Piriformis syndrome to date remains the most misdiagnosed and easily treatable causes of sciatica pain. Most commonly this syndrome is confused with a more serious nerve compression or lumbar disc herniation.
An incorrect diagnosis can mean unnecessary medication, treatment, or surgery while the underlying problem and pain will remain or return.
Function and Structure of the Piriformis Muscle
The Piriformis is a deep muscle that originates from the sacrum (the large bone that connects the spine to the pelvis), passes through the sciatic foramen, and connects to the greater trochanter of the femur (the head of your leg bone). In most cases about 80%-90% the sciatic nerve will pass underneath the muscle, however in other cases the sciatic nerve will pass directly though the belly of the muscle.
Image source: Piriformis Syndrome
The function of this muscle is to externally rotate the extended thigh and assist in abduction (bring outward) of the flexed thigh. Imagine a hockey player skating. He extends the leg to push off with his toes pointed outward. The Piriformis is the muscle that brings the leg back and turns the toes out. This muscle is especially important to keep a proper and more efficient stride.
Symptoms of Piriformis Syndrome
Some of the symptoms of Piriformis Syndrome are as follows:
- Sciatica- radiating pain down the leg
- Deep, boring pain in the buttock Tight and painful hamstrings
- Radiating pain in the calf
- Tightness and decreased mobility in the hip
- Pain in the hip
- Low back pain
- Generally one sided pain
- Numbness, weakness and tingling in the leg or foot however this is uncommon
Causes of Piriformis Syndrome
This painful and annoying syndrome can have several causes, such as a direct trauma, an over usage or repetitive injury, hormonal changes, or postural abnormalities. The cause of this injury that we see most often at Mountain View Pain Center is an over usage or repetitive motion type.
An over usage injury can be caused in two different ways: one from an athlete over training and straining the muscle, the other from pushing yourself to hard after a period of inactivity. If an athlete is constantly training they will develop a dominance in certain musculature. For example, a sprinter is focused more on explosive power in the legs to increase their push off power. This can cause a muscle imbalance and lead to increased strain on the piriformis. We often see this in our office in running backs and hockey players.
The other over usage injury is usually from an increase in activity over one day or perhaps a weekend. We often see this here in Colorado, when the weather begins to warm up families will decide to go for a hike or long walk in the mountains without proper training leading up to the increased length of the hike. This is also seen in athletes if they have a tournament weekend where you are playing several games in a short period, for example youth hockey tournaments. The athletes will be well trained and conditioned, however the increased stress over a short period of time can send the muscle into spasm.
A trauma to the area can cause increased swelling in the tissue around the muscle or in the actual muscle itself. This causes pressure on the sciatic nerve and can cause the muscle to spasm. After a trauma it is also common to see a restriction in the sacroiliac joint, which puts an increased amount of strain on the area leading to further inflammation.
Two great examples are of a trauma are a batter getting beaned with a pitch in the side of the glut muscle or a quarter back getting hit and falling back on his backside. After the initial injury, the body will go into the inflammation phase, drawing more blood to the area and causing a swelling around the Piriformis muscle and the sciatic nerve. This pressure is what causes the radiation of pain into the leg, because the Sciatic nerve runs down the back of the leg. The body will also go into a protective mode and restrict motion to the sacrum. If the proper movement is not restored to the sacrum and pelvis, it can lead to a chronic stress to the area, leading to future episodes of the problem.
Hormonal changes are generally seen in women during pregnancy, due to the shifting of the pelvic basin to compensate for the baby. While in the early stages of pregnancy, the body releases a chemical called Relaxin, which relaxes the pubic symphisis (pubic bone), surrounding ligaments, and joints in the pelvis. This allows the area to widen and have increased space for the baby. This can put increases stress and strain on the sacrum where the Piriformis attaches. This is a very common ailment in pregnancy as well as low back pain.
Postural abnormalities can come from muscle imbalances, underlying structural defects or abnormalities, or simply poor posture. What we at Mountain View Pain Center see the most often is patients reporting with the symptoms from periods of increased sitting. We have treated trucker drivers, cyclists, and those who simply spend and increased amount of time at their desk at work. The reason increased inactivity in a chair can cause the symptoms of Piriformis Syndrome is that over time the muscle will shorten from its constant shortened position sitting. Once the muscle has become physiologically shorter you will lose range of motion in the area and experience tightness and discomfort.
Examination of Piriformis Syndrome
Although the cause and treatment of Piriformis Syndrome is very straightforward, this is a commonly misdiagnosed problem. The reason this is so commonly missed is the symptoms are similar to a nerve compression caused by a herniated lumber disc, which produces sciatica. What your doctor should do is a full history and physical examination to lead to the correct diagnosis.
In most cases, when a patient complains of radiating pain down the leg, the doctor will first think of a lumbar disc problem. A lumbar disc problem can be very painful, so it is good if the doctor investigates, and can rule this out if it is not the cause of the pain. At Mountain View Pain Center, we will take an x-ray of the lumbar spine to rule out any disc space narrowing, any fracture, or abnormality within the spine. If a disc herniation is still suspected after the examination, your doctor may order an MRI to see if there is any compression on the nerve roots or spinal cord.
Once your doctor has done the appropriate test to rule out the herniation he/she should investigate further causes of your symptoms. One indicator that will help clue in your doctor is a test you can even try yourself.
When lying on your back, look down at your feet. If the leg in question is rotated outward , that is a good indicator the Piriformis is in spasm (this is known as the positive Piriformis sign). The reason the foot will be pointing outward is the Piriformis muscle is contracted keeping the thigh rotated externally and will limit the internal rotation movements.
Another good indicator of Piriformis syndrome is through palpation of trigger points, for this test you will be face down on the table. The Piriformis muscle runs from the greater trochanter of the femur and runs at about a 45 degree angle upward and connects to the sacrum. If you reach down to where your hip is and feel the bone sticking out, that is where the Piriformis attaches and runs up from there. If there is a spasm of trigger points, then there will be two indicators.
When pressure is applied to the tendinous insertion over the hip then there will be a deep burning pain or sensation. Pressure over the middle of the muscle belly in (around the middle of the muscle in the gluteus maximus) there will a radiating pain down the leg or into the buttock, this point can be extremely tender to the touch.
Treatment of Piriformis Syndrome
As always go see your doctor first to determine if this is in fact Piriformis syndrome and not a disc herniation. You will need to determine the cause of the problem to determine the correct treatment plan.
At Mountain View Pain Center, we often see a spasm of the Piriformis muscle and restriction of the sacroiliac joint. In a situation like this it is best to find a doctor or clinic that is able to perform physical therapy and joint manipulation to get the quickest and most effective results. This is suggested because if you only work on the spastic muscle and leave the joint restriction or vice versa the fix will only be temporary.
It is also important that your doctor is able to distinguish between a restricted sacroiliac joint and a hyper mobile joint. In the case of a hypermobile joint, your doctor may order the use of a temporary trochanteric belt to help stabilize the area and relieve some tension on the Piriformis muscle. The correct diagnosis in this area is very important. If your doctor recommends stabilization of a restricted joint or manipulation of a hypermobile joint, they may exacerbate the problem.
Before you go through any home treatment, we recommend you stick with your doctor until they suggest you begin home care. The reason for this is the spasm and inflammation needs to be under control, or you run the risk or further inflaming the muscle.
At Mountain View Pain Center, we will first try to stretch out the muscle through PNF stretches (proprioceptive neuromuscular facilitation). These stretches are done to not only release spastic muscle but to also aid in stretching physiologically shortened muscles. These stretches must be performed with assistance, preferably with a trained professional as you can cause injury or strain to the area. One effective stretch is to bring the muscle to it’s the end of its range of motion, without discomfort, and contract the muscle with only a few pounds of resistance for about 5 seconds. After relaxing we will bring the muscle further past the original end range of motion. This is preformed about 2-3 times to increase the muscle length.
Stretching and home treatment, after you have consulted your doctor, is very important for this condition. First of all, if you are suffering from this condition, do not use heat. Many people like to follow the rule of ice for the first 48-72 hours and heat after that. If you use heat on an inflamed swollen Piriformis, you run the risk of further inflaming the area and causing more pain. Heat will feel good while it is on, however a few hours later or the next day you could regret this move. Ice only in this situation. If you have chronic flare ups of this problem, ice after competition even if there is no pain.
Another very important rule for Piriformis syndrome is to stretch before and after your activities. We will discuss stretches that you can do at home or even at your desk at work, when you may feel the symptoms or tightness starting to creep up.
The first and easiest stretch can be done in your chair. Cross the affected leg over the opposite leg and slide the foot upward so it is resting on your knee. Simply lean forward from here until you feel a nice tight band like stretch across the buttock. You are stretching the Piriformis here. Be careful not to bounce or use ballistic stretching to go further as you will aggravate the muscle. Hold this stretch for about ten seconds, take a nice long deep breath and try to lean just slightly farther.
Image source: Piriformis stretch
A similar stretch can also be preformed when laying on your back. Simply cross the affected leg over the opposite side. Reach through the leg and pull upward. You will feel a band like stretch across the affected area. This is another great way to stretch the Piriformis muscle.
Image source: Piriformis stretch
This muscle can be stretched in several other ways, these are just two easy examples of how to loosen up the muscle when you start to feel the tightness. another treatment that we use to aid in a quicker recovery time from Piriformis syndrome is the application of Kinesio tape. We apply Kinesio tape over the spastic Piriformis to help reduce muscle fatigue, pain, and spasming. The tape is excellent for athletes, as the tape does not restrict the muscle or joint. The tape is more elastic and moves with the area, and can be worn for 2-3 days, even in the shower, and wont peel off from wetness or sweat.
Supplements to Aid in Inflammation and Muscle Spasms
Inflammatone – this is brand specific and contains multiple herbs and vitamins that aid in the decrease of inflammation, such as boswellia, ginger, and tumeric. The reason we use this specific brands is we have found it to be most effective, and also cuts down the amount of pills you have to take as it contains all necessary components in each capsule.
Calcium – if you suffer from recurrent muscle spasms you may be deficient in Calcium.
As always, remember to stay hydrated, and stretch before and after excersizing.
This article contains the opinions and examples of treatment plans for whiplash injuries from Mountain View Pain Center in Centennial, CO, and is not intended as a substitute for specific medical advice from a doctor regarding your individual injury or condition. If you have any further questions or concerns feel free to contact our office or leave a comment below.
The Trainer’s Room is written exclusively for Midwest Sports Fans by Centennial, CO chiropractors Dr. Niall McNally and Dr. Ihsan Erhuy of the Mountain View Pain Center in Centennial, CO. You can contact them by leaving a comment below or sending an email to [email protected].
Dr. Niall McNally is certified in chiropractic neurology and has a strong background in sports injuries and in the rehabilitation of common nagging athletic problems. Dr. McNally also is trained in pediatrics, orthopedics, and nutrition.
He graduated from the University of Central Oklahoma and successfully completed his Doctor of Chiropractic degree at the Parker College of Chiropractic in Dallas, TX. A very active athlete, Dr. McNally played hockey up into the junior level. In fact, it was his love for hockey, and the Colorado Avalanche, that originally gave him the idea to one day practice sports medicine and chiropractics in the area.
Dr. Ihsan Erhuy specializes in motor vehicle accident injures, back, neck, and extremity problems, as well as treating pregnant patients and children. He is certified in the Diversified, Gonstead, Thompson, Upper Cervical, Activator, Sacral Occipital, Applied Kinesiology, Soft Tissue techniques.
Originally from Adana, Turkey, Dr. Erhuy graduated from the University of Arizona and also susuccessfully completed his Doctor of Chiropractic degree, along with his bachelor of science in health and wellness, at the Parker College of Chiropractic in Dallas, TX.