As a massage therapist, I have found working the Sacral/gluteal region to be so important in treating low back pain. I think of this Sacral/gluteal region as the Chassis, holding the framework for the whole body. As I massage and stretch the gluteal region, I have found more and more people with Piriformis muscle issues. The Piriformis muscle is such a workhorse helping us walk, balance, run, bike, hike, swim, walk the dog and stand; all those activities we like to do in the Summer. Maybe that’s why I’m seeing so much of it lately! When tightness and tension in the Piriformis muscle leads to chronic pain you may be experiencing Piriformis Syndrome.
Piriformis syndrome is neuromuscular disorder that involves the piriformis muscle causing pain, tingling and numbness in the gluteal/buttocks region (a real pain in the ass!). When the piriformis muscle shortens or spasms due to trauma or overuse, it can compress the sciatic nerve beneath the muscle. There may be pain in the whole sacral region and low back area. Piriformis syndrome can lead to a belt of tension that runs around the waist, low back and hips.
The piriformis muscle is a flat, band-like muscle located in the gluteal region near the top of the hip joint, just off the Sacrum. This muscle stabilizes the hip joint and lifts and rotates the thigh away from the body. This helps us walk, climb stairs, shift our weight from one foot to another, ride a bike and maintain our balance while standing. It is used most every motion of the hips and legs!
The sciatic nerve is a thick, long nerve running just off the Sacrum. It passes alongside the piriformis muscle, goes down the back of the leg, and eventually branches off into smaller nerves that end in the feet. Nerve compression can be caused by tightness or spasm of the piriformis muscle or an enlarged piriformis.
There are so many muscles that connect to Sacrum, I like to say sometimes they act like unruly children in line for recess, pushing and shoving, pinching the Sciatic nerve…When I do trigger point and deep tissue massage to the Sacral region, I’m like the nun in Catholic School telling all the muscles to line up nicely and get along!
Piriformis & Sciatic Nerve
Anatomy photo from www.innerbody.com
Inactive glutes can contribute to piriformis problems because they support hip extension and assist the piriformis in rotating the leg. If the hip flexors are too short or tight, such as when someone sits with hips flexed (as in sitting all day at work, sound familiar?) or stands all day in the same position on a hard surface, such as cement floors (think grocery clerk). This deprives the glutes of activation so the supporting muscles to the glutes (hamstrings, adductors and piriformis) have to work extra hard! This produces tightness and sometimes severe pain in the glutes (hence pain in the ass!)
Muscle overuse resulting in piriformis syndrome can be from activities performed in the sitting position that involves strenuous use of the legs as in rowing or standing in one position without being able to flex muscles. Runners, Cyclist and other athletes engaging in forward-moving activities are most susceptible to developing piriformis syndrome if they don’t stretch and do strengthening exercises. These activities can also lead to increased piriformis size, then sciatic nerve impingement is nearly inevitable.
Another cause of Piriformis Muscle tightness is dog walking! Especially if you have a large dog who likes to tug at the leash and carry you along. Think about the muscles used when holding back a big dog, you tend to put all your weight into your heels, you can just feel your glutes tightening up to hold you steady so you’re not dragged away by your dog. I frequently find tight piriformis muscles in my dog owners.
I have seen Piriformis problems from women who wear high heels and either walk or stand frequently (think of those retail clerks at Macy’s or women in finance) What is it with women and heels? It’s like telling a smoker to quit! Good for massage business I suppose! Which reminds me…
Piriformis syndrome can also be caused by pronation of the foot. When a foot overpronates it causes the knee to turn in, causing the piriformis to work hard to protect the knee. This causes the piriformis to become tight, which can lead to piriformis syndrome. A podiatrist is recommended in this case to adjust foot pronation with orthopedics. Foot Reflexology and Passive Foot Stabilization can be helpful here.
I have seen Piriformis Syndrome in pregnant clients as a result of the forward shift in weight and the increased weight they are carrying creating a strain on the Piriformis, this is another reason for increased chance of Sciatica during pregnancy. The good news is this is usually remedied by having the baby and getting back to a normal weight, improved posture.
Piriformis Syndrome Symptoms:
Piriformis syndrome usually starts with pain, tingling, or numbness in the buttocks ( it’s a real pain in the ass as I keep saying!). Pain can be severe and extend down the leg. The pain is due to the piriformis muscle compressing the sciatic nerve, such as while sitting or standing for a long time. This is also common in pregnancy as the hips, sacrum are shifting due to increase weight gain. Similarily piriformis pressure can come from carrying excess weight even when you are not pregnant, maybe just needing to shed some pounds. Pain may also be triggered while climbing stairs, applying firm pressure directly over the piriformis muscle, or having to stand in the same position for long periods of time (like grocery clerks). I just had to stand in line @ Disneyland and I really felt it in my piriformis! The body is designed to keep moving, not stand still.
The tricky business of diagnosing Piriformis Syndrome:
There is no definitive test for piriformis syndrome. In many cases, there is a history of trauma to the area, repetitive, vigorous activity such as long-distance running, cycling or prolonged occupational standing (grocery clerk again). Diagnosis of piriformis syndrome is often times determined by ruling every other form of hip gluteal pain using X-rays, MRI’s & other tests to rule out herniated disc, osteo-arthritis or need for hip replacement. When nothing is conclusive Doctors may shrug & say, “maybe Piriformis Syndrome?” It seems as elusive as Migraine used to be for women!
What to do if you suffer from Piriformis Syndrome:
If pain is caused by sitting, standing or certain activities, try to avoid the positions that trigger pain. Rest, ice, and heat may help relieve symptoms. I was one of the Massage Therapists in the Group Health Low Back Pain study, where clients were given massage for low back pain and the study concluded that Massage did indeed work! So of course my recommendation for Piriformis Syndrome and low back pain in general would be Massage, Massage, Massage!!!
Tennis ball to the gluteal range (one side at a time) may be helpful as deep pressure to the piriformis can help. Just be careful you are not on the Sacurm (the bony landmark that is like a triangle in your low back/gluteal range) if you have the tennis ball on bone, it will feel really wrong. When it is on the muscles it may just hurt so good! Lay on it for 3-10 minutes on each side. This tennis ball solution can become addicting! Yet less problematic than an Oxycodone addiction!
Tennis Ball in gluteal range
Release the Piriformis Muscle w/ a Tennis Ball
Some health care providers may recommend anti-inflammatory drugs (Advil), muscle relaxants (Valerian or something stronger) or injections with a corticosteroid or anesthetic. I have heard talk of Botox to the region, but don’t know if that works.
Piriformis syndrome is also known as ”wallet syndrome,” because it can be caused by sitting with a large wallet in the affected side’s rear pocket, I think there was a Seinfeld episode about this? Oh now you get the Seinfeld reference from yesterday!
Could it be your WALLET?
Of course I’m a big fan of Deep Tissue Massage, Trigger Point, Acupressure and Shiatsu can help with Piriformis Syndrome (I have some client converts who will tell you so!)
Cupping Treatment to the Gluteal & Sacral regions can help by bringing fresh blood to the area. They now sell Silicone cups that do not require flame, so simple you could quite possibly purchase online and do this treatment for yourself. If you have never tried cupping, I recommend coming in and trying it out, I love it!
Cupping the Piriformis Muscle
Arnica Cream + Arnica Tablets can help.
My Fave Massage Treatment for Piriformis Syndrome is the Pirirformis Pin and Stretch
Place foot medially, shortening the Piriformis, then Pin with fist
Once Piriformis Muscle is pinned, you can bring foot lateral to stretch the Piriformis.
With the clients prone, bend their knee, holding their ankle/foot shorten the Piriformis muscle by bringing their foot in medially (hips rotating). I prefer to use my fist for the most even coverage, but occasionally I will use elbow here if I want to get in deeper. I pin the Piriformis with my fist, then pull the foot/ankle laterally towards me (have the client breathe, this can be an intense stretch!)
There are some exercises and stretches to help reduce pain from piriformis syndrome. These stretches may help:
Yoga is also beneficial.
Superfeet are great for those of us who work on our feet! These insoles will give a bounce to your step and keep your glutes and piriformis happy!
Wearing supportive, gel inserts shoes when standing for long periods of time can help. If you have a job where you are on your feet for more than 6 hours a day, you should be buying new shoes with gel inserts every 6 months to keep that cushion strong.
Heels? Just don’t wear them if you have to walk or stand at all! Or wear them & just come get a massage every week!
My favorite shoes for Gel Support are Asics! I got a pair last year & they were so comfy & put such a spring in my step, that I actually went back & bought a second pair as back up (what can I say they were on sale!) I highly recommend tennis shoes with lots of gel inserts if you are on your feet all day long!
Epsom Salt Baths are great for softening the muscles including the Piriformis! Epsom salts are so affordable you can really put a haping cupful in a warm-hot tub every night.
Have you heard of the Tush Cush? I had one client with hip/low back/ glute pain from sitting all day & she swore by this!
Contents of this Blog are copywritten by Queen Anne Healing Arts.
Here are some of the products I recommend for piriformis syndrome: