A real pain in the butt...

A real pain in the butt...

Posted by Ian Nurse on Jan 29, 2020

Prevention and Treatment of Piriformis Syndrome in Runners

As the Boston Marathon training cycle ramps up again, more and more runners come into my office complaining of the same thing: “so I have this dull ache in my butt! I think it’s my piriformis.” With this sudden spike of a particular injury in mind, I will attempt to answer the following questions: why is everybody talking about the piriformis, and where the heck is it? 


For such a small muscle, the piriformis seems to get a lot of attention. It does play an important role as a hip stabilizer and an external rotator (rotating your leg out and back), but it doesn’t act alone. There are three other external rotators and stabilizers of the hip that play an equally significant role. 


So why does this one little muscle get a whole syndrome named after it? Well, it comes down to the piriformis’ proximity to another extremely important structure, the sciatic nerve. The piriformis muscle and sciatic nerve are close neighbors and even demonstrate varied positioning throughout the population. For most, the sciatic nerve lies directly beneath the lower edge of the piriformis; others demonstrate a split sciatic nerve lying above and below the piriformis; another small group actually have their sciatic nerve bisect the muscle itself. That said, all four deep external rotators, as well as the gluteus medius muscle are positioned close enough to the sciatic nerve to cause irritation. Perhaps a more appropriate name might be “deep external rotator syndrome…”


Traditionally, the term “piriformis syndrome” is used to describe a condition in which tension within only the piriformis muscle produces entrapment and irritation of the sciatic nerve. This entrapment can be caused by numerous soft tissue factors including an excess of scar tissue surrounding the nerve or a muscle imbalance. The sciatic nerve is one of the largest nerves in the body, comprised of nerve roots from L4-S3, so if it becomes entrapped, one can feel a variety of symptoms. Typically, a patient complains of a deep ache in the hip with pain and/or paresthesia (abnormal tingling or sensation) traveling down the back of the thigh and into the calf and foot. Symptoms are often exacerbated when the patient performs squats or stands from the seated position. Clinically, patients notice symptoms more with sitting and during car rides. Repetitive activities such as walking, running, and cycling can become quite uncomfortable as tension over the sciatic builds.


While anatomy plays an important role, there are many avoidable risk factors that contribute to developing this syndrome. As the main hip external rotators are the gluteus maximus and gluteus medius, weakness and imbalance within these muscles impede proper function of the deep hip rotators, thus causing tension. Wearing improper footwear, running on banked surfaces or slippery surfaces, and sitting all day (especially if you have a wallet in your back pocket) are also common causes. Pregnancy, and the resulting relaxation of the pelvic bowl ligaments, is a potential cause. In this case, the deep rotators must pick up the slack for the ligaments. Replacing your shoes before they become too worn out, avoiding banked surfaces, and strengthening of the hip girdle muscles can make a big difference in avoiding this condition in the first place. 


As you can see, while small, these muscles can cause big problems. Thankfully, the most effective form of treatment is a conservative one that involves muscle therapy, stretching, and strengthening. The recover app, located at the link below, includes strengthening programs that can be done 2 or 3 times per week that will make a big difference! 


In addition, a tennis or lacrosse ball can be a simple and inexpensive means of trigger point therapy, which can help break up scar tissue in the glutei and relax the musculature - releasing tension on the sciatic. While external rotator syndrome is both literally and figuratively, a pain in the butt, it’s not an injury that has to stop you from doing the activities you love. 


Ian Nurse


Editor's Note: Dr. Ian Nurse is the founder of Wellness in Motion, a group of runner focused clinics in the Boston area. WIM's staff of acupuncturists, massage therapists, physical therapists, registered dietitians, sports psychologists, and personal trainers are the go to for first timer runners and elite marathoners alike. We’re excited to feature more of Ian’s running health articles on the Recover Athletics blog!