Pain in the Butt: Piriformis Syndrome

January 06, 2017 | 35,002 views

By Dr. Mercola
Pain in your buttocks and radiating sciatic pain is sometimes the result of piriformis syndrome, or tightening and irritation of the piriformis muscle.
This is a small, but highly important muscle that runs from your sacrum, passes under the greater sciatic notch and attaches at the top of the greater trochanter at the top of your femur (thigh) bone.
The function of the piriformis is to externally rotate your hip. Piriformis syndrome may be overlooked in a clinical setting as it looks very similar to other pelvic or lower back musculoskeletal conditions, such as lumbar radiculopathy or primary sacral dysfunction.¹
Many times piriformis syndrome responds to a holistic treatment approach, allowing you to prevent further damage to the area without pharmacological treatment. There are actually two types of piriformis syndrome.² In primary piriformis syndrome there is an anatomic cause for the dysfunction, such as a split piriformis muscle.
Secondary piriformis syndrome is more common and is triggered by a precipitating cause, such as an injury or poor postural control. Among those who suffer from piriformis syndrome, less than 15 percent experience pain from primary piriformis syndrome.³

Function of Your Piriformis Muscles

Although small and seemingly insignificant, the piriformis muscle performs important functions in your ability to walk. The muscle enables your leg to externally rotate, or turn out from the hip so your knee is pointing away from your body.
However, the most important function is to provide stability to your sacrum and sacroiliac (SI) joints as you walk and move.⁴
You have two piriformis muscles that extend from the corner of each femur to the sacrum. They are joined together at the sacrum with a band of connective tissue that cradles the sacral bone and adjusts the sacrum as you move. This is the secret to how your body regulates and stabilizes the SI joints as you walk.
Your SI joints must be loose enough to allow the pelvic bones to move as you walk and run, but stable enough to support your spine. They are important for balance and joint stability, and are involved in most movements of your hips and buttocks, which is why dysfunction of the piriformis muscle can be painful and disruptive.
In the majority of individuals, the sciatic nerve will exit inferior to the surface of the piriformis muscle. In as much as 22 percent of the population, the nerve pierces the piriformis muscle, predisposing you to piriformis syndrome.⁵ As the muscle contracts and tightens it irritates the sciatic nerve.
Your sciatic nerve is a thick nerve that passes down the back of the leg and eventually branches off into smaller nerves toward the lower leg and foot. It is the longest nerve in the human body, supplying sensation and strength to the lower leg.⁶
When the sciatic nerve is irritated, it triggers nerve pain from the upper thigh, through the calf and into the foot.
A delay in diagnosis may lead to more permanent conditions of the sciatic nerve or chronic somatic dysfunction. Using compensatory body mechanics, triggered by the pain and muscle weakness, may also lead to muscle and ligament damage to other areas of your lower extremities or lower back.⁷

Body Mechanics That Can Trigger Pain

The exact cause of piriformis syndrome cannot always be identified. Some of the more common reasons include:⁸

Muscle spasms after an irritation to the muscle or an irritation to a nearby structure, such as the SI joint or hip.
Muscle tightening or swelling of the piriformis muscle after an injury to the area, or muscle spasm.
Bleeding in the area of the piriformis muscle that triggers inflammation to the muscle.

Spasms, irritation and tightening may all be triggered by poor body mechanics, placing undue stress on your muscles and the surrounding structure.
Women experience piriformis syndrome more frequently than men as their body mechanics are different, related to a wider quadriceps muscle angle at the hip causing the angle of the joint to be wider.⁹
Positions that keep your leg externally rotated can increase the tightness of the piriformis muscle and increase the likelihood you'll suffer from pain and discomfort.
For example, sitting with one foot under your bottom, lying in bed with your hips externally rotated (knees pointed outward) all night, or sitting at your desk with your legs spread will keep your hips externally rotated.
Standing in hyperlordosis will also place added stress on your lower back and the piriformis muscle.¹⁰ Hyperlordosis is an exaggerated curve to your lumbar spine. In other words, your lower back curves inward more than it should, putting your buttocks out, your abdomen out, placing stress on your lower back.¹¹
Hyperlordosis may be the result of tight muscles around the hip and spine. This causes some muscles to be stretched and weak, and others to be tight and contracted.¹² Muscles that are more commonly affected are:

Tight erector spinae and quadratus lumborum, muscles that are trunk extensors used to stabilize the spine
Weaker rectus abdominus, internal and external oblique muscles, hip extensors, hamstrings and/or gluteus maximus
Tight hip flexor muscles

Vigorous physical activity, such as marathon running, can also tighten the piriformis muscle, causing pain, as can prolonged sitting and/or having one leg slightly longer than the other.

It Begins With a Pain in the Butt

Symptoms of piriformis syndrome are varied, depending upon the source of the problem and the degree of inflammation and/or muscle tightness. The symptoms will often start with pain, tingling or numbness in your buttocks.¹³
The pain may be worse the longer you sit, or may be relieved by sitting and get worse as you stand and stretch the piriformis muscle.
Many sufferers don't suffer discomfort while running but find climbing stairs, squatting and sitting painful.¹⁴ Application of pressure to the center of your buttocks often elicits pain or tenderness.
The pain of piriformis syndrome is centered in your buttocks, while a proximal hamstring strain will trigger non-radiating pain at the bottom of the buttocks where the hamstring connects to the pelvis.¹⁵
If you experience piriformis syndrome you may also have reduced range of motion in your hip joint, specifically external rotation.¹⁶ You may experience weakness in external rotation of your hip muscles as well. You can test this by lying on a bed or table with your outside leg externally rotated and your knee hanging off and below the surface of the bed or table. Try to raise and lower your knee.
If you suffer from piriformis syndrome you may not be able to elevate your knee while in this position. Since the sciatic nerve is anatomically in close proximity to the piriformis muscle, inflammation in the piriformis may irritate the sciatic nerve and trigger neurological pain that radiates down your leg, sometimes as far as your foot.
Sciatic pain symptoms feel better when walking or lying down, but worsen when sitting or standing.¹⁷ Sciatic pain is sharp and searing, rather than dull, and is described as "pins and needles." You may also experience numbness and weakness in this leg. This pain can be debilitating and make it difficult to stand and walk.
Diagnosis of piriformis syndrome is based on a review of your medical history, physical examination and an evaluation of your lifestyle choices that may impact the development of muscle inflammation and spasms, such as vigorous physical activity, sitting habits and prolonged sitting.

Treatment Options

If you have piriformis syndrome, there are several options for treatment. Using a foam roller is an important part of self-treatment. Fitness trainer Jill Rodriguez demonstrates the correct technique in the video above.
Your physician may recommend using anti-inflammatory or pain medication to help alleviate the immediate discomfort. However, natural remedies can also help reduce inflammation, and physical therapy, stretches and changing your body mechanics may help reduce both inflammation and pain without pharmacological intervention.^18,^19,^20,^21,²²

Avoid Poor Body Position

It is important to avoid body positions that trigger contraction and irritation of the piriformis muscle, whether you have the condition or want to prevent it. By keeping your knee pointing forward while sitting, lying down and walking, you'll prevent your hip from externally rotating and therefore reduce the contraction and inflammation of the muscle.

Use Ice and Heat to Reduce Inflammation

By reducing the inflammation to the piriformis muscle, you'll reduce the irritation to the sciatic nerve and therefore nerve pain radiating down your leg. Using ice reduces inflammation to the area and reduces your pain, while heat increases blood supply which speeds healing. Try alternating ice and heat to reduce pain and speed healing.

Chiropractic or Osteopathic Manipulation

Using specific stretches and manipulating your lower back, chiropractors or osteopathic physicians may be able to help reduce the pain while helping to stretch muscles that have become contracted, inflamed and have spasms.

Iontophoresis

This is a simple procedure using mild electrical current to speed healing by improving circulation and providing electrical stimulation to the muscles. Some practitioners may use iontophoresis to deliver medication directly to the injured muscle, but many times just the electrical stimulation is enough to improve your discomfort.

Massage

Physical therapists and massage therapists can work out tight muscle areas in the piriformis and surrounding structures You can achieve similar results at home using a foam roller. Just be mindful of your technique to avoid worsening your condition. For more information, see "5 Foam Rolling Mistakes to Avoid."

Stretching

Stretching the muscles in your lower back help them move more smoothly and work in a coordinated fashion. Active isolated stretches (AIS) promote oxygenation and circulation to the area. Try this rope stretch from Runner's World:²³
Lying on your back with legs extended, wrap the middle of a rope around one foot, holding the ends in your hands. Lock your knee straight and turn your toes inward. Lift your leg straight up using your quadriceps and hip flexors until your leg is at a 90 degree angle to the floor.
Keep slight tension on the rope in one hand while extending your hand on the same side as the extended leg out to your side to stabilize your body and prevent you from rolling. Keeping your leg straight, bring it across your body and straight down to the surface until your hip begins to roll up. Do not pull your leg into position or it may irritate the area.
Bring your leg back to perpendicular to the floor and then back to the first position. Repeat this eight to 10 times on both sides daily.

Maintain Good Posture

Whether sitting, standing or working out, keep your shoulders, back and pelvis in good alignment. Avoid sitting for extended periods while working. Get up at least every 10 to 15 minutes to walk around. Avoid running on canted surfaces (those that place one leg lower than the other) as it places more stress on one side of your body than the other.

Yoga

Certain yoga poses and stretches help to improve your core muscle strength, improve your balance and stretch your lower back muscles.

Exercises

Gluteal bridges and mini-squats are exercises that help strengthen your gluteal muscles and support your piriformis muscles. Start these after you've been pain free for a month. Start slowly with one set of 10 and work up longer sets and repetitions daily.
Side lying clam exercises also help to strengthen your lower back. Lie on one side, and repeat on the other side when finished. Bend both knees and position them facing forward so your feet are in line with your spine. Keep one hip directly over the other and your back straight.
Keeping your ankles together, raise your top knee without moving your back or tilting your pelvis. All movement comes from the hip. Repeat 15 times building to 2 sets of 20.

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