From healthcentral.com
About a third of all lower back or butt pain is related to piriformis syndrome, and can be relieved with stretching and strengthening exercises
A deep ache or pain in your glutes, which may also radiate down one leg, is one tipoff that you might have something called piriformis syndrome. In this disorder, radiating pain originates in the piriformis muscle, a band of tissue that stretches from the front of your sacrum (the triangular-shaped bone at the base of your spine) to the top of your thigh bone (the femur) on each side.
The piriformis muscle externally rotates your legs and helps stabilize the hips. But when the muscle gets irritated, often from trauma or overuse, it can cause pain. And since the sciatic nerve, which exits the spine in the same general area as the piriformis and extends down the back of each leg, runs close to the muscle (in almost 25% of people it even penetrates piriformis muscle fibres), when the piriformis is aggravated, it can irritate surrounding nerves as well, causing pain down the leg (a.k.a. sciatica), says Nadya Swedan, M.D., a physiatrist in New York City. “It can be so severe it will keep people up at night or make it difficult to sit for long periods,” she adds.
Causes and Risk Factors
Piriformis syndrome is implicated in up to one third of cases of low back and sciatica pain, according to a review in Practical Neurology. Overuse is a key contributor to piriformis syndrome, says Dr. Swedan. “It’s especially common in people who spend long hours commuting in their car in traffic—pressing on the brake, then the accelerator, which requires you to turn your foot in and out.” But even sitting at a desk for several hours a day can do it, especially if you often shift to one side or sit with your foot tucked beneath your butt.
Runners and walkers can also be at risk, especially if they have an underlying weakness in their glutes. “When you land [while running] on the side with the weak glute, the leg rotates in, which stretches the piriformis,” says Laurel Proulx, D.P.T., Ph.D., a clinical assistant professor at Baylor University’s Department of Physical Therapy in Waco, TX. This process repeats every time you bring that leg forward.
Certain other workouts can also be to blame. “We also see it frequently in people who do a lot of barre classes because they spend so much time with their hips in external rotation,” notes Proulx.
Finally, direct trauma to the area—such as falling on your backside—can cause an inflammation in the muscles and trigger the injury.
Why Women Are at Higher Risk
Simply being female raises your risk of experiencing piriformis syndrome. In fact, women are diagnosed with it six times more often than men. This may be due to a few anatomical differences: First, women tend to have a wider Q angle than men. This is the angle between the thigh muscles (a line drawn from the front hip bone down to the knee) and the patellar tendon (a line drawn through the knee and down the front of the shin). The greater angle may alter the balance of the stabilizing muscles around the hip, which can aggravate the piriformis. Second, a study of 224 Japanese athletes, published in the Journal of Physical Therapy Science, found that the female athletes had almost 50% greater internal rotation of the hip joint than men (and a 40% higher incidence of lower limb sports injuries), which may also alter piriformis mechanics.
Finally, research published in the journal Surgical and Radiologic Anatomy found that in many people—especially women—the piriformis muscle attaches in a spot on the sacrum that can potentially compress sacral nerves, in addition to the sciatic nerve.
Signs and Symptoms
In short: It’s a pain in the backside. The main symptom of piriformis syndrome is an aching pain deep in the buttock, just to one side of the sacrum, and sometimes closer to the “sit bone” area. You might feel it while sitting, going up stairs, or moving from a sitting to standing position. When you (or your doctor) press into the area or place a tennis or lacrosse ball there, it can be tender. “It often feels tight and knotty when we palpate it,” says Dr. Swedan. There may also be numbness or burning, shooting, or tingling sensations down back of the leg and even into the lower leg, which reflects the path of the sciatic nerve and its branches.
Getting the Right Diagnosis
Piriformis syndrome is really a diagnosis of exclusion, notes Proulx—which means your doctor may diagnose it after eliminating other potential problems through different tests and exams. “It’s called a ‘syndrome’ because it can involve multiple tissues and movement patterns,” she says. “[The term] is really explaining the region of the pain, not the dysfunction causing the pain. That’s why it’s important to differentiate it from back pain and rule out other causes.”
All of these issues can potentially aggravate nerves and cause pain in the hip and down the leg:
“We’ll also check to see if there is sciatic nerve involvement,” says Proulx. “A lot of times we think of it as irritation, inflammation, and pain of the piriformis muscle, but that can affect the sciatic nerve, which is nearby.”
If your case is unclear or isn’t resolving, an MRI can confirm a diagnosis, although you may be required by your insurance to try physical therapy first before getting an MRI.
Treatment Options
There are a few different choices to address the pain from piriformis syndrome. They include:
Heat. This can help relieve piriformis pain, especially if you’ve had it for more than a couple of days or if it feels tight, says Dr. Swedan.
Myofascial release (MFR). This includes using a tennis or lacrosse ball, foam roller, or a percussive device such as a Theragun to help release muscle tightness. However, this only really works if you follow up immediately with moves that help retrain the muscle by stretching and/or strengthening it, says Proulx.
Pain relievers or pain patches. Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) may temporarily ease inflammation in the affected area.
Steroid or Botox injections. These seem to work if nothing else is helping, according to a review of piriformis treatment techniques published in Cureus.
But you may need to do more to find long-term relief. “These things will manage the symptoms, but they won’t treat the cause of the issue,” says Proulx. That’s why you want to see a professional, who can help pinpoint other potential causes of piriformis syndrome. They’ll watch how you move (walking, running, squatting, standing on one leg) and check your range of motion and muscle strength, says Proulx. This will help them determine whether there are muscle imbalances or even leg length discrepancies that should be corrected in order to get the piriformis to work properly. A physiatrist, orthopaedist, physical therapist, chiropractor, or acupuncturist who specialises in treating orthopaedic issues can all help.
Preventive Strategies
You may be able to avoid this pain in the rear end with a few proactive strategies:
Change up your routine. You may love your barre class, but it may be contributing to muscle imbalances. Adding in some regular strength training, yoga, or Pilates can give your hip muscles a more well-rounded workout.
Get cruising. If you have to spend hours in the car, use your cruise control when you can so you don’t have to constantly be rotating your leg back and forth, says Dr. Swedan.
Sit right. Try to sit with both feet on the floor, without crossing your legs or having one leg tucked under you. Spending hours a day that way can contribute to muscle imbalances. “If you have to sit, change your seat level so your hips are even with or higher than your knees,” says Dr. Swedan. (This also includes raising the seat height in your car if you can.)
Stand more. If you have a desk job, schedule hourly (or semi-hourly) walking breaks to stretch your legs.
The Best Exercises for Relief
It’s important to work with someone who can tell you if your piriformis syndrome is due to the muscle being too strong, too weak, too contracted, or too stretched, since all of these can result in pain. Once you have that figured out, the following may help.
Roll Out
Hip Rolling: Place a foam roller on the floor and sit with your hips along the wide part, knees slightly bent (place hands on floor behind you for balance). Cross the ankle of the painful side across the opposite knee and then lean over to the painful side until you feel tenderness. Once you find it, hold for 30 to 60 seconds, then shift and try to find another tender spot and repeat. You can also do this with a tennis or lacrosse (more intense) ball under your hip.
Stretch the Piriformis
Leg Cross: Lie faceup and draw the knee of the painful side toward your chest. Place your opposite hand on the knee and draw it across your body, so you feel a stretch through the hip. Hold for 30 to 60 seconds; repeat on the other side if you need to. Repeat once or twice. (If your piriformis is already overstretched, you don’t need to stretch it, but you may need to stretch other muscles, such as the adductors, or inner thigh muscles.)
Strengthen the Piriformis
Lateral Band Walks: Place a looped resistance band around your upper legs, just above the knees, and stand with your feet shoulder-width apart, hands on hips. Shift your hips back into a half-squat and step out to the right with your right leg. Bring the left leg in so your feet are shoulder-width apart again and continue. Take 10 steps to the right then repeat to the left, staying in the squat and keeping your knees parallel the entire time (don’t let the knees cave together or flare out). Do two sets to each side. (Note: Dr. Swedan recommends avoiding strengthening moves for the piriformis until you no longer have pain, otherwise you run the risk of overworking it and making the problem worse.)
Work Your Hip Stabilizers
Bird Dog: Start on all fours, hands under your shoulders and knees under your hips. Keep your head in line with your spine (don’t tuck your chin or look up). Extend your right arm forward as you extend your left leg back. Your arm, leg, shoulders, and hips should be parallel to the floor. Hold for up to 30 seconds then switch sides and repeat.
Bottom Line
There are many things that can go wrong in the low back and hip, potentially leading to a vague pain in your buttock. The first step to reducing piriformis pain is to spot any potential postural problems or overuse of the muscles with the help of a professional. With the right exercises and professional guidance, you can retrain the muscle to help stabilize your hips, allowing you to get on with your day—pain-free.
https://www.healthcentral.com/condition/sciatica/pain-in-the-butt
