Have you been dealing with a nagging pain in your buttock that just doesn’t want to go away? You’ve tried everything. Ice, heat, massaging the area, but nothing is working! This annoyance of pain around the backside of your hip may be due to a condition known as ‘piriformis syndrome’, which is somewhat of a conundrum in the healthcare field. This condition can be a real pain in the butt, (pun intended). In this article, we will discuss piriformis syndrome, and what you can do to help relieve the pain that could be stemming from this ‘condition’.
What Is The Piriformis?
Put simply, the piriformis is one of your hip muscles that play a key role in rotation, flexion, and abduction (moving away from the midline) of the hip. It also provides postural stability when standing and walking.
The muscular origin (where the muscle begins in the body) is at the anterior sacrum (front of the tailbone) and runs in a diagonal direction to the outside of your femur (hip bone). You can find this muscle by placing your hand at your tailbone below your low back, then moving your hand slightly to one side of your butt in a downward, diagonal direction.
A large nerve you may have heard of known as the sciatic nerve passes underneath this muscle, and can be a culprit of pain in individuals who have piriformis syndrome. In addition, there are anatomical variations that may exist from one individual to another. For example, not everyone has the same torso or lower leg length, we all have different anatomical make-up! In regards to the sciatic nerve and its relationship to the piriformis muscle as it travels down the back of the leg, it may not take this same path in every individual that is shown in the picture above. Whether these anatomical variations actually matter will be discussed later on.
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A Change In Nomenclature: Deep Gluteal Syndrome
This condition was first described in 1928 and the term was first introduced in 1947. You would think that because this term has been around for a long period of time, the causes behind it would be well understood; however, that is not the case. Within research and healthcare, there continue to be many questions in regards to this clinical diagnosis. The current definition of piriformis syndrome is a condition that is characterized by a combination of symptoms including buttock or hip pain. Moreover, this syndrome causes compression of the sciatic nerve, due to excessive contraction of the piriformis muscle. Pathologies of the piriformis that may cause this sciatic pain include:
Piriformis muscle spasm
Damage to the piriformis from an acute injury or trauma
Anatomical variations of the piriformis muscle, including insidious hypertrophy (muscle growth)
Variations in the course of the sciatic nerve in relation to the piriformis muscle
Weakness of the surrounding hip musculature, placing a more eccentric load (muscle lengthening against gravity) on the piriformis
Moreover, there has been a shift in recent literature regarding the nomenclature of this diagnosis, as you may also hear the term ‘deep gluteal syndrome’. Martin et. al defined this in the Journal of Hip Preservation Surgery as, “the presence of pain in the buttock caused from non-discogenic and extrapelvic entrapment of the sciatic nerve”. What differentiates this recent shift towards deep gluteal syndrome as a more objective term versus piriformis syndrome, is that there are more structures within the hip that can cause entrapment of the sciatic nerve. This includes the fibrous bands of blood vessels, gluteal muscles, hamstring muscles, the deep hip external and internal rotators, and other space-occupying lesions. With these differences in mind regarding terminology, the generalized treatment approach remains the same in regards to improving one’s symptoms with buttock pain.
Fix that Pain in Your Butt
How Do I Know If I Have It? A Diagnosis By Exclusion
Because this umbrella of a term does not always have a ‘clear-cut’ cause, the diagnosis of it is usually by exclusion, meaning all other possibilities of pain around the back side of the hip into the legs is ruled out. Other pathologies that can cause pain in the back side of the hip area into the leg include:
Pain referral from the facets (joints) of the lumbar spine
Because this is a diagnosis of exclusion, healthcare practitioners should perform a thorough evaluation to ensure no other competing diagnoses are contributing to the patient’s symptoms. In an article by Danazumi et. al, the authors discussed that roughly 5% of individuals who are diagnosed as having low back pain were misdiagnosed, as they actually had piriformis syndrome. Yes, this is a small number; however, clinicians should keep this diagnosis in their differential list when deciphering why a patient may be experiencing specific symptoms in their buttock and/or leg.
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What Does Piriformis Syndrome Feel Like?
Common signs and symptoms of piriformis syndrome include:
Potential increased pain in the buttock area when walking and/or running
Pain with prolonged sitting, especially on firm surfaces
Pain can refer from the buttock into the back of the thigh, and even down the entire backside of the leg in the sciatic nerve distribution if more severe
Pain may be reproduced when the hip is in the FAIR position (flexion, adduction, and internal rotation)
Pain may be reproduced with straight leg raise testing (placing tension on the sciatic nerve)
Pain with palpation (pressure) to the piriformis muscle. There may also be increased spasming and ‘trigger points’ of this muscle with palpation
Differentiation of Buttock Pain
Sciatic Nerve and Piriformis Muscle Anatomical Variations: Does This Matter?
Some research that involves studying the anatomy of the piriformis and the way the sciatic nerve interacts with it has included hypotheses that there are anatomical variations present that may put one at risk to develop piriformis syndrome. One study by Beaton and Anson looked at 240 cadaveric dissections of the relationship between the piriformis and sciatic nerve. The results of the study were:
90% of the cadavers had normal anatomy with the sciatic nerve passing below (underneath) the piriformis
The other 10% of the cadavers had variations which included:
A sciatic nerve that split, passing through and below the piriformis
A sciatic nerve that split, passing above and below the piriformis
A sciatic nerve that passes directlythrough the piriformis muscle
Another meta-analysis of 18 studies with over 6500 cadavers demonstrated abnormalities in this anatomical relationship in 16.9% of their sample. As you can see in the image above, other studies have corroborated even more variations than the ones we listed! So the real question is…do these anatomical variations actually predispose someone to developing piriformis syndrome?According to the literature, no. The results in both of these studies revealed there was no statistically significant difference in the prevalence of this condition between those individuals who had an anatomical variation and those who did not. With that being said, it is still beneficial to understand that these anatomical variations do exist, and may provide some context as to why someone is experiencing their symptoms.
How Do I Decrease My Butt Pain?
Currently, treatment options for individuals with piriformis syndrome include exercise, manual therapy, modalities such as shockwave therapy, dry needling medications, or injections. There is no clear consensus that delineates what the best treatment option is at this time due to the lack of evidence in this area of practice. However, several studies have supported physical therapy and specific exercise in helping modulate symptoms related to piriformis syndrome. Below we will show you some exercises that you can perform to help you overcome this nagging pain!
HOW: While laying face up on the floor cross one leg over and across the other. The closer you bring your foot to your butt on the leg that is on the floor the further you will stretch your opposite hip. If this is not enough of a stretch, you can thread the needle by elevating your leg that was on the floor and hugging your shin bone towards your chest. If the crossed leg is slipping you can hold onto it with your opposite hand.
FEEL: You will feel a deep stretch in the back hip on the leg that is crossing. The closer you hug your legs the stronger the stretch.
COMPENSATION: Keep your arms slightly out from your side to achieve the 30 degrees of abduction, don’t have them right at your side.
As previously mentioned, sometimes piriformis syndrome may cause symptoms down the back of the thigh due to sciatic nerve compression or irritation. This exercise will help alleviate those symptoms by helping enhance the mobility of that nerve.
Glute Foam Rolling
Here are some tips for foam rolling your gluteal region:
You can cross your involved leg over your opposite leg to gain a dynamic stretch while you are foam rolling
By leaning towards the involved side, it will help get more pressure on the hip musculature
You can also utilize something with a smaller surface area, which will be more focal and localized to the muscle, such as a lacrosse ball
Sometimes less is more, you may want to back off from an area causing pain down your leg or causing nerve symptoms as this can have a negative delayed effect (AKA you feel your pain later after doing this!)
Only Stretching Is Not The Answer!
A tight piriformis muscle that is often in spasm may receive relief from stretching that was shown with the exercises above, yet that may not help address tissue remodeling and facilitation of blood flow and the benefits you may experience could be short-lived! In addition to stretching, performing muscle activation and specific strengthening exercises will also promote more benefits long term rather than solely stretching! You can learn more about the topic of stretching by listening to our podcast episode below!
A Shift In Focus Towards Hip Muscle Strengthening and Re-Education
The most common hypothesis as to why an individual experiences piriformis syndrome is due to shortening, tightening, or spasming of the muscle. However, there have also been contrary beliefs that this muscle may be working in more of a lengthened position, which makes it subject to higher stresses eccentrically during daily activities. There is also the thought that a really tight/spasming muscle is typically a muscle that’s been overworked or extremely fatigued!
In an article from the Journal of Orthopedics and Sports Physical Therapy by Tonley et. al, the authors discussed if there is a weakness of our gluteus maximus and/or medius (which extend and abduct the hip respectively), our hips may excessively adduct (move closer to the midline) and internally rotate, ultimately lengthening and putting more stress on the piriformis muscle. The authors also reported that other studies on the topic of piriformis syndrome have also found hip abductors to have strength deficits in individuals subject to this condition, which is a key muscle in helping stabilize our pelvis with weight-bearing activities, such as walking or running.
Therefore, our take-home message in regards to the above findings is to not neglect strengthening and muscle re-education, as this may be a key, underlying impairment leading to your buttock pain. Below we will show you some of our favorite strengthening exercises for the hip!
Utilize Functional Range Conditioning
To incorporate muscular activation for your hips, certain functional range conditioning exercises (FRC) can help facilitate this process. FRC is a specific mode of exercise that helps improve mobility by utilizingstrength and neuromuscular control.
Progressive Angular Isometric Loading (PAIL) and Regressive Angular Isometric Loading(RAIL) are specific types of FRC exercises. These techniques help teach the central nervous system (CNS) how to control and function in newly acquired ranges. Utilizing isometric contraction teaches the nervous system to have active control over a particular range (i.e. shortened or lengthened positions). These techniques help expand the available range of motion. In addition, PAILs and RAILs will help build strength and tissue adaptation in both the shortened and lengthened ranges of motion. A key component while performing PAILs and RAILs is to irradiate, which means creating tension throughout the body.
To perform this exercise, you will statically hold a 90-90 hip position for about 2 minutes. After the 2 minutes, you will irradiate (create tension) throughout the entire body and perform a PAIL contraction with one leg by driving the leg into the ground, ramping tension up to 100% effort by the end of the 10-second count.
After the PAIL contraction, you will then switch to a RAIL contraction–again, ramping tension up to 100% effort within the 10-second count–by actively bringing yourself further into a new range. After completing that cycle (Hold position: 2 minutes, then PAIL/RAIL contraction) you will notice that you have acquired a new, improved range! You can then repeat this exact sequence.
The hip thrust exercise is one of the best exercises to activate the gluteus maximus, which promotes hip extension! We have a plethora of hip thrust variations in our exercise library!
What Else Can We Do? Avoid Prolonged Sitting!
A common complaint for individuals with buttock pain is that prolonged sitting makes symptoms worse, especially on firm surfaces. If we stay in one position for hours on end, this is when adaptive positioning may occur, which is when muscles like our piriformis, ligaments, tendons, and other soft tissues become tightened/lengthened within specific positions, leading to mobility deficits and/or pain. We know there is ‘no perfect posture’; however, we can set ourselves up for success by making frequent movement each day a part of our lifestyle. Investing in a standing desk is a great option, or setting reminders on your phone or computer at least 1-2x/hour are great options. Activity modifications go a long way in helping overcome your symptoms!
Piriformis syndrome is still an anomaly in the healthcare field. Individuals usually complain of the nagging buttock or hip pain that can refer to the back of the leg. This is due to increased tension and/or spasm of this piriformis muscle, which then causes compression and irritation of the sciatic nerve. There has been a shift towards the term ‘deep gluteal syndrome’, as more recent research has corroborated more structures within the hip that can cause compression of the sciatic nerve in addition to the piriformis muscle. All of the diagnoses that could cause hip or leg pain should be excluded before confirming this syndrome as a diagnosis.
In regards to treatment, manual therapy and specific exercise, as well as activity modification, have shown promising results, yet more evidence is needed to decipher the best approach to manage this condition. Stretching and soft tissue work can provide temporary relief; however, activation and strengthening exercises will assist in long-term benefits. If you are dealing with pain in your buttock or hip area and have not had a formal evaluation, seek a consultation from a physical therapist or orthopedist who can differentially diagnose your specific symptoms!
Take Control of Your Hip Pain!
It’s all in the hips! Okay, maybe not ALL but in most activities the hips are the main driver of movement. The surrounding hip musculature provides stability and force production for walking, lunging, single leg stance, and squatting patterns. It’s a unique design that requires mobility, stability, strength, and power. If mobility and stability become compromised discomfort becomes the result. In this program, you learn to take control and earn back meaningful activity by improving hip mobility, stability, and strength, or a better way to put it: function!
Sherif graduated from Temple University with a Bachelor’s of Science Degree and a concentration in Kinesiology. He then received his Doctorate of Physical Therapy Degree from DeSales University, graduating with honors of the professional excellence award and research excellence award. After his graduate studies, he served as Chief Resident of the St. Luke’s Orthopedic Physical Therapy Residency Program. Sherif is a Board Certified Orthopedic Clinical Specialist. Sherif focuses on understanding how movement impairments are affecting function while also promoting lifestyle changes in order to prevent recurrences of injury. His early treatment interests include running related injuries, adolescent sports rehab, and ACL rehab in lower extremity athletes. He also has been involved in performance training for youth soccer players. Outside of working as a physical therapist, he enjoys traveling, running and cycling, following Philadelphia sports teams, and spending time with his family.
Disclaimer – The content here is designed for information & education purposes only and is not intended for medical advice.