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What The Heck Is Piriformis Syndrome?

The diagnosis is tricky and can easily be confused with sciatica—and it's one of the most common running injuries.

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Running injuries can be a pain in the butt—sometimes literally. Such is the case with piriformis syndrome, a stubborn condition characterized by pain deep in the buttocks and, in some instances, down the leg or up into the lower back.

It’s an incredibly common (and annoying!) injury amongst runners, especially those who find themselves stepping up in distance or intensity during a new training program.

If you’re experiencing a pain in the butt, don’t lose hope: there’s plenty that can be done to alleviate your symptoms and get you back to running at 100 percent. Here’s everything you need to know about pirformis syndrome and how to not let it set you back.

First off, What is the Piriformis?

The piriformis is a small muscle that lies deep beneath the gluteus maximus, beginning at the lower spine and connecting to the upper thighbone. It assists in rotation of the hips, turning the leg and foot outward—all things runners use constantly.

In about 15 percent of people, the sciatic nerve passes through the piriformis; in others, it runs adjacent. The nerve travels from your spinal cord, through your buttocks, down the back of each leg, to your feet. It’s the longest, largest nerve in your body.

Piriformis Syndrome: Causes & Symptoms

Pain deep in the buttocks is thought to be a result of a too-tight or spasming piriformis compressing the sciatic nerve. When the piriformis muscle gets a little irritated, swollen, or inflamed, the sciatic nerve—an innocent bystander—gets beaten up. As a result, you get sciatic symptoms.

“Runners go to the doctor and say, ‘I’ve got this weird ache in my butt. Sometimes I feel this electricity going down the back of my leg. I try to stretch it out, and it seems to get worse when I run.’ That is the typical history of common injury, piriformis syndrome,” explains Dr. Daniel Vigil, a sports medicine specialist at UCLA.

But pain could also be originating from the nerve itself. “In someone with piriformis pain, I always screen the spine to try to determine if there’s tension through the nerve that could be causing the symptoms,” says Ellie Somers, a physical therapist who works with runners in Seattle, Wash. “If the sciatic nerve is irritated, it can lead people to subconsciously grip through the area of the glutes and piriformis, contributing to more compression of the nerve.”

Factors that can increase the likelihood of piriformis syndrome include:

  • Training errors (say, overdoing it with speed work or being inconsistent with runs).
  • Overexercising or performing repetitive motions (aka marathon training).
  • Long periods of sitting in your everyday routine (like working a desk job).
  • Not warming up before a workout or stretching properly afterward (we’re all guilty of it).

One of the main distinguishing factors is that it’s not an abrupt pain; you’re not running and suddenly have this twinge. It’s more of a slow, progressive, insidious type of problem. Dr. Vigil explains how many runners try to make sense of the pain and think it’s usually from running hills. They ignore it, continue to push through it and stretch it out—but the pain doesn’t go away.

“Electrical shocks go up and down the leg. That’s textbook of piriformis syndrome. Slow onset, progressive,” says Dr. Vigil.

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Treatment of Piriformis Syndrome

Once diagnosed, the first approach is to calm down the piriformis. The muscle is tight, so it needs to relax. Taking time off is the first step to healing.

Whether you can continue to run with piriformis syndrome really depends, but Somers encourages her patients to stay active. If you can tolerate some running, she suggests cutting out speedwork and switching to run/walk intervals until your symptoms resolve. If running provokes pain, try using a bike or an elliptical to keep moving and build tissue tolerance. If your symptoms don’t seem to be improving, seek help from a physical therapist who can provide more specific guidance for your situation.

Dr. Vigil says there are two categories to treatment: stretching and running mechanics modification.

“The reason the runner got this common injury in the first place is probably related to their running mechanics. You need a running coach. Someone that can watch you run. See how long your strides are, look at the way you carry your arms and how you run to find any flaws in your running style. So, piriformis stretching and running mechanics modification is necessary,” Dr. Vigil shares.

Piriformis syndrome
Glute rolling on foam roller. (Photo credit: Getty Images)

Foam rolling is usually a good solution to loosen up muscles. However, the foam roller is really good for superficial muscles—meaning your quads, hamstrings or tight larger muscle groups. Since the piriformis is beneath the gluteus maximus, it’s going to be hard to get down to the piriformis.

“I would recommend not so much a foam roller, but more of a tennis ball. A poor man’s way of accomplishing the same task,” says Dr. Vigil. A tennis ball is not hard like a rock—it has a little give to it—but it’s firm enough to get deep into the piriformis to loosen it up. Simply sit on the tennis ball, roll around for a bit until you find that spot and sit there for a bit.

The key to remember with any treatment is that stretching and massaging the piriformis can help with pain relief, but it’s important to be gentle, as too much of either can compress the sciatic nerve even more.

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Exercises For Piriformis Syndrome

Sidelined by piriformis syndrome? Physical therapist Ellie Somers recommends practicing nerve flossing, which helps to open space around the nerve. and simple exercises that mobilize the nerve comfortably and strengthen the glute muscles.

It’s also important to strengthen the muscles in the hip area. “When a nerve is irritated, it changes how the surrounding musculature fires. We want to keep things sharp in that region so we don’t end up with disuse,” says Somers.

Work in the following exercises to help alleviate your symptoms and strengthen the surrounding muscles to prevent re-injury.

Sciatic Nerve Flossing

  • Lie on your back and straighten your uninjured leg. Flex the hip of your injured side to 90 degrees, keeping the knee bent.
  • Straighten this leg as much as you can while maintaining a neutral spine (do not arch or round your back).
  • From here, alternate between pointing and flexing your toes for a total of 20 repetitions. Repeat several times throughout the day.
Piriformis syndrome
Single leg glute bridge. (Photo Credit: Getty Images)

Single-Leg Isometric Glute Bridge

  • Lie on your back and bend both knees to bring your feet directly under your knees. Press your heels into the ground to lift your hips as high as you can while maintaining a neutral spine.
  • Once at the top of the bridge, lift one leg off the ground while keeping your pelvis level. You should feel your stance-side glute working. Hold for as long as you can tolerate without letting one hip drop or feeling your hamstrings take over for your glutes.
  • Switch sides. Perform 8–10 reps on each side.

Note: If you immediately notice your pelvis tilting or feel a spasm in your hamstring when you come to a single-leg bridge, first practice bridging with both legs on the ground.

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Recovery Timeframe

Before beginning any recovery program, it’s recommended to speak with your doctor if you have any pain to get proper diagnosis.

If you can diagnose it early and figure out what brought on this common injury, it’s pretty quick resolved problem—meaning a few weeks. “I am not talking a couple minutes or a couple days, but it’s also not months to years either. Several weeks, two to four or four to six, would be the length of a typical case,” suggests Dr. Vigil.

As with any injury, it’s important to pay attention to the pain. If it worsens it could be something else in your back. “All seriousness, if you have tingling down your leg that is not going away and it’s getting worse, then it’s a reason to go to the doctor and get it sorted out. Hopefully it’s just piriformis syndrome, but on the other hand, yeah, it might be a slipped disc, bone spur or something worse on your spine,” says Dr. Vigil.