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Glute Pain Part 3: Piriformis syndrome

The Problem!

Piriformis syndrome is a condition that emanates from the piriformis; a muscle that lies underneath the glutes. Piriformis syndrome is the piriformis pinching or clamping the sciatic nerve. This can often be mistaken for ‘true sciatica’ (that occurs in the spine) as the symptoms can be similar. Back pain, glute pain and neurological symptoms down the back of your leg. However, sciatica is a bilateral condition (both side of our body) and therefore can be written off if you only have pain in one leg. Piriformis Syndrome will cause pain when it gets stretched and clamps down on the nerve… Something that stretching won’t fix then? Surely not!?

About the Problem?!

The piriformis muscle comes from the sacrum (the bone between your butt cheeks) and inserts onto the top of your thigh bone (femur) and externally rotates the hip (foot turning out). The sciatic nerve passes through the piriformis muscle (figure 1) in up to 20% of us (compared to going underneath the muscle (figure 2)), as the muscle can grow in a split fashion, with one origin, one insertion but effectively have two muscle bellies. This in itself is not a problem, people have many ‘defects’ from birth and never notice them. However, when the piriformis gets stretched, it will compress the sciatic nerve that passes through it. This will happen when you internally rotate the hip, an act you cannot truly eradicated from your life as it happens from walking.

Figure 1: Sciatic nerve passing through the tendon of piriformis

Further, it has been theorised that only the tendinous parts of the piriformis are responsible for piriformis syndrome. The tendon is believed to be firmer than the muscle belly and therefore have a harsh reaction when compressing the sciatic nerve. This is thought to cause irritation of the nerve trunk and cause the well know symptoms. Should the nerve pass through the muscle belly, no damage, under normal conditions should occur to the nerve, as the consistency of the muscle is too pliable for the compressive force to damage the nerve. However, without a scan or cutting you open to have a look, nobody can say where your sciatic nerve passes through. It is likely, that if you’re reading this then your nerve passes through the tendinous part of the piriformis. And so, you should read the next section!

Firgure 2: Sciatic nerve passing underneath the piriformis

How the problem manifests in you!

Piriformis syndrome is a complex injury, and because of its complexity is still being discussed in current research. The cause of it isn’t always clear and is usually an insidious onset rather than one day waking up with this glute pain. It is also a relatively rare condition, meaning that spinal conditions take priority in assessments so piriformis syndrome can easily go overlooked. Chronic muscle spasm of the piriformis can be a cause of this condition. Shortening the muscle, clamping down on the nerve.

It is the reason that this muscle went into a spasm in the first place that is the cause for concern. For me, Glute strength/activation is a major part of this condition, and should form part of the assessment and ongoing monitoring of the condition as well. The glutes abduct and externally rotate the hip, actions that your piriformis muscle does as well. Should your glutes not be working as well as they should, the piriformis will do more of this role. As it is a smaller muscle, it is likely more prone to fatigue and therefore damage. Causing it to go into a spasm should it be over worked and injured. Likewise, if you hurt one of your glute muscles and don’t address muscle tightness in the rehab process then the piriformis may go into a protective spasm to aid in the immobilisation of the hip.

The Fix to the Problem!

If this assumption of the cause is correct then relaxing the muscle spasm and strengthening your glutes should help relieve the symptoms. This will get the glutes to do more of the work that the piriformis was doing, allowing the nerve to heal by stopping the constant irritation from the spasming piriformis muscle.

Glute Bridges! (Glute activation/strength)

Do them….. lots of them. When you get good at them, wrap a band around your knees and do some more! These will help activate and strengthen your glutes. You may notice that they will also externally rotate your hip, or force you to when you wrap that band around your knees. Which, if you remember from earlier is a problem as this clamps the nerve between the tendon part of the piriformis.

Figure 3: Set up position of Glute Bridge

Figure 4: Top position of Glute Bridge

Golf ball bum roll (Piriformis spasm)

Now for the part that I said wouldn’t work in the last blog post, get a golf ball, place it at the top of your glutes, and sit on it. Use your hands to raise yourself slightly off the floor, roll around until you feel it hurt and then stay there for a while, then roll about there for a while. This should help your brain relax that muscle spasm.

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