.
- Herniated disc with nerve root compression: A herniated lumbar disc that is compressing a nerve root will cause pain down a specific dermatome. Associated weakness and loss of sensation is also expected.
- Facet arthropathy: Arthritis of a lumbar facet joint may cause referral down your leg, especially with lumbar extension.
- Spinal stenosis: Stenosis refers to the narrowing of the spinal canal in which the spinal cord runs. This may be due to previous injury, osteophytes or ageing. Pain will normally be bilaterally (spreading down both legs).
Piriformis syndrome is also known as
- Deep gluteal syndrome