The piriformis syndrome: severe pain in the buttocks, legs and back

The sciatica - severe pain in the buttocks, legs and back

If you experience pain in your buttocks that extends to your back thighs, you may have piriformis syndrome. Fitness and health expert Alicia Filley explains what causes this condition and what you can do about the buttock pain.

• What is piriformis syndrome
• What are the causes?
• Can Piriformis Syndrome be diagnosed with a test?
• Is there a therapy for this type of sciatic pain?

What exactly is the cause of piriformis syndrome?

The piriformis muscle is located in the deep layer of the hip muscles below the gluteal muscles. This muscle attaches to the anterior surface of the sacrum, runs through the greater ischial foramen (large ischial hole) and attaches to the large roll hillock (greater trochanter) of the thigh bone. The piriformis acts as an external rotator when the hip is extended and as an abductor when the hip is flexed .

The sciatic nerve is the largest nerve in the human body. It has its origin in the spinal cord at the level of the 4th lumbar vertebra to the 3rd cross vertebra. This nerve is in close proximity to the piriformis muscle, and in most people its exit point is in the pelvis just below the piriformis muscle. But surgical observations and cadaver studies show that these two muscles are arranged differently in 22% of people. (1)

Briefly something on my own behalf

Piriformis syndrome, stretching exercises

Our training world expert Katharina Brinkmann has developed the first online program that specifically deals with this disease.

Katharina has not only compiled the most important information about the background and development, but also an exercise concept specially tailored to the piriformis syndrome concept.

Simple and effective techniques that will help you stretch the shortened muscle, strengthen the pelvic girdle, and correct poor posture.

This will teach you how to treat piriformis syndrome yourself so that your pain will soon be a thing of the past. Quite simply from home!

Sciatica and piriformis

The piriformis syndrome is irritation of the sciatic nerve caused by inflammation of the piriformis muscle. Symptoms are sharp pain in the buttocks or severe pain in the nerves that may spread to the middle of the back of the thigh. Occasionally, there is also a feeling of numbness and tingling that can reach the calves and toes.

In addition to these symptoms, you may experience lumbar back pain, which gets worse when you sit for a long time. Since the symptoms of piriformis syndrome are similar to those of a herniated disc, in which a disc presses on the sciatic nerve, a thorough medical examination must be carried out to rule out such a thing.

If a disc disease is diagnosed, which is often the case with older runners and cyclists, it cannot be ruled out that piriformis syndrome is the cause of the pain.

In California, researchers examined 239 patients with unrelated sciatica. (2) Many of these patients had prior lumbar spine surgery because the pain was suspected to be caused by a herniated disc .

In the group of patients examined here, the pain was only slightly or not at all relieved by the operation. 42% of people ultimately diagnosed with piriformis syndrome complained of lumbar back pain. As a diagnosis of exclusion is often made, it is difficult to determine the actual frequency of piriformis syndrome in the population.

Test to detect piriformis syndrome

Unfortunately, there is no test that can definitely prove piriformis syndrome. One way to determine the cause of sciatica pain is to reproduce the pain. If lifting the extended leg, the so-called straight leg raise test (SLR), leads to a positive result, one can generally assume that the pain is more likely to come from the spine or sacrum than from the piriformis muscle .

In this test, the person concerned is lying on their back with their legs straight. The examiner lifts the leg on the painful side. If the examined person feels pain in the sciatica, the SLR is positive. It should be noted, however, that in the California study, 41% of people diagnosed with piriformis syndrome had a positive SLR test result at the first examination.

The FAIR test

If the pain is reproduced with the FAIR test (for flexion, adduction, internal rotation of the hip), it is more likely to be a piriformis syndrome. In the FAIR test, the person concerned lies on the non-painful side and positions the painful leg with a 60-degree hip flexion, knee flexion, hip adduction and internal rotation. (1) The examining person pushes the knee down, thereby causing the piriformis to stretch that compresses the sciatic nerve.

On examination, there may be tenderness over the piriformis muscle, which feels like a sausage-like hardening. The following changes in posture can occur: a rotation of the sacrum to the painful side, a misalignment of the sacroiliac joint, and a rotation of the lumbar vertebrae. If the person is lying on their back, the painful leg may be turned slightly outwards as a result of the shortened piriformis muscle. Delayed nerve conduction velocity can occur below the piriformis, especially if the person concerned is in the FAIR position.

Here you can find a detailed article on the topic: What is Piriformis Syndrome?

Therapy against piriformis syndrome

Piriformis syndrome manifests itself in the early stages as an inflammatory reaction to overload, trauma or postural damage . When the piriformis is severely inflamed, it causes the sciatic nerve to become pinched. Treatment with over-the-counter non-steroidal anti-inflammatory drugs will relieve pain and reduce inflammation. It is also advisable to treat the pain with other conservative means, e.g. B. Rest, compression and cooling of the painful area.

Treatment for piriformis syndrome

As the disease progresses, there is a cycle of muscle spasms, pain and compensation through posture. At this stage, the patient is usually referred to a physical therapist. Ultrasound and ice spray can be used to treat inflammation and reduce muscle spasms.

Soft tissue problems can be treated manually, e.g. B. through myofascial trigger points to release tension. The shortened muscle is then stretched with sporting exercises and stretching , the pelvic girdle is strengthened and postural damage is corrected. In a 10-year study, scientists from New York found that physical therapy given 2 to 3 times a week for up to 3 months resulted in a 60-70% improvement in most patients. (3)

Although the symptoms usually only occur in one leg, the pain-free leg should definitely be treated as well. The New York study found that overexertion (43% of 876 patients) and injury (18% of 892 patients) were the most common causes of piriformis syndrome. As part of the studies mentioned, the nerve conduction of the symptom-free leg was also examined in patients with piriformis syndrome.

Measures against piriformis syndrome

The test results were significantly worse compared to a control group without piriformis symptoms. Since overexertion and injuries usually occur on both legs, the therapeutic measures should also always be carried out on both sides.

If conservative measures are unsuccessful, it is possible to give an injection for the piriformis pain. In the aforementioned California study, the researchers' procedure was to inject anesthetics and corticoids into patients suspected of having piriformis syndrome.

If the symptoms completely or almost completely disappeared, it was considered confirmation of piriformis syndrome. Patients who had symptoms returning in less than 1 week were referred to a surgeon for further treatment. If it took longer than 1 week for symptoms to return, patients received up to 2 additional injections 4 weeks apart. If the pain was not completely eliminated even after these additional injections, these patients were also referred to a surgeon for further treatment.

Piriformis syndrome was diagnosed in 68% of the 239 patients examined. Of these, 23% were completely symptom-free after 1 or 2 injections. In 37%, the injections provided longer-term pain relief (longer than 6 months) before symptoms reappeared. However, no physiotherapy was carried out after the injection treatment. This explains why the symptoms returned.

Surgery for piriformis syndrome

During a surgical procedure, the tension on the piriformis tendon is released so that the sciatic nerve is no longer compressed. It is also examined whether the sciatic nerve has scarring or tissue sticking that could lead to irritation. 59% of the patients referred to a surgeon in the California study were extremely satisfied with the results of the operation. Even after a long time (more than 2 years after the operation), patients reported very good results in 62% of the cases.

For the operation, which used to be considered a major procedure (with an incision similar to that of a hip operation), only an approx. 3 cm long incision is now necessary. As a result, a surgical intervention no longer means the end of a sporting career. Most can resume their usual daily activities after just 2 weeks and start training in deep water running or swimming again soon.

As a further article, we strongly recommend:

Stretching exercises against piriformis syndrome

Small muscle, big problem

Functionally, releasing the tension of the piriformis also has an impact on the biomechanics of the hip, since the piriformis is a relatively short external rotator and weak abductor. So how can it be that such a tiny muscle causes such severe pain in the buttocks? The course of piriformis syndrome is influenced by both internal and external factors. Internal factors are e.g. B. the anatomical position of the piriformis in relation to the sciatic nerve, postural defects such. B. as a result of a different leg length, an infection in the muscle, myositis ossificans, and a tumor. (4)

Piriformis Syndrome - severe pain in the buttocks, legs and back © healthyfood-musclestrength

Piriformis Syndrome in Runners

Runners experience overuse due to external factors, e.g. B. running too long, extending the running quota too quickly or poor running technique. Differences in terrain, worn shoes or running on sloping surfaces also overload weak muscles. When the primary muscles of the hip fatigue, the smaller accessory muscles like the piriformis have to work harder to maintain shape. This compensation work for the stronger muscles puts a strain on the piriformis. Applying force to the buttocks, such as a fall or a blow, can injure the piriformis and trigger an inflammatory reaction.

A good rule of thumb is not to add more than 10% per week to your running. You should definitely remember that you keep changing the direction of travel on the track or on sloping roads. The functional difference in length of the legs that occurs when you walk on an inclined surface creates additional stress on the pelvic muscles.

From a leg length difference of 1 cm, the alignment of the pelvis is impaired. In such cases, you should seek advice from a physical therapist as to whether or not it is advisable to raise your shoes. If you want to ensure that your muscles can effortlessly handle any external factors that may arise, you should definitely increase the core strength of the pelvic girdle muscles.

Strength is important

Endurance athletes, especially runners, are known to neglect the strength part of their training. Many believe that practicing their sport alone will give them enough strength . When it comes to running, however, just the opposite is true. Endurance runners who do long runs even lose muscle strength in their legs. (6)

In New York, fitness experts examined the strength of the hip muscles in 8 men and women before and after a 2-hour run. and 17%, respectively, while hip flexion force decreased by 19% in both men and women.

Strength building in the context of injury prevention

In a descriptive analysis, Minnesota researchers looked at hip strength in runners with a running-related injury. (6) They found a clear relationship between weak hip muscles and a running injury in 30 recreational runners . The muscles of the injured leg were noticeably weaker than those of the healthy leg.

In a control group with uninjured runners, there was no difference in hip strength between the two sides, as was the case in the experimental group. Although this is not proof of a causal relationship, it does make it clear what an important role hip strength plays in the context of injury prevention.

Hip strength as a prevention against piriformis syndrome

As a result, more hip strength can also lead to better performance. In a joint project, scientists from Spain and the USA investigated the effect of a sport-specific, periodic strength training program on endurance runners on shortening the stride length. (7)

For this purpose, 18 sub-elite runners were randomly divided into 1 of 3 training groups each. During the 8-week training program, the subjects completed either a periodized or a non-periodized strength training program or no additional strength training at all.

For training units that were carried out at the pace of a competition, the running distance was repeated up to 20 times and the step length was measured in relation to the speed (SLG). A comparison of the SLG values ​​of the first and last third of the repetitions showed that the values ​​in athletes who had completed a run-specific, periodic strength training program did not decrease between the first and the last runs.

In contrast, the SLG value decreased significantly for the runners in the two other study groups. The group that did not do strength training saw the greatest decrease. So the longer you can postpone muscle fatigue, the more consistent your stride length will be, and the better your performance will be.

Through a force-specific training of the corresponding muscles, you can avoid the accessory muscles having to step in instead. In this way you achieve better results on your running route and also avoid injuries.

Alicia Filley Lives in Houston, Texas and is the Vice President of Eubiotics: The Science of Healthy Living, which advises people who want to improve their health, fitness, or athletic performance through exercise and nutrition.

Our tip from the Trainingsworld editorial team!

With simple and effective techniques for buttock, leg and back pain back to a pain-free everyday life!

• Use Katharina Brinkmann's online coaching now and learn simple and effective techniques against your pain. With exercise videos in real time!

• Get to know the real causes now and how you can treat yourself easily and successfully.

• Exclusive exercises that are specifically geared towards the Piriformis Syndrome and cannot be found on the net in this form! With the 4-step plan you will soon find your way back to a pain-free everyday life

References

1. Journal of the American Osteopathic Association. November 2008, Vol. 108 (11), 657-64.

2. Journal of Neurosurgery Spine. February 2005, Vol. 2, pp. 99-115.

3. Archives of Physical Medicine and Rehabilitation. March 2002, Vol. 83 (3), pp. 295-301.

4. Orthopedic Clinics of North America. 2004, Vol. 35, pp. 65-71.

5. Journal of Orthopedics & Sports Physical Therapy. March 1998, Vol. 27 (3), pp. 189-196.

6. Clinical Journal of Sport Medicine. January 2005, Vol. 15 (1), pp. 14-21.

7. Journal of Strength and Conditioning Research. 2008, Vol. 22 (4), pp. 1176-1183.