Piriformis Syndrome
Tom Craggs
Another very common pain we find runners asking about is piriformis syndrome - this can be a pretty debilitating issue and can also be confused with other injuries. Please note this is a pretty detailed article and best viewed on a desktop (though will work on a mobile!)
1. What is it? The piriformis is a small muscle that can wreak a large amount of discomfort! It's purpose is to laterally rotate and abduct the femur. It attaches at the anterior sacrum, the base of the spine the superior margin of the greater sciatic notch and inserts on the greater trochanter of the femur. Between these two points the piriformis runs through the greater sciatic foramen which, as the name suggests, is also where the sciatic nerve (amongst other nerves) travels. This can cause problems because when piriformis becomes tight because it can compress the sciatic nerve that runs underneath it (in most cases). In about 17% of the population the piriformis the sciatic nerve is routed differently including directly through the belly of the muscle itself.
2. Diagnosis & Signs As with all injuries it's very important to get properly diagnosed by a sports doctor or a physiotherapist. Piriformis syndrome will tend to flare up as as persistent pain in the glutes which might feel particularly sore or increase in pain when sitting for long periods particularly with your knee dropped out to the side or if you are flexed beyond 90 degrees at the hip. Often pain will refer down the hamstring or along the back of the leg and feel quite 'nervy' with symptoms similar to that of sciatica (which is actually a lower back issue). Pain will get worse with running.
3. Common Causes Generally tightness or cramping in the pirfirmis muscle itself is the problem. This can be simply down to a lack of regular and effective stretching, however even with a good stretching routine the piriformis can become over worked and tight through poor running biomechanics, building up training too quickly, poor choice of footwear or because the supporting/surround gluteal muscles are weak. Runners/cyclists/triathletes who spend lots of time sitting down or driving can be particularly prone to this issue and has mentioned if you are one someone whose sciatic nerve routes through the priformis muscle itself you will be more predisposed to piriformis syndrome if you neglect proper stretching and conditioning.
4. Management and Prevention Below we outline some of the key basic exercises runners can do help manage and prevent piriformis syndrome. None of the advice below should replace anything a physiotherapist or sports doctor has advised for you to do after assessment. The key to piriformis issues is that you need to manage both the symptom and the cause. The symptoms require massage, physical therapy, self massage and stretching as well as potentially nerve flossing. The cause relates to improving your strength and running biomechanics. As with most running injuries the first step is to rest or significantly cut back your volumes of running, if you can continue to cross train pain free then use this to maintain cardiovascular fitness but be aware that bike, elliptical and and aqua jogging can also cause piriformis pain. Don't just plough and hope this pain will go away - the chances are it wont. Check out your footwear and have a qualified running coach or physiotherapist assess your biomechanics to ensure you have the correct footwear. If you sit for prologued periods ensure you take breaks and get up and active completing some of the below.
Step 1) Direct Treatment. The piriformis muscle sits deep in the hip so whilst I could definitely recommend some of the self release options below I would strongly advise seeing a sports physiotherapist or very local local sports massage therapist who will be able to work deeper into the muscles than you might be able to self massage - in the acute phase this could even be a couple of times a week. Deep tissue therapy is one of the key fixes for this issue to break down the knots that have shortened the muscle and trigger points in the fascia and if you can find a therapist who can combine this with dry needling this can also really help. Getting onto this early at the first sign of issues can really help prevent what can become a persistent issue.
Step 2) Self Release. Self massage using a foam roller or even better spikey massage ball on your glutes and piriformis and hamstring will help to ease some of the tighter spots and trigger points.
Step 3) Stretch. Daily stretching is critical to easing piriformis syndrome and is critical to include if you want to return to pain free running. Hold each of the following stretches for 40 seconds and repeat 2-3 times.
Step 4) Flossing. I have mentioned already that much of the pain associated with piriformis syndrome is related to compression of the sciatic nerve. Nerve flossing helps by restoring the function of the nerve by allowing it to slide freely around the muscle and other soft tissue. This is best done after the initial pain has been managed through massage and stretching. It's particularly important if you are getting referred pain down the back of your leg.
Sometimes known as the pigeon stretch, fold leg underneath you drop body over bent leg aim to keep hips down and foot forward.
Keeping back tall hug knee to opposite chest.
Gently push your knee away.
* Start by sitting on a high chair in a slightly slumped position with your head slightly dropped down and forwards.
* Start to straighten your leg (on the side you have the pain) with your toes plantar flexed.
* As you start to feel a slight stretch or tension dorsi-flex the toes at the same time as you raise you head holding for 3-4 seconds.
* Repeat 20 times for 2-3 sets.
Step 5) Strengthen. One of the key reasons the pirifiromis gets tight is that it is over working because the other, more powerful glute muscles are under active or weak. Unless your strength and running biomechanics are addressed you can reasonably assume you will see piriformis syndrome returning in the future. The excises below are a starting point once leg levels have reduced through the above and should be completed ideally 3+ times a week. Complete 2-3 sets of each exercise for 45-90 seconds. Over time you may wish to include more compound exercises including weighted squats and walking lunges once you have a base in place. Some of these exercises such as the clam and bridging exercises provide an excellent pre run glute activation routine.
​
* Clam. Lie on your side with your feet tucked up and raise and lower your top knee without letting your hips roll backward through the movement. Repeat up and down to feel a burn in the glute medius muscle in the hip.
* Abductions. In the same position now straighten the top leg and again raise and lower ensuring your hip does not roll backwards or forwards. Repeat the clams and abductions on both sides.
* Banded Side Step. With a thera-band just above the knees take a semi squat position and ensure there is some tension against the band from your legs. Take small sideways steps ensuring there is resistance against the back throughout the movement. Repeat leading with the other leg.
* Banded Bridge. Using a theraband around your knees roll up into bridge position by engaging the glutes to extend at the hip. Keep you abdominal muscles engaged. Combine with your hip extension apply pressure out onto the band to activate glute medius. If you feel this mostly in your hamstrings tuck your feet further under towards your hips. Hold statically aiming to not let the hips drop.
* Single Leg Bridge. With one leg straight raise yourself up into a bridge position (as above). Aim to not let the hips 'sag' on the side where you have your leg extended. Once you have a nice alignment from shoulder to hip to knee bring the foot back, drop your hips to the floor and then repeat on the other leg. Alternate continuously.
Step 6) Address the Biomechanics. Runners who have a pronounced 'hip drop' as they run, or whose feet cross over a midline as they run due to limited glute max and medius limited activity will often see priformis needing to compensate. The strengthening exercises will help to reduce this but its important to also work on 'locomoting' this work through movement and running drills. There are loads of drills out there that, with proper form, will improve glute firing and activity in your running gait so below I have included a couple of videos with tow of the more simple drills to work on.
​
* Walking Knee Hug - Check out the video of Mel competing this simple drill. Notice the trip extension of ankle, knee and hip but crucially that the stability in the movement is created by a big contraction in glute max.
​
* Straight Leg Kick Out - In this video India Lee demonstrates a drill we also use for plyometric development and calf and tibialis engagement but of key relevance here is noting India's high hip position and ability to maintain balanced hips on foot strike through effective recruitment of glutes and proprioception.