Pain in the…piriformis.

What is piriformis syndrome?
Simply put, piriformis syndrome is a pain in the butt; deep to the gluteal muscles.

Piriformis syndrome is a muscle spasm, tightness, contraction or adhesion-related frictional irritation occasionally resulting in sciatic nerve impingement. These scenarios can cause pain deep in the buttocks and/or radiating or referring pain down the back of your leg.
Typically, the piriformis muscle contracts to rotate the leg outwards (externally) as well as stabilize the hip. In a runner, this can help stabilize and resist excessive inward collapse and rotation of the leg and knee.

Who most commonly gets piriformis syndrome?
It is very common in endurance athletes, particularly runners, but can be implicated with too much sitting, in sport that sit (cycling, rowing etc.) or sitting at rest, especially on extra soft or hard surfaces.

What are the common causes of piriformis syndrome?
Causes can be various and individual but the primary cause is typically overuse due to a compensation for underuse of other hip and gluteal muscles and/or tightness of the inner leg (adductor and hamstring) muscles putting extra load on the piriformis muscle. Also, compressive irritation can also be implicated as mentioned above with sitting. Biomechanics or running technique corrections or ‘tweaks’ can also assist the recovery process.

How do you diagnose piriformis syndrome?
Piriformis syndrome be often confused with a disc bulge, lower back and spinal pathology, or hamstring strain/tendinopathy. For Diagnosis, a good history, which may reveal a new activity or overuse of the area, is important in diagnosis followed by active and passive range of motion testing, palpation and orthopaedic tests of the lower back, leg and hip to see what might reproduce the symptoms/signs or contribute to the injury.

How do you treat piriformis syndrome?
There are various treatment approaches depending on severity, including passive treatment such as Active Release Techniques or Myofascial release, needling, adjusting the hip or spine, stretching (hip and adductor muscles), and foam rolling.
Also, active therapy following or concurrent to passive therapy to ‘activate’ or strengthen the hip stability muscles is important to assist with the more passive treatments. Some time off or a subtle change in biomechanics (running technique) can also reduce the injury specific pain and reduce the load on the piriformis.
A modification or reduction of the running schedule followed by a gradual return to running is often required as soon as symptoms develop. Very rarely in an injection or surgery is necessary.

How do you prevent piriformis syndrome?
For prevention, it is important to take ‘down weeks’ or replace normal training with occasional cross training in order to let areas that are building tension or frictional irritation heal even before symptoms develop. In general, a very gradual increase in running/training as well as strengthening, particularly of the legs with an emphasis on the glutes, quads, hamstring and calf muscles are helpful in prevention.
Occasionally, biomechanics of running, such as increasing cadence, landing more softly, and landing under the hip, running with a slightly wider stance have been shown in the research to modify pain and change tissue load long enough to aid in the recovery process or piriformis and other running injuries. Although the research is poor, preventative stretching and foam rolling may be helpful for some.