Piriformis Syndrome: A Pain in the Butt

“I keep getting that deeeeeep pain in the rear!” my client says.  “I can’t seem to stretch where it hurts.”

Can you relate? But what is it?

Your butt? Sciatica? Or something else?

The most common culprit is piriformis syndrome.

The piriformis is a small, pizza-slice-shaped muscle that lies deep under the gluteus maximus and controls external rotation of the hip and stabilization of the pelvis.

It can be a real pain in the butt.

It can cause symptoms like pain, numbness, burning, and tingling (which could extend all the way from the hip to the toes).

Many of the people I see with this pain, have been told by their doctor (or Dr. Google) that they have sciatica, when it's often piriformis syndrome. 

Both the pinching of the sciatic nerve by vertebrae in the spine (sciatica) or the compression of the sciatic nerve by a tight piriformis muscle in the butt (piriformis syndrome) can cause pain to radiate up into the back or down the leg. As a result, most people--even doctors--associate it with sciatica. Symptoms can overlap, and medically it may be kind of a ‘same difference’ situation, but it does matter in regard to massage treatment.

The major difference between sciatica or piriformis syndrome is where the compression occurs.

Sciatica is pain resulting from compression of the nerve at the lumbar vertebrae in the spine. This can be caused by spinal rotation, vertebral disc compression or asymmetrical pelvic rotation and usually, but not always, sends pain, tingling and numbness down the entire length of the leg. In many cases of sciatica, there will also be pain in the buttocks.

Piriformis syndrome is caused when the piriformis muscle, which lies on top of the sciatic nerve, gets too tight and spasms, causing it to compress the sciatic nerve, like a kink in a garden hose. Pain is often centered in the middle of the butt (glutes) and can be tender to the touch and/or painful when sitting. In some cases, the spasm will occur in the glute.

What causes the piriformis to tighten up?

Excessive amounts of sitting - This can cause the piriformis to stretch and compress the sciatic nerve. Also, it can cause pelvic instability because the glutes, piriformis and other muscles become underactive. This can lead to the muscle going into spasm when asked to suddenly perform a strenuous activity such as running. You're asking it to perform under stress (running) when it's not prepared to. Kind of like a pop-quiz.

Excessive internal rotation of the femur - When your foot turns in like a pigeon this is internal rotation, and it causes the piriformis to lengthen. The piriformis is an EX-ternal hip rotator, so excessive internal rotation will cause it to lengthen too much and over time become overactive trying to hold that lengthened position. This often leads to trigger points and overly tight (hypertonic) muscle fibers.

Poor pelvic floor/core control - Having a strong pelvic floor and core stability is not necessarily having 6-pack abs. If you're a runner or dancer, core stability is a must to reduce the risk of many types of athletic injuries. A weak core causes other muscle groups to pick up the slack, which causes them to work harder and will eventually lead to fatigue and overactivity. 

Additionally, piriformis dysfunction also often results in tight inner thigh muscles (adductors).

Your physician or physical therapist should be able to assess and differentiate between true sciatica and piriformis syndrome and give you an official diagnosis. As a massage therapist, I can’t diagnose, but we can work together to solve the issue regardless of an official diagnosis. 

Treating Piriformis Syndrome - Luckily, piriformis syndrome is relatively easy to treat, in most cases. Here are 4 simple and effective ways you can get rid of piriformis syndrome.

Ice - sitting on a bag of frozen peas can help to reduce inflammation and swelling, which in turn can take some pressure off the nerve. Just remember not to overdo it. Inflammation is your body's way of healing, so a little inflammation is a good thing.

Stretching - One of my favorite yoga stretches for the piriformis is pigeon pose (modify to suit your body's ability; don't try to go any deeper than you can tolerate). This effective pose will target not only the piriformis, but the glutes and deep hip rotators. However, if your piriformis is tight because of too much internal rotation, it’s far better to stretch the inner thigh (adductors) to take some stress off the piriformis.

Foam rolling - Using a foam roller, ball, or other tools to target trigger points of the muscle or relieve stress on the attachment points at the sacrum or the top of the thigh bone (greater trochanter of the femur) can help relieve pressure on the nerve as well.

Be sure to use the correct tool for rolling. I often have clients use lacrosse balls, which is a very hard tool. However, more pressure is not always better. "No pain, no gain" is the wrong motto here. A tennis ball might be more appropriate, especially at first. 

Like massage, you need to work within your body's pain tolerance level and work with your nervous system. You also only need 30-60 seconds of sustained pressure to get relief. More or longer pressure can make an already irritated muscle worse and can cause issues up to and including nerve damage. Meet your body where it's at.

One more thing: you also want to be careful not to accidentally compress the nerve yourself.
If you're unsure of how to use a tool, just ask, I'll be more than happy to give you a demonstration.

Massage - If stretching and foam rolling isn’t enough or you just don't want to do the DIY method, it might be time to see a professional. A licensed or certified massage therapist has the dexterity and training to get into areas a foam roller cannot or help stretch you in ways you may not be able to do alone.
If you're ready to take that step, you can book your next appointment here.

Once the soft tissue dysfunction is removed, strengthening the glutes, core, and hip flexors is recommended for lasting results. A corrective exercise specialist, personal trainer, or physical therapist may be able to help with specific exercises to strengthen weak muscles to keep the problem from returning. ​