The piriformis is a hip muscle that runs from the sacrum to the outer aspect of the greater trochanter.  Piriformis Syndrome is a condition in which the piriformis muscle goes into spasm irritating the sciatic nerve.  The sciatic nerve can become pinched when it passes above the piriformis muscle or through the piriformis muscle.  The sciatic nerve passing through the muscle is a deviation from its normal course that is seen clinically in 10% of people due to anatomical variations.

Signs and Symptoms: 

Piriformis Syndrome occurs when the piriformis muscle becomes tight or cramps, causing pain as it compresses the sciatic nerve in the buttocks and refers pain along the path of the sciatic nerve. Symptoms can occur either locally around the nerve and surrounding muscles or in referred areas throughout the body:

• Deep and dull aching in the buttock and thigh
• Pain in the calf
• Pain in the low back that is aggravated while sitting and walking 

Symptoms may be made worse by sitting, climbing stairs or performing squats.

On-Site Management: 

P.R.I.C.E.

PROTECT the area from further injury by avoiding exercises that produce pain.

REST: cutting back on the amount of training can be difficult, but key to recovery. 

Place ICE on your buttock for 15-20 minutes every 1.5 to 2 hours for the first 2 to 3 days or until the pain goes away. 

COMPRESS the area by having a trainer or physiotherapist use a hip wrap with a tensor. 

ELEVATION is not necessary.

Massage. Massaging the area can be done either by a therapist or by the individual by using a tennis ball. The athlete places the tennis ball on a hard surface and then sits on the ball and gently moves back and forth across it, making sure that the ball is applying pressure to the tender spots in the buttocks area. Work towards full range of motion in the affected leg compared to the unaffected leg.

Medical Referral and Rehabilitation:

Athletes should seek out a medical referral to a therapist for proper evaluation of posture, footwear and body mechanics. The therapist can also direct the athlete to proper stretching activities and correct return to play criteria.  Treatment will target decreasing the swelling and pain with the possible use of nonsteroidal antiinflammatory drugs, as well as work on stretching and strengthening the area including the hip and core.  Acupuncture, dry needling (IMS) and massage are often helpful in providing symptomatic relief. 

Posture. Ensure that proper posture both in standing and sitting are being used. ‘Slouching’ or standing with all your weight on one foot is improper technique. Sitting tall and applying weight evenly over both feet when standing are more favourable techniques. Also when going on long drives, take frequent breaks to walk and stretch.

Stretching. The Pretzel Stretch is a good piriformis stretch. Start off by lying on your back, bend your knees and cross your left leg over your right so that your left ankle rests on your right knee in a figure four position (if the pain is on the right side reversed the direction above). Then bring your left leg towards your chest by bending at the hip. Reach through and grab your right thigh to help pull things toward your chest. You may also put a sheet around your right thigh to use to pull it toward your chest. For muscle balance purposes, it is always best to stretch both sides.

Footwear. Evaluate the footwear being used. Do they need to be replaced or do orthotics need to be introduced?

Return to Activity: 

This is a gradual process and may take some time. In general, the longer you have symptoms before you start treatment, the longer it will take to rehabilitate. Always follow the treatment plan specific for you from your therapist but a general plan would include these progressions to return to activity:

• Work towards full range of motion in the affected leg compared to the unaffected leg. 
• Work towards full strength of the affected leg compared to the unaffected leg.
• Work towards jogging straight ahead without pain or limping.

For competitive athletes, you should extend the list to include the following:

• You can sprint straight ahead without pain or limping.
• You can do 45-degree cuts, first at half-speed, then at full-speed. You can do 20-yard figures-of-eight, first at half-speed, then at full-speed.  
• You can do 90-degree cuts, first at half-speed, then at full-speed.
• You can do 10-yard figures-of-eight, first at half-speed, then at full-speed.

Prevention: 

To prevent Piriformis Syndrome from returning the following steps should be taken:

Posture. Ensure that proper posture both in standing and sitting are being used. ‘Slouching’ or standing with all your weight on one foot is improper technique. Sitting tall and applying weight evenly over both feet when standing are more favourable techniques. Also when going on long drives, take frequent breaks to walk and stretch.

Stretching. The Pretzel Stretch is a good piriformis stretch. Start off by lying on your back, bend your knees and cross your left leg over your right so that your left ankle rests on your right knee in a figure four position (if the pain is on the right side reversed the direction above). Then bring your left leg towards your chest by bending at the hip. Reach through and grab your right thigh to help pull things toward your chest. You may also put a sheet around your right thigh to use to pull it toward your chest. For muscle balance purposes, it is always best to stretch both sides.

Footwear. Evaluate the footwear being used. Do they need to be replaced or do orthotics need to be introduced?

Brukner, P. and Khan, K. Brukner and Khan's Clinical Sports Medicine Brukner, P. and Khan, K. (2007) Brukner and Khan's Clinical Sports Medicine. 4th ed. North Ryde: McGraw-Hill. 

Rouzier MD, Pierre. Piriformis Syndrome. Ampang Puteri Specialist Hospital, KPJAPSH. N.p., n.d. Web. 18 Mar. 2013. <http://www.apsh.kpjhealth.com.my/Piriformis-Syndrome-article-1017.html>.

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