PT corner with Kristin Williams – pain in the butt

PT corner with Kristin Williams – pain in the butt

If you’ve ever had Piriformis Syndrome, you know it can be a real pain in the butt…literally! The piriformis is a small muscle located in the buttock, just underneath the gluteus maximus. It’s one of six lateral rotators of the hip, but it is unique in that the sciatic nerve runs directly underneath it. The sciatic nerve is the largest nerve in your body, derived from the nerve roots from the lower back (L4-5) to the sacrum (S3). So while most other nerves in your body are as thick as spaghetti or linguine, your sciatic nerve is as thick as your pinky finger! So imagine this large rope-like structure coursing from the lower back and diving under the flat, pyramidal piriformis before heading south down the leg. In 10-20% of the population, the sciatic nerve actually pierces through the piriformis muscle, which is quite unfortunate anomaly.

So it’s not difficult to imagine how having issues with the piriformis muscle can affect the sciatic nerve. This is called Piriformis Syndrome and it’s a real pain in the butt. Symptoms can include pain and numbness or tingling in the gluteal region and possibly down the leg. While it is often caused by trauma, it doesn’t have to be sudden in nature. Prolonged sitting in hard chairs (Zooming all day long perhaps?) is believed to cause repetitive microtrauma to the muscle and/or spasms within the muscle belly, all of which compress the sciatic nerve running underneath. It is also common in runners and cyclists due to the repetitive nature of those sports.

Unfortunately, there’s no specific test to diagnose Piriformis Syndrome, so the diagnosis is made primarily based upon the symptoms. Patients present with localized tenderness to the muscle belly in most cases, as well as tightness and decreased soft tissue mobility. Traditionally, people respond very well to soft tissue massage, trigger point release, stretching, joint mobilization and strengthening of the hip and core when it comes to conservative treatment. Some of my favorite exercises include:

  • Figure 4 stretch/pigeon pose – since the piriformis acts as an internal rotator of the hip above 90 degrees of hip flexion, these two stretches into hip external rotation are key! If you’re sitting for a long time, you can cross the ankle on the thigh in sitting (like chair Figure 4) and hinge forward at your hips to keep the muscle from cramping.
  • Tennis ball on the wall – if your muscle is feeling tight, lean your hip against a tennis ball and the wall. Sustained pressure for 90 seconds can help release the muscle or a gentle rolling massage works well too. Just watch that you’re not compressing an irritated nerve and making things worse!
  • Hip external rotation with a band – tie an elastic band around your ankle and kneel on a swivel chair. Kick the heel towards the opposite leg, internally rotating the femur. Do this quickly and against light pressure to really warm up the muscle. Follow up with Figure 4 or Pigeon Pose.
  • 90/90 Sciatic nerve glides – Lie on your back and grab behind your thigh so the knee is over the hip and bent to 90 degrees. Slowly straighten the knee, while keeping the hip flexed to 90 degrees. When you start to feel some tension in the buttock, rebend the knee. Perform 25-50 repetitions, never into pain. You’ll notice that you’ll be able to straighten the knee more along the way.

In persistent cases, trigger point injection therapy is quite effective, especially in a muscle that is acutely inflamed or in spasm. And because this is a nerve impingement issue, finding ways to relieve tension on the nerve further up and down the chain (remember the birds on the wire?) is also very effective in treating symptoms.

As they say, an ounce of prevention is worth a pound of cure. Restoring and maintaining optimal hip mobility and stability is key! Your LYT yoga practice is a wonderful place to start. We focus on the hips and a neutral pelvis as a way of minimizing stress on the body as a whole. So get on your mat, get your hips and glutes LYT up, and hopefully, you can avoid any literal pains in the butt for a long time!



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