Why You (Probably) Don't Have Piriformis Syndrome
The commonly misdiagnosed condition with treatments that might be impairing your recovery.
In this article:
What is piriformis syndrome
Why it is such a common diagnosis and discussed online
Why you probably don’t have piriformis syndrome
Why the treatments often recommended aren’t helping you
How to diagnose piriformis syndrome yourself
Which type of piriformis syndrome your have (Hint: there is more than one)
How to treat your piriformis syndrome
Many people experience sciatic nerve pain that feels as though it begins in the hip joint and then travels down into the buttock and possibly all the way down the back of the leg and into the toes. When the pain seems to originate in the hip, these symptoms are often diagnosed as piriformis syndrome. If you search online for these symptoms, there is a good chance you will come across plenty of information online that gives you the impression this is a common condition and is likely the cause of your pain. However, piriformis syndrome is actually very rare and most of the time a misdiagnosis.
The fitness and fashion industries actually share some commonalities. Similarly to the cycles we see in the fashion industry with different styles falling in and out of favour, the health and fitness industry also experiences cycles as different conditions and treatment approaches become a common diagnoses or focus in the industry.
Often this stems from a new piece of research that happens to pick up a lot of traction. It begins to shape the industry, possibly affecting diagnostic assessments or influencing common treatment protocols. As the new research trickles down through the industry, we often "lose sight of the forest for the trees". We become myopic in our focus on the new information that's gaining popularity and lose sight of the true breadth of the field. This tends to lead to a lot of nuance and detail lost along the way.
Piriformis syndrome is an example of a condition that's popularity outpaced its true prevalence. If you have been diagnosed with piriformis syndrome (without an MRI to confirm and/or a thorough physical assessment of your hip and lumbar spine), or you have been researching for yourself and have come across information leading you to believe it may be the cause of your pain, chances are, you don't have piriformis syndrome.
In this article, I will explain why this is the case and explain why there are more common causes of sciatica.
What is Piriformis Syndrome?
The piriformis muscle is a thick, flat muscle. It is one of our deep hip muscles that are found underneath your larger glute (buttock) muscles. Its main role is in lateral rotation of the hip.
Lateral rotation of the hip is when the hip rotates outward, away from the middle of the body. Imagine standing up straight and then turning one of your feet outward, so your toes point away from your other foot. This motion involves rotating your thigh bone (femur) in the hip socket to move your leg and foot outward.
Piriformis syndrome occurs when the piriformis muscle irritates the sciatic nerve and causes pain. The sciatic nerve typically runs underneath the piriformis and then carries on down the leg. However, in about 12% of the population, the sciatic nerve actually runs through the piriformis muscle instead. Making it more prone to irritation from certain changes in the piriformis muscle.
The commonly believed cause of piriformis syndrome is when the piriformis muscle spasms or becomes excessively tight and compresses the sciatic nerve. You can see how in people with a sciatic nerve running through the muscle belly this could obviously cause some discomfort.
Many in the industry are also however finding that this syndrome may be caused by a piriformis muscle that is excessively stretched. This causes excessive strain on the muscle during certain movements that can lead to inflammation that affects the nearby sciatic nerve and causes pain.
(I will explain how you can tell the difference between a tight or stretched piriformis muscle later in the article.)
Why you probably don't have piriformis syndrome
When you combine the relative rarity of the anatomical variation that increases susceptibility to this syndrome with the requirement for a muscular pathology to be present in a specific hip muscle, you can see why the real world prevalence of piriformis syndrome would be very low. Studies attempting to identify how often sciatic symptoms are caused by piriformis syndrome have found it to be between 0.3-6% of sciatica cases.
Additionally, not only is true piriformis syndrome very rare, but the prevalence of lumbar spine pathologies that have the potential to cause sciatic symptoms are extremely common. About 80% of us will experience at least one episode of lower back pain over our lifetime. Of all the potential causes of low back pain, the most common is a disc injury. And of all the discogenic injuries that occur in the lower back, the overwhelming majority occur at the level of the spine in which the sciatic nerve roots exit.
So you can clearly see why if you are experiencing sciatica, the likelihood that your piriformis muscle is the cause rather than a lumbar spine injury is extremely low.
Anecdotally, in clinical practice, I have encountered very few true piriformis syndrome cases. In the overwhelming majority of people experiencing radiating pain that appears to be emanating from their hip, I am able to demonstrate that the actual cause of their pain is triggered by changes in the lower back rather than their piriformis muscle.
Now if you're someone that says "be damned with statistics, I want to know for sure that I don't have piriformis syndrome", then let's dive a little deeper.
How to assess for piriformis syndrome
When assessing someone in person, it would typically involve lengthy testing of their lumbar spine and hip to confirm the pain mechanism and exclude other possibilities. Trying to explain all of that would have both of us wishing there was a TL;DR.
So instead I am just going to describe one simple test for you to help you point in the right direction.
Hip Internal Rotation
(You will need a friend to help you with this one)
While lying on your back, your friend is going to grab your ankle with one hand and hold under your leg, just below the knee, with the other.
Then they will raise bend your knee and raise your leg until your thigh is 60 degrees off the floor.
Now your friend is going to pull your ankle, while stabilising your leg around your knee, to rotate your lower leg away from your body.
This causes your thigh bone to rotate inwards toward the middle of your body, with the head of your femur rotating inside your hip joint.
Repeat this on both legs and compare if one side is more restricted than the other, while also taking note of pain symptoms.
If you have piriformis syndrome, this movement will very likely cause pain to be felt deep in the back of your hip.
If this test does not cause your pain. Then it is definitely worth it to thoroughly investigate your lower back and confirm if a lumbar pathology is actually the cause of your pain.
If you know someone that has been told they have piriformis syndrome, share this article with them and ask them how they performed in this test.
To stretch, or not to stretch
It depends...
Many people with sciatica experience a feeling of tightness in their glutes, hamstrings and/or calf muscles. However, this almost always has nothing to do with muscular tightness. And rather is related to sciatic nerve root irritation. Stretching these muscles will likely also increase tension on the sciatic nerve - which will only irritate it further. You may experience temporary relief as a result of stimulating your stretch-reflex, giving you the false feedback that stretching is benefiting you. But if the pain continues to return, it is much more likely that stretching is merely masquerading the repeated irritation you are placing your sciatic nerve.
BONUS INFO: The stretch reflex refers to an increase in neurological activity that occurs in response to a muscle being stretched. This feeds back to the muscles causing them to contract. This contraction prevents our muscles from over-stretching beyond their limits and causing damage like leading to a joint hyper-extending for example.
However, it also has an analgesic (pain relieving) effect as it dulls the pain signal temporarily. This may seem like a good thing, however we commonly stretch into postures that actually aggravate lumbar spine pathologies and dull the signal telling us we shouldn't be doing it. It provides a false feedback loop in which the temporary pain relief encourages us to stretch more, only to further irritate our injury making us feel we need to stretch again.
Just consider, if your sciatic nerve pain is caused by a pathology in your lumbar spine, how is stretching your hamstring going to positively impact that injury?
So when is stretching a good idea?
If you the hip internal rotation test did cause you pain deep in the back of your hip, then your piriformis muscle may be the cause of your symptoms and stretching might be a good idea. However, before you rush off to stretch your tightness away (probably sick of me telling you stretching isn't a good idea), we need to determine if you have a tight piriformis, or a stretched piriformis.
A tight piriformis will benefit from stretching. But stretching an already lengthened piriformis will only make your symptoms worse.
When you performed the above test. I mentioned to notice if one side was more restricted than the other.
If your painful side was more restricted, i.e. you thigh was unable to rotate inwards enough (your friend was unable to pull your lower leg as far away from your body), then you have a tight piriformis. And it's worth giving stretching a go.
However, if you were less restricted on your painful side. Then you have have a stretched (or lengthened) piriformis. And stretching would be counterproductive. Instead you would need to strengthen you lengthened piriformis to help prevent it becoming irritated and inflamed.
Let me know what you found with this test. Did it replicate your pain? Was there a difference in the range of motion between your painful side and non-painful side?
Well if you have made this far and I still haven't convinced your that piriformis syndrome and stretching are probably not the cause or solution to your problems, then I will spend the rest of this article giving you a treatment options for both a tight and a stretched piriformis.
So only continue with this article if you feel very confident that piriformis is the source of your problem.
And if you have any other questions or queries about the information in this article, I wanna hear them! Let me know how can I improve this article to more clearly provide this information to you.
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