Piriformis Syndrome

The piriformis muscle is located within buttock region and connects the lower spine to the head of the femur. Sometimes the muscle undergoes spasm or swelling, and compresses the sciatic nerve under it, causing pain in the region, called Piriformis Syndrome.

Anatomy

A pear-shaped muscle, the piriformis muscle is present in the gluteal (hip) region, and originates from the sacral

One of the major nerves of the lower spine and limb, the sciatic nerve, passes under it. In a small proportion of patients, the Sciatic nerve may pass through the piriformis muscle or even above it.

It also lies beneath the gluteus maximus muscle. Its role is to rotate the leg outward when the hip is flexed during walking which is important to prevent a person from falling (Chang et al., 2022).

How Does Piriformis Syndrome Present?

Patients may experience Sciatica like symptoms.

Common symptoms include:

• Burning or shooting pain down the back or outside of the hip and leg

• Numbness and/or tingling in the buttocks

• Dull ache or pain in the hip region

• Pain aggravated on sitting

• Loss of power in the lower legs causing a limp

• Pain at night

• Bowel and bladder incontinence, and groin pain if the pudendal nerve is involved (Roy, 2014)

How does one sit with Piriformis Syndrome?

Piriformis syndrome can worsen due to prolonged sitting and may eventually lead to the person being unable to sit for lengthened periods of time.

Learning how to sit with piriformis syndrome is essential in managing its symptoms, and certain things need to be considered, which include:

• Posture – while sitting, keep shoulders back, feet resting on the ground, avoid raising your knees higher than the level of the hips. Sitting cross-legged can also aggravate the condition (Snijders et al., 2005)

• Support – adding seat cushions, lumbar support, and footrest if needed, can help take the pressure off the piriformis, thus alleviating pain. Ergonomic chairs and desks are specifically designed for this purpose

• Breaks – if sitting is required for longer periods, make sure to take adequate breaks from time to time, and get up and stretch for a bit

How to Sleep with Piriformis Syndrome?

In this condition, sleeping can either be difficult because of the pain, or the pain can be affected by sleep posture.

There are a few ways to try and minimize the chances of this happening.

We have advice and tips on how to sleep with piriformis syndrome.

Some things can be incorporated into your sleeping routine to ease the symptoms:

• Support – making sure to use the mattress and pillows that provide the best support to your back can go a long way, eliminating further risk of Piriformis muscle spasm, and relieving pain.

• Sleep positions – Sleeping on your back, add two pillows under the knees to slightly raise them, and while on the side, place a pillow between your knees. This keeps the muscle relaxed while you sleep.

• Stretch – body stretches before sleeping can help relax the tense piriformis muscle, leading to increase in quality of sleep. The stretch we recommend is lying on your front and stretching outwards with the arms and legs for 30-60 seconds

• Warm bath – before bed, soothes and destresses the muscles

• Heat pad/patch on the muscle at night can also work (practice care when doing this)

What if my Piriformis Syndrome Won’t Go Away

If piriformis syndrome is ignored, or not managed properly, it can become a chronic condition. In mild cases, the person suffering from this issue is usually given some over-the-counter painkillers, including NSAIDs like ibuprofen or naproxen. However, if the pain is not relieved, stronger analgesics, like opioids or muscle relaxants or neuropathic painkillers, may need to be prescribed.

Physical therapy including deep tissue massage, dry needling, and manipulation techniques can be useful in cases where routine activities, such as sitting, or walking are affected. The range of motion improves significantly, leading to better performance overall (Tonley et al., 2010).

Heat therapy can also prove beneficial if piriformis syndrome won’t go away, as it loosens tight muscles and helps relieving nerve compression.

On the other hand, icing can reduce any swelling in the region, promoting healing of the muscle and nerve.

In case of chronic and recurrent pain that significantly affects activity, a painkilling injection in the region containing an anti-inflammatory medicine may be administered, which reduces the symptoms and improves the quality of life (Vij et al., 2021).

When all treatment options have failed and still you still find that your piriformis syndrome won’t go away, an MRI of the lower lumbar or pelvic region may be required to try and see the structure of the muscle and its relation to the nerve, to check any co-existent disc pathology and to assess the sacroiliac region can help greatly

Often with injections and rehab, most cases of Piriformis syndrome to resolve and surgery is advised as a last resort.

Is Walking Good for Piriformis Syndrome?

In this condition, walking can prove to be quite a painful activity, and a lot of patients might start avoiding it altogether because of this reason. However, lack of physical activity can be even more harmful, as the muscles weaken, and the overall power of the midsection and lower legs declines. To help, the patient needs to make some modifications during walking.

• If walking helps with pain – take a few short walks in the week

• If walking increases pain, then to stop and get evaluated by a Doctor. You will need to be rechecked to potentially re-evaluate the diagnosis

• Walking with upright posture is important, walk with your back straight, tuck in your stomach, keep your shoulders back

• Focus on breathing evenly throughout

Is walking good for piriformis syndrome?

If done correctly and gently with the correct posture, walking can be quite beneficial to Piriformis Syndrome. Be guided by pain during and after the walk. If the pain eases or doesn’t increase, walking is safe. On the other hand, if you find walking is causing pain or making your condition worse, it is safer to be re-evaluated as mentioned previously. (Mondal et al., 2017).

Test for Piriformis vs Sciatica

Piriformis syndrome is a condition which causes sciatica, which itself is more commonly caused by a disc herniation.

Often clinicians can find it quite difficult to differentiate Piriformis Syndrome from Sciatica.

So how do we tell if its Piriformis syndrome or Sciatica?

The straight leg raise test (Lasegue’s Maneuver) is performed as a general test for sciatica, but to differentiate in this case, a test for the differentiation of piriformis vs sciatica is required. This can then lead to correct treatment and earlier recovery.

The FAIR test (stretching the muscle by Flexion, Adduction, and Internal Rotation) is performed by having the patient lie on their side, and passively flexing, internally rotating and adducting the hip. The test is positive for piriformis syndrome if this action elicits a pain response (Chen & Nizar, 2012).

Runner’s Piriformis Syndrome

Piriformis syndrome is more common in athletes who run. The muscle rotates the hip, helps to balance weight on one leg, and engages actively during running along with other stabilizers of the hip joint to keep the pelvis in place, every time the foot hits the ground.

In runner’s piriformis syndrome, the muscle is at a greater risk of spasm because of fatigue and overuse. If the symptoms interfere with running, a few changes can be made to prevent their worsening, and long-lasting damage, like:

• Avoid running everyday for long periods or reduce running load

• Running uphill should be stopped while pain is present

• Alternate between heavy and light training weeks

• Ensure that you get adequate amounts of rest

Conclusion

Piriformis syndrome can significantly affect a person’s life, making simple activities like walking and sitting quite painful. However, consulting a doctor when your symptoms start to show, can prevent the condition from worsening, and aid in quicker recovery.

References

1. Chang, C., Jeno, S.H. and Varacallo, M. (2022) Anatomy, Bony Pelvis and Lower Limb, Piriformis Muscle, National Library of Medicine. Available at: https://www.ncbi.nlm.nih.gov/books/NBK519497/ (Accessed: January 28, 2023).
2. Roy, B.A. (2014) Piriformis syndrome : ACSM’s Health & Fitness Journal, ACSM’s Health And Fitness Journal. American College of Sports Medicine. Available at: https://journals.lww.com/acsm-healthfitness/fulltext/2014/07000/piriformis_syndrome.3.aspx# (Accessed: January 29, 2023).
3. Snijders, C.J., Hermansa, P.F.G. and Kleinrensink, G.J. (2005) Functional aspects of cross-legged sitting with special attention to piriformis muscles and sacroiliac joints, Science Direct. Clinical Biomechanics. Available at: https://www.sciencedirect.com/science/article/abs/pii/S0268003305002135 (Accessed: January 29, 2023).
4. Steiner, C. et al. (1987) Piriformis syndrome: Pathogenesis, diagnosis, and treatment, De Gruyter. De Gruyter. Available at: https://www.degruyter.com/document/doi/10.1515/jom-1987-870422/html (Accessed: January 29, 2023).
5. Tonley, J.C. et al. (2010) Treatment of an individual with piriformis syndrome focusing on hip, JOSPT. Journal of Orthopaedic and Sports Physical Therapy. Available at: https://www.jospt.org/doi/full/10.2519/jospt.2010.3108 (Accessed: January 29, 2023).
6. Vij, N. et al. (2021) Surgical and non-surgical treatment options for piriformis syndrome: A literature review, Anesthesiology and pain medicine. U.S. National Library of Medicine. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8241586/#:~:text=and%20functional%20ability.-,Physical%20therapy%2C%20steroid%20injections%2C%20botulinum%20toxin%20injections%2C%20and%20dry,are%20available%20if%20treatment%20fails. (Accessed: January 29, 2023).
7. Mondal, M. et al. (2017) International Journal of Health Sciences and Research, Research Gate. Available at: https://www.researchgate.net/profile/Pravin-Kumar-29/publication/318318389_Prevalence_of_Piriformis_Tightness_in_Healthy_Sedentary_Individuals_A_Cross-Sectional_Study/links/596376b90f7e9b819490651b/Prevalence-of-Piriformis-Tightness-in-Healthy-Sedentary-Individuals-A-Cross-Sectional-Study.pdf (Accessed: January 29, 2023).
8. Chen, C.K. and Nizar, A.J. (2012) Prevalence of Piriformis Syndrome in Chronic Low Back Pain Patients. A Clinical Diagnosis with Modified FAIR Test, Wiley Online Library. Pain Practice. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1533-2500.2012.00585.x (Accessed: January 29, 2023).