Piriformis Syndrome is a complaint that we often hear about from our patient. Pain can be debilitating and may make a patient question whether or not relief is an option. In this blog, we will discuss:
- What is piriformis syndrome?
- Can piriformis syndrome cause back or hip pain?
- What is the treatment for piriformis syndrome?
- How can you treat piriformis syndrome at home?
1. What is piriformis syndrome?
Piriformis syndrome is inflammation of the piriformis muscle. This muscle is pierced by the sciatic nerve. With inflammation in this area, compression of the nerve can take place, leading to pain down the leg.
You can see in this picture that there are other muscles around the piriformis that can also become inflamed and lead to similar symptoms.
Repetitive microtraumas in this area, such as running or other endurance activities, typically lead to piriformis syndrome or other tissue inflammation. However, it can also be caused by daily microtraumas such as long durations of sitting, especially if sitting on a hard surface or in a cross-legged position, as this leads to a lot of stress build-up in the piriformis muscle itself as well as the surrounding tissue.
What is a microtrauma? An injury resulting from repetitive stress to a tissue. Microtrauma can include the microtearing of muscle fibers, the sheath around the muscle and the connective tissue. It can also include stress to the tendons, and to the bones. The body then inflames the area of microtrauma as a healing or protective measure. Without controlling the cause of inflammation, and continuing to repeat the cause of inflammation, injury can develop.
2. Can piriformis syndrome cause back or hip pain?
The piriformis muscle is one of our deep external rotators of the hip. Not only does this group of muscles provide external rotation, but they are also our lateral stabilizers, specifically during internal rotation of the hip. For runners or walkers, our bodies require stability in order to remain upright. When the repetitive movement stresses out the stabilizing tissues, tension or trigger points develop, leading to pain. When a muscle is in pain, it enters “protective mode” and becomes sensitive as your body’s way of saying “something is not right here.”
Pain can be felt at the location on the piriformis, in back side of your hip with piriformis syndrome. However, It can also be felt elsewhere due to our fascial connections and how our bodies are designed to move. This is called referred pain. Common areas that that referred pain can be felt with piriformis syndrome are the leg, the opposite hip, the front of the hip, and the back.
Fascia is the “saran wrap” of our body. It is how we are connected and how our bodies function in synchrony. This phenomenon is also how we can develop referred pain. Tension or trigger points in one muscle, such as the piriformis, can irritate or pull at the fascia, leading to pain felt elsewhere.
Pictured here are the fascial slings that demonstrate how inflammation in the piriformis or other deep external rotators of the hip can lead to referral of pain in other areas of our body. It requires a thorough exam, assessment, and understanding of anatomy in order to diagnose the root cause of pain. To reiterate, though pain is felt in say the back or the front of our hip, it can be caused by tension or issues in other areas of the body.
3. What is the treatment for piriformis syndrome?
At IHS, we focus heavily on functional assessments to guide us through our treatment plans. Too often are ice and stretching the number one focus for treatment in patients. While ice temporarily reduces pain via reducing inflammation, it restricts blood flow. Restriction of blood flow means delayed healing.
Piriformis syndrome, as mentioned earlier, typically results from repetitive microtraumas/microtears to the tissue. While stretching may also temporarily help, it is vital to focus on healing and stabilizing the piriformis or other related musculature.
The treatment is specific to the patient. A thorough, functional assessment to look at provoking movements, non-provoking movements, and how the body accomplishes daily tasks such as sitting in a work chair or running on a sunny day are all important factors that lead to the best possible diagnosis.
Let’s look at some examples of real cases that have been seen at IHS, removing the patient identity for privacy purposes.
Case 1: A work from home employee with right sided posterior hip pain
(All aspects summarized for blog-sake)
Patient presents with posterior hip pain onset 1 month ago, exacerbated by sitting or getting up from sitting. It sometimes will radiate down the right hamstring but stops at the right knee. The patient also mentioned that sometimes when attempting to get up at work, his hip will feel stiff or stuck until he gets moving. Ice and movement help temporarily but the pain has stayed a 4/10 on the pain scale and described as dull achy tension. The pain is worse at night but really only after a long day of work.
Exam: Patient has decreased flexion and extension and both cause pain in the low back. Patient is also unable to stand still on left leg for 10 seconds without wobbling or dropping the right foot to stabilize. The right side is showing much more stability. Patient is unable to perform a deep squat due to pain in the area of complaint.
Assessment: Upon history taking, analysis of the exam which include orthopedic testing, palpation, and a few more functional tests, it was determined that the left side deep external rotators have not been optimally performing, leading to right sided compensations. The patient also has difficulty breathing into lower abdomen.
Treatment: Dry needling in order to stimulate blood flow to the injured area as well as to reduce inflammation. Each time a needle is inserted, up to 10,000 cells are damaged. Your brain senses this insult and begins the healing process to regenerate fresh, healthy tissue. Soft tissue therapy using Active Release Technique, an active form of soft tissue therapy that further helps to heal the injury. Manipulation in order to restore joint motion. Rehabilitation, specifically using DNS technique in order to help “re-wire the brain” into achieving stability and correcting faulty movement patterns, as well as coaching on how to have proper work ergonomics, in order to address the root cause.
Treatment was a success! The patient has been pain-free and discharged from care for a few weeks now with no issues day to day.
Case 2: An active runner who partakes in multiple half marathons and also travels often for work
(All aspects summarized for blog-sake)
Patient presents with left lateral hip pain, tender to touch, and sometimes clicks with running. Patient states she just got back from a 4 hour flight for work and the pain feels sharp/stabbing and won’t subside. Treatment has been provided in the past but no lasting relief. The pain will sometimes radiate into the groin and she typically experiences back stiffness, but this is not her primary concern. Patient has had this pain on and off for years. She has a half marathon this weekend so would like relief prior to running as running typically exacerbates the symptoms, not so much during the race but afterward, the patient will feel “sciatica” down the left leg. When asked, the patient pointed to the lateral hamstring/IT band and says that it shoots down this pattern.
Exam: Palpable tenderness into left tensor fascia late, gluteus medius, and deep external rotators. Single leg stance shows lack of lateral stability when standing on right leg. Painful Thomas Test (hip flexion) on the left. Painful FABERE (hip flexion, adbuction, external rotation: on the left. Shallow breathing noted with lack of intra-abdominal pressure.
Assessment: Lack of right sided lateral stability likely causing strain/overuse of left sided stabilizers, leading to pain in the piriformis and other hip musculature. This is a form of functional hip impingement.
Treatment: The same techniques were used as were used in the above case, but modified based off of this patients particular needs and areas of dysfunction. Treatment again was extremely successful. This is also a case where the patient needs more maintenance care as overuse injuries and the strain from travel are a normal part of the patients activities of daily living.
4. How can you treat piriformis syndrome at home?
When “googling” treatment for this type of pain, you will commonly see stretches and/or ice and avoid the exercise.
However, while these option may provide momentary pain relief, they are not solutions that fully address the true problem at hand.
Our recommendation would be to get an assessment from a functional provider to analyze where your body is making compensation patterns that are leading to tissue injury. This way, the rehabilitation that is prescribed is more focused and better pertains to the reason that the injury developed to begin with. This will lead to quicker pain relief and also allow for longevity in the exercise/activity of choice.
Here are some common rehabilitation therapies that we work through together in the clinic in order to give you the tools you need to progress at home. We assess and coach through the movement patterns in each exercise to help re-train your brain to coordinate the appropriate movements.
This will help to loosen the muscles involved to provide palliative relief.
Lying on your back, be sure to maintain contact with your back can the ground at all times. Arching your back leads to erector tension, overactive hip flexors, and can further exacerbate the piriformis pain you are experiencing.
Deadbug can be modified by isolating limb movements in order to build these movements with core stability as your basis.
The goal is to work up to alternating opposite arm/leg movements.
This should be held 30-60 seconds. It can be progressed by first raising the top leg, and holding for 30 seconds.
The final progression would be to straighten the knees and come from the ankles.
Bird dog is a progression from dead bug, as you back is not supported by the ground. Therefore. Gravity makes if more challenging. Your deep external rotators help to prevent your hips from rotating/shifting on movements, which is a key aspect of bird dog.
By engaging the muscles it strengthens the muscles and ends up reducing pain!
5.Banded Monster Walks
Putting a band around your foot also helps recruit the tensor fascia lata in addition to the glutes. Be sure to not allow the knees to cave inward.
This blog was intended to help our audience feel comfort in knowing that Piriformis Syndrome, though can be very painful, is also very treatable!
Piriformis syndrome is inflammation of the piriformis muscle. This muscle is pierced by the sciatic nerve and can lead to burning or sharp symptoms down your leg.
However, surrounding the piriformis are many other muscles that can lead to similar symptoms, or cause referred symptoms. This is why it is vital to receive a functional assessment to determine the root cause and get you back to a pain-free lifestyle.
While at home rehabilitation can be helpful, it is common to need treatment in order to not lead to progression of pain and injury. Dry needling with tens therapy helps heal the tissue and provide pain relief. Soft tissue therapy helps bring blood flow and elongate the tight tissues. Manipulation helps to restore joint motion. Finally, functional rehabilitation is what helps empower the patient to hasten treatment progress as well as to handle any future injury on their own.
Content provided by Dr. Jen Brenneisen
- Papadopoulos EC, Khan SN. Piriformis syndrome and low back pain: a new classification and review of the literature. Orthop Clin North Am. 2004 Jan;35(1):65-71. doi: 10.1016/S0030-5898(03)00105-6. PMID: 15062719.
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