Piriformis Syndrome

Piriformis Syndrome

Shooting leg pain, sharp buttock pain, or leg numbness can all be symptoms of a sciatic nerve entrapment at the piriformis muscle.  This is known as piriformis syndrome.  When the muscle is overly spastic, inflamed, injured or otherwise painful, this can affect the nerve underneath it.  Pinching of the nerve there can cause radicular symptoms such as shooting leg pain, numbness or sharp pain in the buttocks or lateral hip.  Pain is typically worse with compression when sitting on it, or bending, but can be aggravated as well in usage such as walking or stairs. If you have ever sat on your wallet, and had your leg go to sleep, you have experienced one part of piriformis syndrome.

Piriformis irritating sciatic nerve

I do feel it’s a little bit like carpal tunnel or migraines, in that it is over diagnosed.  Lots of folks with ‘migraines’ actually just have bad headaches, and the same with carpal tunnel and other causes of wrist pain. Similarly, many who have been told they have piriformis syndrome may actually have greater trochantic bursitis, or a lumbar disc issue. The difference here is that when we are talking about conservative treatments, the piriformis and its neighbors should warrant treatment if they are dysfunctional in any hip or lumbar complaint.  A thorough exam can differentiate.

Symptoms of piriformis syndrome may be acute, as the result of a trauma, or may develop slowly from repeated irritation. Piriformis muscle irritation can result from a strain, a fall onto the buttocks or catching yourself in a “near fall” event. In other instances, the process may begin following repeat microtrauma, like long distance walking, stair climbing or from chronic compression- i.e.sitting on the edge of a hard surface or a wallet.

The Anatomy

The piriformis is a deep hip muscle, and it has gotten more attention than its neighbors. Its known for its proximity to the sciatic nerve, and ability to trigger sciatica.  In fact, in some people the nerve actually passes through the muscle, but I promise that doesn’t matter or increase ones likelihood of symptoms.

The piriformis serves as part of two groups of muscles, the deep hip external rotators and the pelvic floor. The deep hip external rotators, sometimes called the short hip extensors, are almost identical in nature to the shoulders Rotator cuff. They both go from girdle bone to long bone.  While the rotator cuff helps pull the humorous into the socket, the Piriformis and neighbors help pull the femur into socket.  Most of their tension is used to pull the femur into sockets, they create some motion of the long bone in rotation and extension.  Like the shoulder, most motion of the leg is still created with bigger superficial muscles like the gluteals, hip flexors and hamstrings. Also as in rotator cuff injuries and scapular dyskinesia, any dysfunction of this region warrants an assessment of lumbopelvic stability.

Piriformis and deep hip anatomy
Rotator cuff

Pelvic Floor roll

Look at the roll the piriformis plays in pelvic floor. I’ve talked about the necessity of the pelvic floor to be able to be strong as it lengthens (eccentric contraction) when bearing weight or creating intra-abdominal pressure and you can read it here.  Again, the common thread is the ability of the muscle to lengthen under load.

Piriformis pelvic floor

Assessment and Treatment

As a chiropractor with lots of experience in treating lower back injuries, I find the muscle plays its biggest roll in how is helps control hip flexion and rotation. When hip flexion and rotation is limited by a tight piriformis (and its neighboring deep hip external rotators), the lumbar spine has to make up the difference.   The spine and brain can be quick to accommodate a hip mobility dysfunction. In most cases, the injury occurs at the spine; in these true piriformis cases, the injury is local to the hip.

I can’t overstate the importance of the muscle to be able to lengthen under tension during these motions.  If it stays too tight, this pressure can irritate the sciatic nerve, creating the classic piriformis syndrome.  This pseudo-sciatica can look and feel just as bad as a disc causing sciatica.   Testing wise, we would rule out the pain being of spine origin, and be able to recreate the pain with a couple ortho test and palpations (see video).

Relief

Treatment is definitely more than just treating the piriformis. Treating the short hip extensors is something that we might do with literally any condition where hip rotation and flexion needs improving.  Lots of techniques are available, but I don’t think we can really understate just how deep the muscle is.  On a guy my size, it’s femoral attachment is very easy palpated, but the belly of the muscle is easily 10cm from the surface.  If you’re getting massage or myofascial release on it, it might feel good, but it’s probably not affecting the belly of the muscle.

If you want to treat the belly of the muscle with manual techniques, I do think that the only way is with dry needling.  This sort of treatment is often used in my office, but its not for everyone or every case.

Nerve flossing techniques can help decrease nerve irritation and are typically used and taught.  Manipulation can be used and is helpful, but the results will be short lived if we do not load it to retain the benefits, and then reinforce it.  I find DNS based exercises as the absolute best intervention for piriformis issues.  These focus on training the muscle the way it moves in life; as part of the pelvic floor and lengthening under tension.  Again teaching the patient how to perform these is vital for lasting relief.  I use ChiroUp to send information and home exercise videos, it’s great.

DNS

Summary

Piriformis syndrome is real, but over diagnosed. When present, the muscle is spastic and too tight, causing irritation of the sciatic nerve.  Nerve mobilizations can help ‘cool off’ the nerve. Treating the muscle is appropriate  in many back and lower extremity conditions, including piriformis syndrome. Dry needling is the most effective manual technique.  DNS training is the most effective exercise for it. Teaching the patient how to manage is vital, and this includes figuring out what the irritation stems from activity wise, so that it can be modulated or trained better for.

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