Piriformis Syndrome…A Pain In The Butt!

Piriformis Syndrome might be the most glorified treatment of massage therapy that exists. You seem to hear about it being the culprit for all butt pain and if treated with massage, your days of suffering will be gone forever.  I do agree with the fact that massage therapy is an effective tool for combating sciatic pain. However, before we go anointing massage as the absolute cure for sciatica, we should know what it is, and how it comes to be such a pain in the butt…pun intended (my sense of humor is nosediving).

Figure 1. Photo Credit: Blausen.com

The first fact that we need to establish is “sciatica” and piriformis syndrome are not the same thing. Piriformis syndrome can cause “sciatica” like symptoms, but it is not what causes the medical definition of sciatica…which isn’t a thing. The actual medical term for sciatica is a lumbar radiculopathy which is itself only a symptom of any sort of nerve compression in the lumbar spine. In other words, a nerve compression in the lumbar spine causes a radiculopathy (nerve pain) when some sort of disc or spinal condition causes nerve pressure. This causes symptoms like pain, tingling, and numbness in the gluteal, posterior leg and foot. These symptoms are commonly referred to as sciatica.

Piriformis syndrome is an actual condition involving the interaction of the piriformis muscle and the sciatic nerve. It is defined by some as a “peripheral neuritis” which is a fancy way of saying that the piriformis muscle causes irritation to the sciatic nerve.  Per its definition, it has no relation to any sort of spinal condition and should be distinguished as so.

This is an important fact to know because it completely changes how we apply treatment to a client. If the sciatic pain which our client was experiencing was due to some sort of lumbar spine condition, we would treat it as so. We may focus a bit on the piriformis for symptom relief and hip mobility, but it certainly would not be our main focus. Our main efforts would be geared toward creating proper function in the lumbar spine and decompression of the discs, not releasing the piriformis muscle.

(You can read more about massage for disc injuries here)

So how does the piriformis affect the sciatic nerve?

Figure 2. Piriformis and Sciatic Nerve Interaction

To figure this out, we must know a couple things about the sciatic nerve. First, know that the sciatic nerve is enormous. It is the biggest nerve in the body at about the size of your thumb. That’s nice for us because it is fairly easy to palpate. This allows us to identify where the interaction between the sciatic nerve and the piriformis actually is. We need to know this so we can be hyper-specific when treating with massage. Second, like other nerves in the body, the sciatic nerve has the engineered ability to move and glide as our leg and foot move. This ability allows for flexibility and movement without hampering functionality.  This principle is extremely relevant to piriformis syndrome and its treatment.

As the hip is flexed the sciatic nerve glides and moves under a few muscles. One of these muscles, of course, is the piriformis. If for some reason the piriformis muscle is putting pressure, or even disallowing the nerve to move freely, irritation is going to occur to the nerve structure. This is what would be considered piriformis syndrome.

So what causes piriformis syndrome?

The reason why the piriformis muscle becomes an issue is individual to the client, but there are some common factors. Sometimes trauma (direct fall on the glute or hip) to the area causes bruising and scar tissue leading to limited flexibility in the piriformis. Also, overuse syndromes are a common way for the piriformis muscle to get beat up. Repetitive activities, like running, cause overuse of muscles in the hip, especially if there is chronic glute weakness. This results in supporting muscles, like the piriformis, obturator, and gemelli muscles, to overwork; resulting in potential injury. Another scenario is pelvic alignment. If the pelvis has a posterior tilt, the external rotators of the hip will be chronically shortened. This creates less space for the sciatic nerve underneath the piriformis opening up the possibility of sciatic irritation. Also, posterior pelvic tilt usually goes along with hypertonic glutes, so already the piriformis is shortened.

These are only a few potential reasons why piriformis syndrome occurs. Many more are possible. In fact, one other is worth mentioning simply for completeness. A genetic variation in the anatomical makeup of the piriformis allows for the sciatic nerve to pierce through the piriformis muscle. When this is the case, piriformis syndrome is almost guaranteed.

How Do We Treat Piriformis Syndrome?

So, in order to treat piriformis syndrome, we need to focus on two things. Lengthening of the piriformis muscle, and gliding of the sciatic nerve. The first of these two can occur fairly easily. A pin and stretch technique is my tool of choice, but certainly, any myofascial or deep tissue release directly to the muscle will also be effective.  Also, a good stretch focused on the piriformis is certainly in order. I would do both the massage and the stretch, in that order, during a session.

The one thing that I would caution you about is to make sure you are not directly on the sciatic nerve. Earlier we talked about how the sciatic nerve is fairly easy to palpate due to its large size. I would recommend practicing finding and palpating it in order to feel comfortable with treatment. It can be easy to be elbow deep in someone’s glute and think that you are treating the piriformis, when, in actuality, you are really compressing the sciatic nerve and potentially irritating or even injuring it. Many times, the nerve itself is mistaken for a piriformis trigger point because the symptoms that are felt when pressure is applied replicates the same pattern. It may be a “good hurt” for your client, but nothing good will come of it.  Any treatment we do needs to be around the nerve, not on it.

This brings us to the second half of our treatment. Many times, due to adhesive tissue being laid down from injury, the sciatic nerve will not be able to glide smoothly under the piriformis muscle. The is true because the adhesive tissue glues the nerve to the muscle, causing irritation. This is, in my opinion, where most cases of chronic, ongoing piriformis syndrome stem from. When adhesive tissue is involved, normal movement of the sciatic nerve is impossible and irritation results, causing nerve symptoms in the buttocks, posterior leg, and foot.

So how can we improve sciatic nerve movement?

As the hip is flexed with the knee straightened, the sciatic nerve moves in an inferior direction underneath the piriformis. In other words, it slides under piriformis as the leg is flexed. When adhesive tissue is present between the two, tension will develop quite quickly when this motion is done. Usually, this results with pain in the buttock region and posterior leg being replicated. We will need to be aware of this as we treat the condition.

Treatment can be done with a method which resembles a nerve glide technique. We will use the normal ability of the sciatic nerve to glide and move in order to pull it away from the piriformis. In essence, we are breaking the adhesions that have formed around the sciatic nerve at the interaction point with piriformis.  This can be done with a very simple maneuver.

Start by having the client lay on their opposite side of the one which is affected.  Next, begin by finding the sciatic nerve where the piriformis crosses over it. I find it easiest to find the sciatic nerve first and then palpate from inferior to superior along it until I feel the piriformis muscle crossing over the nerve in a perpendicular fashion.

Figure 3. Palpation Location

 Once located, find where the inferior border of piriformis and the sciatic nerve come together. This is where we will focus our attention. Using your thumb, apply pressure at the inferior border of the piriformis, making sure we are not on top of the sciatic nerve but just lateral to it. Once we have applied our pressure, shift your direction of pressure up in a superior direction; parallel to the nerve. This will bow the piriformis muscle superiorly. The reason for this placement is to pin, or block, the piriformis muscle and not allow it to move. By blocking the piriformis, we will keep the muscle from pulling inferiorly with the sciatic nerve as it slides inferiorly in our next step.

Now that we have the piriformis blocked we can pull the sciatic nerve inferiorly using the ability of the nerve to move with hip flexion. This creates the capacity to break the adhesions away from the sciatic nerve at the piriformis, increasing relative motion between the structures. We will have our client slowly flex the hip while keeping the knee straight to pull the sciatic nerve inferiorly.  As the hip is flexed, tension will increase much quicker than normal. This occurs because of our blocking of the piriformis, disallowing for any extra movement that could occur without our pressure. Have your client flex the hip as far as possible without causing unwanted pain. It may be moderately uncomfortable for them depending on the acuteness of the symptoms, however, some discomfort is okay.  Once end range is reached, bring the leg back to neutral and relax your pressure. This maneuver should be repeated 3-5 times. Increased range should be gained with every pass.

During the last 1 or 2 passes, added foot movement can be used to encourage more sciatic nerve movement. Once the hip is flexed and just before end range, we will simply instruct our client to move the foot like they were operating a gas pedal (dorsiflexion and plantarflexion the ankle). This tensions and slackens the nerve, allowing for extra nerve gliding and a more effective treatment.

Once this method is applied, the sciatic nerve should be moving freely under the piriformis. Depending on how acute the sciatic pain is will determine if relief is felt or not. Even with proper treatment, it can take a day or so for the nerve irritation to subside and symptoms to go away. Also, depending on how chronic of a condition it is, multiple treatments may be in order.

Even once the nerve is free, stretching to the piriformis will need to occur. Generally speaking, this should be done very gently if acute pain is present as stretching a muscle over an already irritated nerve can irritate it even more. As the acute pain subsides, more aggressive stretching can be done to lengthen and release the tissue. The commonly known piriformis stretch is great for this and should be done multiple times daily.

So, the next time a client comes to see you with sciatic pain, make sure you know what and how to treat it.  If it is truly piriformis syndrome, these techniques should give you a way to treat it thoroughly. Hopefully, they walk out of our office WITHOUT a pain in the butt.


 

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