Piriformis Syndrome

12 March 2023

Piriformis Syndrome

Is this muscle causing your buttock and leg pain?

The Piriformis Muscle

The piriformis runs from the sacrum to the greater trochanter (the prominent bone around the outer hip that you can easily feel). It plays an essential role in walking as well as stabilising the hip. When it contracts, it can externally rotate the hip.

The muscle has a close anatomical relationship with the sciatic nerve (see image below).

The Path of the Sciatic Nerve
This image illustrates the different anatomical relationships between piriformis and the sciatic nerve.

In some people, the nerve or part of the nerve may pass through the muscle (B and D). In others, the nerve passes beneath it (A). In some people, the path of the nerve may differ between sides.

As piriformis is so close to the sciatic nerve, problems with this muscle can lead to sciatic nerve irritation.

Piriformis Syndrome
When the piriformis muscle becomes irritated, it can lead to what is called piriformis syndrome. This syndrome is a collection of symptoms and signs, including:

Pain in the buttock
Shooting-like pain, tingling, burning or aching down the back of the leg (sciatica)

These symptoms may be aggravated with sitting as well as movements of the hip.

Piriformis syndrome can arise from:

Falling onto the buttock
Leg length differences
Changes to the spine
Long periods of sitting

Research suggests that the incidence of piriformis syndrome may range from 0.3% to 17.2% among low back pain patients (1, 2). Therefore it is important that the student has been examined by a health professional to rule out other causes.

Location of Pain
In this image, the red circles highlight a point called the greater sciatic notch. Poking around the area may reveal mild to moderate sensitivity. Pain may also be felt along the piriformis muscle belly.

Sensitivity of these points is not confirmation you have piriformis syndrome. However, these areas should not be painful, so it does indicate an issue of some kind. Such issues could arise from the:

Hip
Sacrum
Lumbar Spine

Therapy

The mainstay of movement therapy involves targeting the piriformis muscle. Techniques which help lengthen and relax it in the short term are ideal. In the longer term, strengthening piriformis and other muscles in this region may be required.

In some individuals, even slight movement can irritate the nerve producing strong symptoms in the buttock and down the back of the leg. This can make movement therapy tricky, to begin with. In these cases, starting with chiropractic or massage therapy may be better. The individual can also gently apply oil to the region to help it soften and settle.

Here are some ideas around movement that can help with piriformis.

1. Standing Pidgeon Pose

This is one of my favourite ways to start opening up the piriformis and other deep muscles of the hip.

It does require a little balance and upper body strength, so it may not be suitable for an older individual, for example. However, what I love about this variation is that you don’t need to get down on the floor, which can sometimes be awkward for someone with this syndrome.

💁‍♂️ One of the best ways to help lengthen the piriformis is by placing the hip in flexion and external rotation (as is my front leg in this video).

💁‍♂️ Some techniques bring the buttocks into contact with the ground. That pressure can irritate piriformis and sciatic nerve further. This variation avoids that.

💁‍♂️ It is relatively easy to maintain a neutral spine getting into, holding and getting out of this position. So if there are issues with the lower back, strain can be avoided.

💁‍♂️ Once in position, hold it for around 30 seconds, gently feeling the lengthening around the back of the hip. Repeat 2-3 times.

Making the Posture Active
As symptoms settle, experiment with this:

Hold the pose for 30s.
Without moving, gently press the knee into the chair for 10 seconds
Stop pressing into the chair, relax the hip and then hold the pose for another 30s.
Repeat.

Doing this activates the hip you are working on and will help strengthen it. The other benefit is that after the contraction, it's often possible to get a deeper relaxation of the muscles and lengthen them further.

I say wait until symptoms settle because, in the active phase contraction, the hip muscles may further compress the nerve and increase symptoms.

2. Modified Moving Pidgeon Pose

What I like about this pose is that it asks the hips to move through a large active range. This is great for improving hip mobility, control and muscle tone.

During the main lengthening phase, which should be held for around 30 seconds, you may feel quite a stimulus to the piriformis muscle. Make sure that this feels pleasant and comfortable. If too intense, back off until it does. If you experience pain down the leg along the sciatic nerve, come straight out.

Here are some other thoughts

💁‍♂️ There may be some discomfort around the hip on the side you are working on from its contact with the floor. That can irritate the piriformis further. Instead, try using a really soft pillow under the hips. If this does not help, this pose might not be for you right now.

💁‍♂️ When you raise the trunk back up, pushing off with the front leg helps strengthen the hip. However, if this is too hard or does not feel right, use your hands and arms to do this work in the short term.

💁‍♂️ Really control movement as you transition between sides.

💁‍♂️ Don't practice listening to this crazy music. Observe your body and breath.

3. Hip Aeroplane
The following video is of a movement, sometimes called Hip Aeroplane. This is a fantastic way to explore the hip and helps improve hip stability, endurance, strength and flexibility. It also is great way to improve the piriformis muscle.

The video demonstrates three levels of the pose that progressively challenge balance you can experiment with.

Here are some tips and thoughts:

💁‍♂️ Piriformis is an external hip rotator. But it also becomes a hip ABductor when the hip is flexed. So bending forward, lowering the opposite hip towards the floor, and then raising that side back up can be a great way to challenge controlled lengthening and contraction of the piriformis.

💁‍♂️ If you get groin pain doing this, stop! Have a health practitioner examine you; there may be an issue with the hip joint.

💁‍♂️ This movement is not the starting point if you have a known problem with the hip labrum or degenerative joint changes. Start with more accessible movements; if appropriate, progress to this.

💁‍♂️ Control, Control, Control. Make this all about your ability to move without shaking or jerking - smooth movements. Think quality vs quantity.

💁‍♂️ Vary the angle you bend forward; you will find that it stimulates the hip very differently. You may find a particular angle that challenges you. Work with that.

💁‍♂️ Don’t think the further you bend forward, the better. Explore all angles possible for you.

💁‍♂️ Remember, muscles don’t work alone. We are challenging lots of different muscles at the same. That’s why I love movements like this.

Other Points to Consider When Working with Piriformis Syndrome

💁‍♂️ Any movement or position that reproduces symptoms should be avoided,

💁‍♂️ Avoid sitting in ways that may put pressure on the side involved. And totally avoid sitting on hard surfaces. That includes seated asana in the short term.

💁‍♂️ If possible, sleep on the opposite side, and place a pillow between the knees. This prevents the thigh from going into ADduction, which may irritate things.

💁‍♂️ It can be helpful to maintain a neutral spine when practising as this can protect the spine from strain. Problems here may be contributing to piriformis syndrome.

References
1. Kean Chen C, Nizar AJ. Prevalence of piriformis syndrome in chronic low back pain patients. A clinical diagnosis with modified FAIR test. Pain Pract. 2013 Apr;13(4):276-81. doi: 10.1111/j.1533-2500.2012.00585.x. Epub 2012 Aug 2. PMID: 22863240.

2. Hicks BL, Lam JC, Varacallo M. Piriformis Syndrome. [Updated 2022 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448172/