Do you experience pain and even numbness in your buttock after sitting for a long period of time? Do you notice it may be worse if you sit on a hard seat, in tight pants or (gasp!) with your wallet in your back pocket? Do you find yourself adjusting in your seat while on a long flight, at the theater, in your car, or perhaps at work due to your pain? If so, you may have piriformis syndrome. Piri-what? The piriformis muscle (pronounced “peer reformist” without the “T”) is a small, flat long triangular shaped muscle, connecting the “base” of your spine, the sacrum, to your thigh bone. This small muscle, for reasons I’ll briefly explain later, can become inflamed, spasmed, or overused causing compression of the sciatic nerve as it courses beneath it on it’s way from your spine to your leg. Piriformis syndrome (PS) is a type of sciatica characterized by often chronic gluteal tenderness and/or burning pain that may radiate into the back of your leg and as far as your foot. It can be exacerbated by activities that further compress your sciatic nerve by the piriformis muscle such as sitting, running, or even stair climbing.
PS is considered an “extra-spinal” condition, in other words, the sciatic nerve is compressed by a structure outside of the spinal column. It occurs more frequently in women than men with a female-to-male ratio of 6:1, most probably due to the anatomical angle of the female pelvis to femur, or thigh bone. This post is intended to give background information on the condition, some likely causes and a few safe and easy stretches and exercises you can try to relieve your pain. It is not intended to be a substitute for a thorough evaluation by a licensed professional. If you are having pain that is accompanied by changes in bowel and bladder function, loss of control and sensation of your limbs, night pain, and/or sudden weight loss, please seek medical attention!
As mentioned, the piriformis muscles (left and right) is a small, deep gluteal muscle connecting your sacrum to your leg. Your sacrum is that wedge shaped bone at the base of your spine. The sacrum can be likened to the keystone of an arch completed by the right and left ilia (or pelvic bones) via the sacroiliac joints (SIJ). The load coming down through the spinal column is distributed through the 2 sides of this arch down to the ground via your legs and feet and, in turn, the ground force or impact of every step you take travels up to the spine via your legs, hips and ilia, then through your SIJ to your sacrum. A bit complicated but one can appreciate the interdependence of the bits that are ideally stable (joints) and the bits that are ideally mobile and strong (muscles) in keeping the whole system (your body) feeling good!
The piriformis is a rather small muscle, think local stabilizer versus global mover that can help move your leg to the side, to the back, and rotate it so that your toes point outward. When this muscle is shortened, or contracted while your leg is stationary, it, in turn, can “tug” on your sacrum. Now, it’s important to remember that you have a left and right piriformis muscle, so an imbalance in one can impact the other. This is even more important in cases where someone may have some SIJ instability because a “tight” or “loose” piriformis can tug on or allow too much slack for the sacrum and potentially rotate it out of alignment.
SIJ instability is just one example of what may cause PS but the point is that a compromise of the piriformis muscle can compress the sciatic nerve, which exits just below the piriformis muscle. Other possible causes for sciatic nerve compression by the piriformis are inflammation, aberrant biomechanics at the hip, direct compression, microtrauma from overuse, spasm (varying causes including a direct trauma or past surgery, i.e. hip replacement), foot/ankle/knee issues and even pelvic floor muscle issues (yes, too tight or too loose). There is of course, the possibility of an anatomical anomaly of the sciatic nerve exiting through the piriformis, the nerve itself bisected by this muscle and other variations as seen below. Fewer than 16% of PS cases have been found to have an anomaly and the evidence of an unusual anatomical presentation causing PS is low.
Now, as I sometimes say, the “criminal” in this case may or may not be silent but the “victim”, the sciatic nerve, is often crying. It’s no wonder the sciatic nerve is an easy target because it is quite large and therefore easy to squeeze. When I was a student in PT school, I was floored by the size of this nerve bundle! I realized I’d imagined nerves to be like electrical wires; thin and spindly and able to wind and weave through tight spaces. Instead, it was about the thickness of the thumb of the person it inhabited! No wonder it’s susceptible to compression and that just sitting on it for a long time can aggravate it.
We know that some of you may not be interested in nerding out on the anatomy of the piriformis muscle but one can at least appreciate the interplay of the lumbopelvic bony and soft tissue structures. With a few easy stretches and exercises, a little anatomical knowledge, and some awareness of what triggers your symptoms, you may be able to kick your piriformis pain in the butt. If this helps but doesn’t eliminate the issue, it may be worth visiting us at Cynergy Physical Therapy for a full assessment, to help put together the pieces from the larger picture since you now have an appreciation for the role this little muscle plays in the complexity of your body’s posture and movement!
Lay on your back with both knees bent, cross the ankle of the affected leg over the opposite knee. If you don’t feel a stretch in the buttock of the “crossed over” leg, clasp your hands beneath the thigh and hold your legs toward your chest. Hold for 20-30 seconds. Perform on both sides 3x.
Lay on your back with both knees bent and feet resting flat on the floor. There may be a slight and natural arch in your lower back. Inhale through your nose, then exhale through your mouth, as though fogging up a mirror or warming your hands. This will create a slight closure in your throat and build a little pressure intended to promote increased abdominal recruitment. Keeping your knees bent, “march” your legs alternately while stabilizing your pelvis and back. Perform 2 sets of 8-10 repetitions.
Hip flexor stretch
Kneel on a padded surface, with the affected side aligned with your trunk and the opposite knee bent forward with the foot anchored. Gently tilt your hips so that you’re lifted in front, dropping your tailbone slightly behind you. You should feel a moderate stretch in the front of the hip. To increase the stretch, lunge forward slightly. Hold for 20-30 seconds. Perform on both sides 3x.
This muscle is often weak in people suffering from piriformis pain. Strengthening and utilizing the larger gluteal muscles can help reduce the load on the irritated piriformis. Lay on your back with both knees bent and feet resting on the floor about hip width apart. Engage your core in order to brace your pelvis and spine, press evenly through your feet and lift your hips using your buttocks muscles, hold for approximately 3 counts, then lower your hips to the floor. Perform 2 sets of 10 repetitions.
Avoid #1 and try #’s 2 and 3…
Good luck and I hope you kick your pain in the rear!
Emily Gayeski, PT, DPT