Piriformis syndrome is an uncommon form of lower back/buttock pain. Pain from the lower back/buttocks can travel to upper thighs or less often below the knee. Pain is produced or worsens on sitting or exertional activities such as running or playing sports (e.g., basketball, hockey or tennis etc.). Piriformis is an important muscle for the lower body. This muscle originates from the lower back and attaches close to the top of the hip joint. Piriformis is involved in almost every functional movement of the lower leg. It stabilizes the hip joint and rotates the thighs away from the body. This muscle also stabilizes our posture and balance when we are standing and enables us to shift weight from one foot to another and maintain balance.

There is no definitive test to diagnose the piriformis syndrome. However, presence of the following signs/symptoms raise a high suspicion: history of buttock pain that gets worse on prolonged sitting and running, history of trauma around the buttock region, absence of nerve root findings (intact sensation and myotomes) and tests which put the piriformis muscle in a tension position such as the Flexion- Adduction-Internal Rotation (FAIR) test.

Besides trauma, physically demanding sports and sedentary lifestyles, piriformis syndrome can also be brought on by malfunctioning gluteal maximus and/or gluteus medius muscles. When we have weakness in these muscles, our legs tend to rotate inward (knees coming together) during weight-bearing tasks (such as during climbing stairs or performing squats). Due to weakness of gluteus maximus/medius muscles, greater eccentric load is put on the piriformis muscle, thereby leading to overlengthening of the muscle and compression or irritation of the sciatic nerve (Jankovic et al, 2013). Studies show that strengthening the gluteal maximus/medius muscles in isolation or through movement re-training (e.g., avoiding excessive inward rotation of the legs during stair climbing) lead to significant improvement or complete resolution of symptoms and function (Fishman et al, 2002).

In addition to strengthening and movement re-education, stretching the piriformis muscle is also an important part of the rehabilitation. Regular stretching (about 5 repetitions every 1—2 hours, 30 second holds) keeps the piriformis muscle flexible, lean and long. These qualities achieved through stretching may also make the muscle resilient to trauma and irritation during exertional activities.

Finally, if your health care provider suspects piriformis syndrome, you should take these three steps to help speed your recovery:

• Avoid sitting for prolonged periods (take stretch breaks every 20 minutes)

• Prevent further trauma to the buttock region (avoid ballistic activities, high-demand sports etc. until your physiotherapist approves return to sports)

• Perform regular daily stretching

Although the piriformis syndrome is a nagging pain in the butt, full recovery and return to sports is achievable through participating in an evidence-based rehabilitation program. Some evidence supports 60- 70% improvement in symptoms and function after 2-3 months of physiotherapy (Hopayian & Danielyan, 2018).

References

• Hopayian, K., & Danielyan, A. (2018). Four symptoms define the piriformis syndrome: an updated systematic review of its clinical features. European Journal of Orthopaedic Surgery & Traumatology, 28(2), 155-164. Systematic review of cross sectional and prevalence studies

• Keskula, D. R., & Tamburello, M. (1992). Conservative management of piriformis syndrome. Journal of athletic training, 27(2), 102.

• Jankovic, D., Peng, P., & van Zundert, A. (2013). Brief review: piriformis syndrome: etiology, diagnosis, and management. Canadian Journal of Anesthesia/Journal canadien d’anesthésie, 60(10), 1003-1012.

• Kanwal, R., Imran, J., Awan, W. A., Khan, R., & Malik, S. (2018). STRETCHING EXERCISES VERSUS DEEP FRICTION MASSAGE FOR THE MANAGEMENT OF PIRIFORMIS SYNDROME. The Rehabilitation Journal, 2(02), 65-69.

• Tabatabaiee, A., Takamjani, I. E., Sarrafzadeh, J., Salehi, R., & Ahmadi, M. (2019). Ultrasound- guided dry needling decreases pain in patients with piriformis syndrome. Muscle & nerve.

• Fishman, L. M., Dombi, G. W., Michaelsen, C., Ringel, S., Rozbruch, J., Rosner, B., & Weber, C. (2002). Piriformis syndrome: diagnosis, treatment, and outcome—a 10-year study. Archives of physical medicine and rehabilitation, 83(3), 295-301

• Kim, D. H. (2018). A Movement-System-Impairment Approach to the Evaluation and Treatment of a Patient with Piriformis Syndrome: A Case Report.