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.
|
Short Piriformis |
Long Piriformis |
| · 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).
Treatment
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.
Pain Management
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.
Stretching
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.
If you are looking for some quality soft tissue tools, I recommend checking out Rogue Fitness. They offer a variety of balls and rollers you can use for this treatment.
Strengthening
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.
Clamshells
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
Bridges
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
Touchdowns
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
Final Thoughts
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,
With
References
- 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.
Big thanks to 3d4Medical and their app Complete Anatomy for the visual of the body today. If you would like to use their app at a discounted price, check out this link: https://store.3d4medical.com/application/user-kind?id=1&promo=uRSj7I7YOr
Hi Aaron
If possible can you do an article on Hamstring tendinopathy, with regard to strengthen the area. I injured it last August, got physio etc.. back training 2/3 weeks but still a lingering strain after squaring when sitting.
Thanks
John
John! Great question – I’ll be sure to write on that topic eventually! Thanks so much for submitting a topic.
This is a great article and I appreciate how in depth you went with diagnosis and treatment. I’m a massage therpaist who works with alot of powerlifters and I know I will put this article to great use!
Thank you very much for this post, it is really helpful for me since I have been over a year suffering from this kind of pain. My question is, if you have a short piriformis you should not do any strengthening exercises at all? Thank you
Thanks for this great article. I now have a plan of action to follow.
[…] nerve). This pain can be caused by a disc bulge in the spine or an entrapment of the nerve by the piriformis much lower at the hip. Pain that is felt traveling down the front side of the thigh is caused by a […]
Wow! Thank you so much for this information. I have been treating my periformis injury as a short periformis and have had no success with pain management. I even took a month off lifting to stretch and work on mobility with the same symptoms to re surface after only 2 weeks back on the barbell. NOW I know I was doing it all wrong. I can’t wait to feel the results once implementing the strengthening techniques given here! Thank You!
You’re so welcome Jordyn! I’m glad to help!
Dr. Horschig,
Thank you for taking the time and energy to educate yourself and extend your knowledge to medically uneducated simpletons like me. I have hope thanks to you.
I’ll report back when I have healed after implementing your routine for enough time.
Seriously, thank you!
[…] Read it here. […]
Thank you for this informative article! I have long piriformis syndrome I believe. Are there cardio exercises I can do that won’t make it worse?
Is there a reason why in your single leg squats you have more trunk flexion than you would with a normal squat?
I have short piriformis, and have been struggling for 3 years. I did pt for 8 weeks, deep tissue and chiropractic. Then saw 2nd dr, more pt, deep tissue, dry needling then was told it was my hip. Had arthroscopic surgery repaired labrum, lengthening It, and had bursitis. More pt and I am still hurting. I believe my piriformis runs thru my sciatic and I can’t get relief. I believe I need surgery but can’t find anyone here in sc. any advice you can give me please.
Hi Carol, I am suffering with it for 20 years but all the doctors did not know what it was! 2 back fusions later I am more mucked up than ever. I finally googled my symptoms and that is what came up and the only exercises that relieved the pain was a Youtube vid by wj Chen. “How I cured my Piriformis Syndrome (sciatica)” If you go to piriformissyndrome.me, it was started by someone who had to have surgery…I am starting the process. Of what I have read in the forum, there are only 4 expert doctors that do this surgery. If you read enough of the forum, you do not want just any doctor to do the surgery! Good luck!
Hey!
I’ve got a little question about using a Lacrosse ball for soft tissue mobilisation. When you put some pressure on your tender area with this ball, wouldn’t it be possible to further irritate the sciatic nerve because of the pressure you apply on the short piriformis
Gwiz you should talk about myofascial chains
[…] Hip Rotation Mobility: See This Blog […]
I’m suffering with a Sharp pain radiating from my right buttock all the way down to my foot. The chiropractor, my primary doctor, acupuntura doctor said is Sciatica. But now I can understand better, it makes more sense, I don’t get better with the streches because I think I have a “long piriformis syndrome”. I live in Miami FL. Dr. Aaron, do you know any specialist or medical center you can recommend me to go in South Florida?
Very god article. Started 3 months ago with a pelvic twist injury. Was in severe pain. physical therapists and some other professionals stretched the living daylights out of it. I kept saying STRENGTHENING seems to only work. I finally have a chiro who gently manipulates the si joints back into place with only drop table and told me to stop all stretching. He is working with me first on glute bridges and modified clam shells and thats it besides TENS to help with pain. I believe I am on the right track now. thanks !!!
Thanks for this helpful article! I have pririformis syndrome secondary to sexual victimization. This is actually not uncommon in female rape victims, I’ve learned – so you are helping more than athletes with this article. Thanks so much for taking the time to help out all of us!!!
excellent article!
I would like to know if TENS (Transcutaneous Electrical Nerve Stimulation units ) can be used safely, to heal.
[…] How to Correctly Treat Piriformis Syndrome […]
Hello Mr. Dr. Aaron. I am Hakan. I am from Turkey and Antalya City. I want to thank in advance for your piriformis information. Unfortunately there arent enough professional people about priformis in Antalya. I red your explanations and i decided ,i have short priformis syndrome. I want to ask you about treatment. Should i only, Pain Management, Stretching and Soft Tissue Mobilization.
But Strengthening, Clamshells, Bridges, Touchdowns are only long priformis syndrome , isnt it ?
Again than you, your explanation and all website..
Hakan Murat YALÇINKAYA
Hey
When I do the banded squat there is a sharp pain close to my buttock. Should I search for an other cause of the pain or do I need to keep doing these ?
Greetings
Thank you Dr. Horschig, I am currently dealing with long piriformis syndrome and doing the strengthening exercises has helped my pain tremendously. I have noticed however that my glute maximus is still not activating when I am squatting or even walking and I am wondering if you have any advice on how to turn it on when the glute bridge is not working?
Dr. Horschig, thank you so much for the clear and detailed information.
I think I’m suffering from reading a great article 💪 thank you and I think I’m dealing with the shirt type… it’s a pain in the arse for certain 🙌
Thank you for bringing this back around. As a student-athlete I my athletic trainer did a lot to work on my piriformis, and I never knew why. This article helped me understand why I was always told to focus on a pelvic tilt in my exercises. Keep up the great work! – Brian @RecoverX
This is a Wonderful article and I appreciate how you went with diagnosis and treatment in a detailed manner. Nowadays all these treatments as well as the studies have become easier with the help of 3d animation.
This is phenomenal! Every single video I have watched on YouTube shows you how to stretch your piriformis which was making my pain worse. But after using these exercises and diagnosing myself with a lengthened piriformis, WOW I have found relief! This article is so well written and very detailed. Thank you so much for the information and for helping the “pain in my butt” lol
Thanks so much. I have this injury right now, so painful.. what a blessing you are..💐
Dear Dr.Aaron,
I had slump test positive on 45°, single raise test positive on 40°, inner left foot rotation 10° and windlass test positive. Few “Dr.” were convinced that is l5 s1 DH, and operation only way out. I was unable to walk, to sit, banding and rotation was impossible without pain. On MRI nothing visible, no sign of discus hernia. At the end was PS. From my experience your few simple tests to check if is herniated disc or PS are completely wrong. This injuries are not joke and superficial approach and disinformation can be very harmful. Please check this article: https://jaoa.org/article.aspx?articleid=2093614 , information in it will be of great use to you.
Br,
Nairolf
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I found this article and began performing the stretches for short piriformis…. In one day from the seated stretches, I have extreme pain in my fibula head today. What is going on and will this get better overnight? I have squats to perform on Friday lol.
very nice article, useful information.
Thank you — great article on the difference between short vs long PS and the correct fix for each! Unfortunately for those of us with more candles on the birthday cake, another factor to take into consideration is hip joint deterioration from osteoarthritis. THAT will cause loss of range of motion / pain, making it difficult for piriformis to move through full range of motion.
How do I know? It has happened to me with both hips. 🙁 As my right hip joint deteriorated (Dx from x-rays and exam by orthopedic doctor after months of conservative but ultimately unsuccessful soft tissue triggerpoint therapy), it has been my experience that internal and external rotation slowly decreased as joint deterioration progressed. After my right hip replacement I regained normal internal / external rotation and range of motion (without hip joint pain, yay) in right hip; now the left hip is going kaput the same way and I’m scheduled for a left hip replacement.
How often you recommend these exercises?
[…] To read the full blog on this topic (including all of the cited research behind the fixes today) check out this link: https://squatuniversity.com/2017/11/21/how-to-correctly-treat-piriformis-syndrome/ […]
I did the test for long vs short piriformis, and this came out: my internal rotation was the same in both legs, but external rotation was much lower in the affected leg. What does this mean?
Are there any exercises that will help me get rid of Short Piriformis? the streching is really helpful but i just cant seem to get rid of it. are the strengthening exercises only applicable for Long Piriformis Sydnrome?
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Thanks so much for all of your knowledge. I listen to your podcasts often and just read this after listening. Need to stop those long hold pigeon stretches I’ve been doing in yoga.Your test shows long piriformis for sure on my painful side. (stretch feels great though…) been doing long sets of single leg squats and think that will be key going forward. Keep sending out the great stuff!
Acupuncture works great for piriformis syndrome, I should know, I am a licensed acupuncturist in the state of Texas and I treat this almost every day in my clinic with great results. I have done hundreds if not thousands of these treatments.
[…] To read the full blog on this topic (including all of the cited research behind the fixes today) check out this link: https://squatuniversity.com/2017/11/21/how-to-correctly-treat-piriformis-syndrome/ […]
I believe I have lower back sciatica after testing for Piriformis Syndrome. Is there any ways to treat that?
Great information. I seem to be one of the few that fall into the short piriformis category. I do lots of strength training and my muscles are always tight. I will definitely incorporate these stretches to see how they affect me. I’m curious why the pain is only felt on one side and not both? Is this due to being out of balance when lifting? Having a dominant side? I did have a lower back injury several mo ths ago and I read piriformis could be a side effect
Thanks again for the information
This was supremely helpful. I’m pretty sure I have the short kind from rollerskating and not stretching and acting like I’m still 15. When I try the internal rotations the pain is felt closer to my inner thigh, but very deep, yet I know my inner thigh muscles aren’t tight ’cause I can stretch those painlessly. It also hurts deep in the glutei and radiates down to the thigh. I’ll be stretching and using that ball. Thank you!
Great article. Thank you for sharing. I thought I’d damaged a disc, but now I’m thinking I have short piriformis syndrome.
Is it safe to have a massage or/and electrical stimulation on the piriformis if it s a long piriformis?
I have piriformis syndrome and my doctor asked me to start therapy and stretching
from what I read now though, I must not stretch that muscle , but is the massage safe?
I am a flexible yogi and suppose that I have overstretched my piriformis, therefore, I have the long syndromes. One question I have it, does it make sense to do the splits on the floor, using the opposite leg ( non inflammatory one ) as the front leg? I feel as if that will even out the symptoms on the affected ( opposite ) side?
I am not a social media person, but someone who has been dealing with a problem from my back since 2016 I started with MRI &PT and was told that my back was very weak and a herniated disc’s, after 4 weeks of therapy twice a week I came out with a pain in my (L) hip that was not there ,I was asked by my doctors what was my goal at that time I was 53 years old and running and kicking soccer balls with my then 6 year old grandson and my goal was to get back to that, to make a very long story short I went to 4 different doctors and a spine specialist 2 MRI’s from 2016 until 2020 therapy session from every one 8 nerve blocks until I actually felt like there was no help for me I am a Strong believer in GOD and through it all I kept my faith but it sometimes got weak , just when I found myself crying and going to bed with covers over my head in a dark room I prayed and had a long talk with God although I was 57 at that time I told Him that I got more years to be here and I didn’t believe that I had to be in this pain I told every doctor that I went to that the pain was in my hip but they kept doing treatments on my back so after praying and asking God to show me and lead me ,I google the anatomy of the body and it was a digital screen and I rotated it around until I spotted this very small muscle and I said this is the pain that I’m having this was a Monday I started those exercises for Piriformis muscle from videos I began to feel better that night and on the video that I was watching said that this is something you need to do 2 or 3 time a day for the rest of your life , I was scheduled to have another nerve block on that Wednesday ,I went on with the block. The key thing was after all of the therapy sessions no one ever told me that to be aggressive with the exercises and the healing would start taking place in about 3 months but the videos did and I am here to let you know that I am 58 years old and back kicking the soccer ball with my 11 year old grandson , riding my bike and now looking forward to my annual traveling out of town to do my 5 & 10k’s again but COVID-19 right now I’m not in a hurry.Every day when I think about how not 1 of those doctors ever mentioned this muscle and I kept saying it’s a pinch in my hip certain ways that I would turn was so painful but I Thank God every day because everything online is not crap. Again thanks for sharing your knowledge 🙏🏽 I truly hope this help someone else.
I’m confused by this statement in your article. It has multiple negatives so it is not clear: “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.”
Can you clarify?
Here’s how I interpreted it, taking out the double negatives “unable” and “without”: If your friend tries to raise your leg to that height and in the process, this recreates your current symptoms in your opposite (bad) leg, its possibly a positive sign for a herniated disc.”