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  • Writer's pictureDaniel Selin

Piriformis syndrome

Piriformis, buttocks, buttock pain, stretching, radiating pain, hamstring pain, hip pain, self-care, strengthening exercises, manual therapy, Helsinki, OMT physiotherapy

The hallmark signs of piriformis syndrome include pain in the buttock and hip area, which occasionally radiates down the back of the thigh. The pain is often dull and disruptive, and numbness or tingling may also be present in the affected area. Piriformis syndrome occurs when the deep external rotators of the hip, often the piriformis muscle, exert mechanical pressure on the branches of the sciatic nerve, irritating it.


Piriformis syndrome can be broadly divided into two categories: primary and secondary piriformis syndrome.


Primary piriformis syndrome is caused by abnormal anatomy, resulting in a divided piriformis muscle or a deviation from the normal course of the sciatic nerve.

In the image above, variations in the relationship between the sciatic nerve and the piriformis muscle can be seen:


A) The sciatic nerve passes below the piriformis muscle, which is the so-called normal variant.

B) The sciatic nerve is divided, with one branch passing normally below the piriformis muscle and the other passing through it.

C) The sciatic nerve is divided, with one branch passing above the piriformis muscle and the other passing below it.

D) The sciatic nerve passes through the piriformis muscle.

E) The sciatic nerve passes above the piriformis muscle.


However, variations in the relationship between the sciatic nerve and the piriformis muscle are relatively rare and do not necessarily cause symptoms on their own. Less than 15% of piriformis syndrome cases appear to be due to anatomical abnormalities.


Secondary Piriformis syndrome occurs when pain is triggered by an external factor that alters the muscle function in the buttock area, causing increased pressure or load on the sciatic nerve. This can happen thru a single macrotrauma, such as a fall or blow, or multiple microtraumas that lead to macroscopic tissue changes over time. Also ischemic changes in the muscles can lead to Piriformis syndrome.

However, the most typical cause is a single macrotrauma that explains the onset of the symptoms. In this case, the trauma to causes inflammation of the soft tissues and an increase in muscle tone, which together compress the sciatic nerve trunk. The macrotrauma may have resulted from a direct injury or may be due to postoperative inflammation or injury. The underlying cause of the symptoms may also be biomechanical challenges in the pelvic or low back area.

Common causes of Piriformis syndrome include:

  • Injury to the buttock area, such as a fall or blow

  • Lower back and pelvic problems that cause the piriformis muscle to tighten as part of a protective mechanism

  • Dysfunction of the gluteal muscles, resulting in increased load on the Piriformis muscle

  • Repetitive overloading or not recovering from load

  • Walking-related challenges that transfer the load to the Piriformis muscle

  • Hip surgery

  • Excessive training

  • Foot-related challenges that alter the function of the lower limbs

  • Abnormal anatomical relationship between the sciatic nerve and the Piriformis muscle.

 

Symptoms

The symptomatology of Piriformis syndrome is often diverse. Typical symptoms include a dull and continuous pain felt in the buttock of the affected side, a numbness or tingling sensations in the pelvic region and possibly a radiating pain in the leg.

Pain worsens with prolonged sitting or standing, and situations where there is an increased strain or stretch on the Piriformis muscle. Pain often subsides during walking or in positions where there is no stretch or strain of the Piriformis muscle.

Piriformis syndrome is often confused with sciatica, as their clinical symptoms are very similar. However, Piriformis syndrome does not cause neurological deficits such as weakened reflexes, changes in muscle function and strength, or altered sensation of the skin. If you have obvious weakness in your lower limbs or changes in the sensation of your feet, it is more likely that you are experiencing a disc-related irritation of the sciatic nerve rather than that caused by the Piriformis muscle.

Typical symptoms of Piriformis syndrome include:

  • Pain, tingling, or numbness in the lower back or buttock, which radiates down the leg

  • Sharp or dull, intense, radiating pain

  • Difficulty sitting or putting weight on the affected side

  • Tension and sensitivity of the Piriformis muscles

  • Ischialgia-type of pain upon standing up or during external rotation of the hip

  • Pain is often triggered by climbing stairs, running, prolonged sitting, or increased pressure on the Piriformis muscle.

 

Treatment

The primary treatment for Piriformis syndrome is conservative, combining pharmacological and non-pharmacological pain management methods with a graduated exercise program developed by a physiotherapist. The exercise program aims to improve the biomechanical properties of the lower limb and reduce excessive loading or stretching of the gluteal area.


The goal of treatment is to reduce pain and improve function. This is achieved through a precise, graduated, and personalized exercise program, which may include mobility-enhancing exercises, strength training as well as manual therapy.


Commonly used medications for pain relief include a combination of anti-inflammatory and muscle relaxant drugs. If the pain is severe, medications suitable for neuropathic pain or local anesthetics may be considered.


Surgical intervention should be considered only when conservative treatment (e.g., physiotherapy) fails to achieve the desired results or when the patient experiences severe pain that impairs functionality.

 

Physical therapy

Physical therapy begins with a thorough assessment of the underlying factors, based on which an individualized rehabilitation program can be created. It is necessary to distinguish the underlying factors and determine which factors have contributed to the onset of the pain.

Based on the precise evaluation, a treatment plan is developed, tailored to the individual findings, with the goal of reducing the increased load and tension on the Piriformis muscle as well as improving functionality.


Physical therapy is always designed individually and often includes a combination of the following methods:

  • Manual therapy: soft tissue manipulation and joint mobilization to reduce muscle tension and possible spasms, as well as increase circulation and mobility.

  • Strengthening exercises: this improves pelvic stability and reduces loading peaks on the Piriformis muscle.

  • Pain management: heat and cold therapy, manual therapy or acupuncture.

  • Biomechanical assessment and treatment.

  • Myofascial release: promotes gliding and mobility of the fascial tissue and improves fluid circulation in the Piriformis and surrounding muscles.

  • Mobility exercises: improves overall mobility and reduces increased loading on any individual muscle or muscle group.

A combination of manual therapy and home exercise programs has been shown to produce good results in the treatment of Piriformis syndrome as long as there is an individualized treatment plan.

 

Self care

  1. Move regularly: Exercise can help reduce Piriformis syndrome symptoms and improve muscle function. Recommended forms of exercise include walking, cycling, swimming, and water aerobics. Strengthening exercises are also advisable, however, these should be started cautiously, gradually increasing the load over time. Overly strenuous exercise often increases tension and symptoms.

  2. Avoid prolonged standing or sitting: Prolonged standing or sitting worsens symptoms and increases static tension in the muscles. Take a break from sitting every 20 minutes.

  3. Use cold: Cold therapy can help alleviate pain and potential inflammation. You can use ice, a cold pack, or cold gel.

  4. Try heat: Heat therapy relaxes muscles and reduces the pressure on nerve tissue caused by tense muscles. You can use a heat pack or heat gel.

  5. Stretch regularly: Dynamic and light stretches of the hamstrings and glutes can promote blood circulation and increase mobility. However, avoid intense and prolonged stretches as these often increase tension in the area.

  6. Use a massage ball or foam roller to treat the Piriformis muscle and surrounding tissues. It's a good idea to continue the treatment until the pain caused by the treatment is reduced by about half compared to the initial state. The treatment can be repeated 1-2 times a week.

  7. Try an ergonomic chair or a cushion under the buttocks to reduce pressure on the Piriformis muscle.

  8. Ensure adequate rest: Sufficient sleep and rest help the body recover and can help alleviate Piriformis syndrome symptoms.

  9. Consult a physiotherapist: If your pain persists despite self-care measures or interferes with your daily activities, consult a physiotherapist.

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