Welcome back to Squat University! For the past few weeks we’ve been discussing a range of injuries that can take place around the hip. Now that we’ve wrapped up our discussion on groin pain, it’s time to move on to the piriformis syndrome!
Piriformis syndrome is an injury that creates pain deep in the glutes and possible radiating symptoms down the back of your thigh.1 Although we’ve known about this injury for decades (with research dating back to 1928), the exact cause and best course of treatment has continued to puzzle those in the medical field.2
So what is the piriformis muscle?
The piriformis is a small muscle that lies deep inside your hips underneath your larger glute muscles (glute max and medius). The muscle is essentially a lateral hip rotator, but it can also act to help extend the leg and keep it from collapsing inwards during movements like the squat. It can also function as a portion of your pelvic floor, help stabilize your pelvis, and assists in controlling for anterior pelvic tilt.3
The injury that is considered piriformis syndrome occurs when this muscle compresses or irritates the large nerve that runs around (and even sometimes through it 12% of the time) called the sciatic nerve.8 This nerve runs from the low back (lumbar spine), down your thigh and even extends to your feet. When irritated, it can cause pain deep in your glutes as well as symptoms like numbness and tingling that shoot down the backside of your leg.
So how do we fix it?
The first thing we need to do is figure out if the cause of the pain is coming from the piriformis or the low back. Like I mentioned, the sciatic nerve originates from the lower sections of your spine, meaning the cause of your pain could be due to an injury such as a herniated disc! Piriformis syndrome is therefore a form of sciatica (injury to the sciatic nerve) and distinguishing it from a back injury is the key to successful treatment of your symptoms.
Piriformis Syndrome vs Low Back Sciatica
So how do you know if your symptoms are due to a problem with your piriformis muscle or your low back? Here are a few simple tests.
First, start by moving your low back and see if it reproduces your symptoms. Bend forward and try to touch your toes. Lean backwards, side to side and rotate as far as possible to the right and left. If the piriformis muscle is to blame for your current symptoms, none of these motions should recreate pain.
Next, the Crossed Straight Leg Test can help determine if the pain you have is possibly due to a disc herniation in your low back. Lay on your back with your legs completely straight. If you have pain that radiates down your right leg, have a friend raise your left leg as high as possible without the knee bending. Most people should be able to raise their leg to close to 90° before feeling a good stretch in their hamstrings. However, if your friend is unable to raise your leg to that height without recreating your current symptoms in your opposite leg, it’s a positive sign for a possible herniated disc.4 If you only feel a stretch sensation, this would indicate a negative finding. For the test to be positive, the nerve-like pain must be reproduced.
So if we don’t think the low back is the cause of your current symptoms, we can start to focus our attention on the piriformis muscle. This is where things get a little tricky.
Short vs Long Piriformis Syndrome
Historically the piriformis syndrome was through to be only caused by a muscle spasm or excessively tight piriformis muscle.3 When short or in spasm, the piriformis muscle can compress the sciatic nerve creating pain and radiating symptoms down the leg. However, a number of experts today now believe this injury can also be caused when the piriformis is excessively stretched or elongated.5,6
With a lengthened piriformis, repetitive movements of the hip (such as knee collapse when squatting or lifting with an excessive anterior pelvic tilt) can strain the muscle and cause friction on the nearby sciatic nerve, resulting in inflammation and pain.1
Therefore, we actually have two possible causes of piriformis syndrome (long or short piriformis) that will require two drastically different treatments to fix! The difficult part is then distinguishing between the two, as there are a number of similar symptoms. Let’s talk about how to differentiate between the two.
|· Glute pain with or without radiating pain down the posterior thigh
· Pain often increases with prolonged sitting
· Limited medial or internal rotation on affected hip
· Painful when pressing deep into glute
· Responds well to stretching & soft tissue mobilization
· Strengthening in a shortened position can recreate symptoms
|· Glute pain with or without radiating pain down the posterior thigh
· Pain often decreases with sitting
· Excessive medial or internal rotation on affected hip
· Painful when pressing deep into glute
· Responds well to strengthening & movement re-education
· Associated with poor movement (knee collapse &/or anterior pelvic tilt).
Testing for Hip Rotation
One of the easiest ways to differentiate between short versus long piriformis syndrome is to evaluate the amount of rotation someone has at their hip. Start by lying on your back. Have a friend grab your leg, bend your knee and lift your thigh to a 60° angle from the bed.
From this position we can rotate the lower leg away from the midline of the body to assess the amount of medial or internal rotation you have. Perform the same movement on both legs.
If someone has short piriformis syndrome, they will show less medial rotation on their painful side compared to their opposite leg. At this position of the thigh (around 60° of hip elevation) the piriformis performs the movement of lateral rotation. If it is short or in spasm, a short piriformis won’t allow the leg to move medially.
If you have long piriformis syndrome, you will often show excessive medial rotation on your painful side compared to your opposite leg with the same test. This is because your piriformis has become lengthened and elongated due to the excessive strain placed on it while you move (usually allowing your knee to cave in during squatting).
Like I mentioned earlier, your treatment for this injury will be dictated based on whether you have short or long piriformis syndrome. Let’s now go through a few categories of common treatments.
Regardless of the muscle length, most people can achieve short-term relief of their symptoms if they sit with their legs crossed at the ankles.3 In this position, tension is taken off the piriformis muscle that would otherwise create irritation/compression on the sciatic nerve. If you sit all day, this can be a great first step to dealing with this injury.
In the past, one of the most common treatments for piriformis syndrome was to stretch the muscle. However, we now know this treatment shouldn’t be used with everyone! Stretching the piriformis should only be performed when you have short piriformis syndrome. If you try to stretch a muscle that is already lengthened, it will only contribute to the injury and make things worse!
The Figure 4 stretch is an easy to perform treatment for anyone with short piriformis syndrome. Start by lying on your back with your knees bent. Cross the ankle of your affected leg over your opposite thigh. From this position, grab your pain free thigh and pull it towards your chest until a stretch is felt deep in your hip.
Because of how the piriformis is aligned in your hips, it becomes a medial rotator when the hip is flexed past 90°. This is why this stretch is able to help elongate the muscle when your hip is in a laterally rotated position close to your chest.
You can also perform this stretch while seated. Cross your legs by placing the ankle of your painful leg on your opposite thigh. With your back flat, lean your chest forward until a stretch is felt deep in your hip.
Recommended sets/reps: 3 sets of 30-second stretch
Soft Tissue Mobilization
Another treatment that works wonders for those with short piriformis syndrome is deep tissue massage or mobilization. Sustained pressure to this short or spasmed muscle can help it relax and decrease its tension on the sciatic nerve.
Grab a lacrosse or tennis ball and lay on the ground. Cross your legs to help expose the piriformis muscle. Place the ball in the middle of your glute max muscle and roll slowly on it until you find a painful spot. When you find a tender area, sit on it for a minute before rolling off. If this treatment is right for your body, you should notice some decrease in symptoms after standing back up.
Because most cases of piriformis syndrome are now believed to be due to a lengthened muscle associated with poor movement (knee collapse and/or anterior pelvic tilt) we can assume a large majority of athletes who train and compete in barbell sports will fall into this category. If this is you, stretching and deep tissue work won’t have much of an impact and could make your symptoms worse. Instead, strengthening the glutes and fixing your poor movement and posture will be the key to successfully treating long piriformis syndrome.
The clamshell exercise helps strengthen the lateral hip rotators to limit excessive knee collapse or medial rotation during movement.
Step 1: Start by laying on your side with your knees bent to 90° and hips bent to 45°. Place a small resistance band around your knees.
Step 2: Rotate your hip by raising your knee (like a clamshell opening). Hold this position for a second or two before relaxing down. Make sure to not raise your leg too high, as it will cause your lower back and pelvis to rotate as well.
We can also perform this exercise to a standing position in order have more functional carryover to our weight training movements.
Step 1: Stand in your squat stance with the small resistance band around your knees. Perform a small squat descent and hold this position.
Step 2: Drive both knees out against the band resistance. Hold this position for a second or two before relaxing back into the starting position. Make sure to keep your feet firmly planted into the ground during this movement (don’t let your foot roll on it’s side!)
Recommended sets/reps: 2 sets of 20 repetitions
Research has shown that strengthening the glute max is a key component to treating long piriformis syndrome.7
Step 1: Lay on your back with your knees bent and a resistance band around them.
Step 2: Drive your heels into the floor, brace your core and then lift your butt off the ground.
Step 3: In this elevated position, make sure your knees are pushed wide against the band resistance and you are squeezing your glute muscles as hard as you can. Hold this position for 5-10 seconds before coming back down. You should be feeling your glutes and upper hamstrings working hard in this position. If you are feeling your low back working hard, focus on bracing your core like someone is going to punch you in the stomach before lifting your hips from the bed (this will be common for someone who shows the postural problem of anterior pelvic tilt). If you are only feeling your hamstrings, drive your heels into the ground more and think about squeezing your glutes.
Recommended sets/reps: 2 sets of 20 repetitions for 5-10 second holds
If you want to increase the difficulty of this exercise, you can perform this movement with your back on a bench and a barbell across your hips (aka a hip thruster).
Recommended sets/reps: 3 sets of 10 repetitions for a 5 second hold
Eventually we need to transform our glute strengthening into a functional activity in order to find lasting results. The goal is to eventually perform this single leg squat from a box height of at least 12 inches without your knee collapsing inwards. If you can’t perform this squat with good quality on a small box, you have to stay on that height before moving up.
Step 1: Find a small box (or stack of weights), around 4 inches in height. Stand on the box with one leg hanging off the side. Before any movement occurs, brace your core and make sure your pelvis is in a neutral position (no anterior pelvic tilt).
Step 2: Without your pelvis tipping forward, drive your hips back and lean your chest forward. Squat down until you can gently tap the heel of your free leg. Your knee should be in line with your stance foot the entire squatting motion. If you don’t feel your glutes working hard, over emphasize the hip hinge (push your hips back further and incline your chest). After 20 reps your glutes will be burning if you’re doing these right.
Recommended sets/reps: 2 sets of 20 reps
Piriformis syndrome is a tricky diagnosis as the treatment plan can drastically change due to the position of the piriformis muscle (long vs short). I hope this article was able to give you a better understanding for how to tell the difference between the two so that you can make the best decision on how to start fixing your symptoms.
If your symptoms do not respond to any of the above mentioned treatments, or become worse, I recommend going to see a medical practitioner (doctor, physical therapist, etc.) to assist in your recovery.
Until next time,
- Hall, CM & Brody LT. Therapeutic exercise: moving toward function (2nd). Lippincott Williams & Wilkins, Philadelphia, 2005.
- Michel F, Decavel P, Toussirot E, et al. The piriformis muscle syndrome: an exploration of anatomical context, pathophysiological hypotheses and diagnostic criteria. Ann Phys Rehabil Med. 2013 May;56(4):300-11
- Hertling D & Randolph MK. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. Philadelphia: J.B. Lippincott, 1996. Print.
- Hudgins WR. The crossed straight leg raising test: a diagnostic sign of herniated disc. J Occup Med. 1979;21(6):707-8
- Kendall FP, McCreary EK, Provance PG. Muscles Testing and Function. 4th Baltimore: Williams & Wilkins. 1993
- Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis: Mosby. 2002
- Tonley JC, Yun SM, Kochevar RJ, et al. Treatment of an individual with piriformis syndrome focusing on hip muscle strengthening and movement reeducation: a case report. JOSPT. 2010; 40(2):103-11
- Magee, DJ. Orthopedic Physical Assessment. Philadelphia :Saunders, 2002. Print.