About Piriformis Syndrome
The piriformis is one of the six small muscles of the hip that make up the deep external rotators. Though relatively small, the piriformis can cause a great deal of pain and discomfort in a condition known as piriformis syndrome. Because of its proximity to the sciatic nerve (a very large nerve that, along with its branches, supplies the entire leg), inflammation and tight spasms in this small muscle can cause pain that radiates to a large area. For this reason, piriformis syndrome is considered a neuromuscular condition.
Best described as a “pain in the butt,” piriformis syndrome is characterized by deep buttock pain (usually unilaterally, or on just one side of the body) that is difficult to pinpoint. This pain is typically worsened by sitting, climbing stairs, and performing squatting motions. Apart from this most commonly reported symptom, piriformis syndrome can manifest itself in many different ways. Some patients report tightness and decreased mobility in the hip and hamstrings. Piriformis syndrome also commonly causes sciatica-like pain radiating down the leg, which often leads to this condition being confused with herniated discs and other lumbar spine and spinal nerve disorders. Diagnosis of piriformis syndrome is often achieved by ruling out these other possibilities.
Risk Factors
- Gender: as with many chronic overuse injuries, women are affected by piriformis syndrome more often than men. This is most likely due to structural differences in hips of men and women. Women have a higher Q angle, or the angle between bone markings on the front of the hip and just below the knee. Because women have wider pelvic girdles, they are generally at a higher risk for injury.
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| Lumbar Lordosis |
- Lordosis: Individuals with an excessive curve in their lumbar spines, resulting in a “sway back” tend to have tight piriformis muscles, increasing the risk of irritation to these muscles.
- Prolonged Sitting: Some evidence suggests that people who work in jobs that require them to sit for extended periods of time are at a higher risk for developing piriformis syndrome and/or sciatica. Prolonged sitting may be due to an office job, frequent extended periods of time sitting in a car, etc. The body is designed to function at its best in a standing position, so prolonged sitting is likely to cause irritation to the muscles and nerves in the hip/buttocks region. Poor posture in seated positions can exacerbate this risk factor.
- High Running Volume: Distance runners and other athletes who spend a great deal of time running have a high susceptibility to almost every overuse injury involving the lower limbs. The repetitive nature of running can lead to a muscle imbalance in which certain muscle groups become much stronger than others. Because the piriformis performs hip external rotation, which is not a typical running motion, it may be disproportionately weak and at a higher risk for strain and irritation.
Treatment
- Early Conservative Treatment: Treatment for piriformis syndrome should begin as soon as possible after symptoms first appear. When caught early, simple conservative treatments can be the most effective. Nonsteroidal anti-inflammatory drugs can be used in conjunction with ice and rest to control early symptoms.
- Pharmacological Treatments: If home treatment is unsuccessful, doctors may prescribe muscle relaxants to patients suffering from piriformis syndrome. Also, patients sometimes opt for local steroid injections for an anti-inflammatory effect on the piriformis muscle. These have proven to be effective with little complications other than infections at the site of injection.
- Physical Therapy: Strengthening routines prescribed by physical therapists are another effective treatment for those suffering from piriformis syndrome. This usually requires 2-3 therapy sessions a week for 6-8 weeks. Exercises generally focus on strengthening the muscles of the hip, specifically the adductor and abductor muscles. Physical therapy also entails a great deal of stretching. The stretch shown on the right is a classic way to isolate the piriformis muscle. Physical therapists might also incorporate myofascial release techniques, massage, tissue mobilization, ultrasound and/or iontophoresis into therapy sessions. However, the effectiveness of these treatments varies among individuals and is still being researched. - Surgery: Only in very extreme cases, surgery may be necessary to treat piriformis syndrome. Surgical procedures usually entail a tendon release of the piriformis, and if additional pressure needs to be released from the sciatic nerve, a portion of the piriformis muscle may be removed. Surgery is typically followed by physical therapy.
An Ounce of Prevention
The risk of piriformis syndrome can be reduced with regular (but not excess) exercise. Training loads should be increased gradually to prevent piriformis syndrome, as well as a multitude of other overuse injuries. Warming up before exercise and cooling down and stretching afterwards can help reduce the risk of muscle injuries. Prolonged periods of sitting should be avoided where possible. While seated, it is best to maintain good posture and keep feet flat on the ground, rather than crossing the legs.
Sources and Additional Information
Sports Physical Therapy Institute http://www.sportspti.com/research
Sports MD http://www.sportsmd.com/SportsMD_Articles/id/327.aspx
Journal of the American Osteopathic Association http://www.jaoa.org/
Milton J Klein, DO. Piriformis Syndrome http://emedicine.medscape.com/article/308798-followup