Being injured is a pain in the bum, right? But what if the “pain in the bum” is, well, your backside??
This is the first blog of a couple of common derrière based problems.
Piriformis syndrome has been described in literature for over 70 years (ref 1); yet, it remains controversial. To the extent that there are on-going debates as to whether it is over-diagnosed, or under-diagnosed! Confusing? Maybe, but lets start with the things we can agree on;
We can all agree that the symptoms presented both in the general population, and in runners particularly, are:
- Pain in the buttock, tightness/loss of movement, tingling/pins and needles, and/or weakness/numbness which can sometimes radiate into the lower back and down the backs of your legs, sometimes as far as the toes.
But how do these symptoms manifest themselves? We need to take a look at 2 structures;
The piriformis is a small, relatively short muscle buried deep within the glutes, one of only 2 muscles joining the spine to the legs. It runs from the sacrum (base of spine) to the greater trochanter – the outside of your hip. Because of its position, the piriformis muscle helps rotate your leg outward when your hip is extended, but rotates your leg inward and into abduction when your hip is flexed. During the running gait cycle the piriformis is most active during the stance (foot planted on the ground) – approx. 60% of the cycle.
The sciatic nerve is a very thick nerve which originates from your lower back (L4-S3), through your glute muscles and down the backs of your legs, all the way to your toes…..The sciatic nerve passes directly under the piriformis muscle in most people, however it is thought that in between 15%-20% of the population it passes through the piriformis.
Let us also acknowledge the word ‘syndrome‘; Oxford Dictionary defines a syndrome as “A group of symptoms which consistently occur together, or a condition characterized by a set of associated symptoms“ . Essentially – medically at least – a syndrome is nothing more than a group of symptoms: True cause varies. See; Illiotibialband syndrome, patellofemoral pain syndrome, irritable bowel syndrome.
So whilst we have to accept that there is no universally agreed-upon criteria for piriformis syndrome, a systematic review paper published in 2010 by Hopayian et al (ref 2) defined piriformis syndrome as “sciatica caused by compression of the sciatic nerve by the piriformis muscle.”
Thus, the theory goes; irritated piriformis – irritated sciatic nerve – pain = Piriformis Syndrome (PS)
So what can we do about PS?
As you can imagine with limited conclusive research, and much ambiguity around the true cause of this syndrome, treatment studies are not in abundance. Most treatment modalities naturally treat what is thought to be the causing factor, a problematic piriformis muscle. A conservative place to start would be to stretch the muscle (ref 3). This can be done in a multitude of positions, some of which can be seen in the following video.
It may be that the underlying cause of the pain is less simple that a ‘tight’ pirifomis, and it may be a case that you need to strengthen the muscle, or indeed your hips in general (ref 4). Again, due to the lack of high-quality studies, and the absence of research on treatments specifics, there is limited scope to describe specific advice in a general forum. Befriend your local therapist if symptoms persist!
Anecdotally, other popular methods to address the symptoms include massage, foam rolling and a few lifestyle changes; avoiding doing things that irritate the piriformis muscle such as prolonged sitting (standing desks are becoming more and more popular), and if you are able to still run, avoiding antagonistic workouts such as speed sessions and dedicated hill repeats.
Remember, it is important as part of the diagnostic stage of PS, that other conditions that can cause similar symptoms are identified, either by objective medical tests like an MRI scan (herniated discs or other low back/pelvis issues) or in a clinical setting.
REF 1 Benson E, Schutzer S 1999. Posttraumatic piriformis syndrome: Diagnosis and results of operative treatment. Journal of bone and joint surgery
REF 2 The clinical features of the piriformis syndrome: a systematic reviewhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2997212/
REF 3 Christensen K 2006. Rehab recommendations for piriformis syndrome. Dynamic Chiropractic.com
REF 4 Tonley, S. C.; Yun, S. M.; Kochevar, R. J.; Dye, J. A.; Farrokhi, S.; Powers, C. M., Treatment of an Individual With Piriformis Syndrome Focusing on Hip Muscle Strengthening and Movement Reeducation: A Case Report. Journal of Orthopaedic & Sports Physical Therapy 2010