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Featured Article | Physical Therapy

How to treat piriformis syndrome

August 24, 2020
By Health Loft

What is piriformis syndrome?

The piriformis is a deep muscle that is located at your hip joint and is an important stabilizer of your hip when you are performing a variety of movements including walking, standing, single leg balance, and running.  Piriformis syndrome is a common cause of hip and deep buttock pain, or sciatica due to the muscle interfering with the sciatic nerve.  This interference is generally due to tightening or spasms of the piriformis muscle which causes compression of the sciatic nerve.. 

You may experience pain in various areas down your leg with piriformis syndrome, because of the route  of the sciatic nerve. You may have pain radiate to the outside of the thigh, calf, or foot in addition to the hip and/or buttock. You may also feel pain in your lower back. Most people usually feel a deep, dull ache in the buttock region with potential numbness and tingling down the leg. Your pain may come on suddenly such as from an injury or trauma, or the pain may come on gradually with overuse.

Oftentimes, it can be difficult for your doctor to pin down exactly why the piriformis is interfering with the sciatic nerve.   When a cause is identified you are diagnosed with either primary or secondary piriformis syndrome.   Primary causes include anatomical deviations and secondary causes involve trauma. Piriformis syndrome is most often caused by trauma to the buttocks leading to inflammation and/or piriformis muscle spasm with resulting sciatic nerve compression.

 

Physical Therapy for Piriformis Syndrome

Physical therapy interventions for piriformis syndrome includes myofascial release, manual therapy, strengthening of lower body musculature and piriformis stretches, use of a hot or cold pack to reduce pain, and relative rest from aggravating activities.

Myofascial release involves the physical therapist applying deep, manual pressure (similar to a massage) to the piriformis to reduce your pain and decrease muscle spasms. Alternately, you can get a tennis ball or lacrosse type ball and roll on it where your pain is located at home. Manual therapy involves your physical therapist performing what are called joint glides to help reduce your pain and increase the amount of motion at your hip joint. Your physical therapist will provide a force to the ball of the hip joint (the femur) in various directions depending on what motions are limiting you. You will follow this up with exercises to ensure the range of motion improvements from manual therapy become more permanent.

If your injury less than a week ago, utilize ice to reduce swelling and pain. If your injury has been going on for longer, you can use heat before performing your exercises to reduce pain and warm up the tissues. Heat is beneficial prior to stretching as it can increase tissue elasticity. When applying ice or heat, make sure to use layers between the skin. Apply the ice or heat for 15-20 minutes. Avoid lying directly on a hot pack because this can increase your risk of getting burned. 

High impact activities such as jumping, changing directions, running, and climbing stairs will likely be problematic and need to be avoided during your rehabilitation. Be sure to limit your time sitting if this makes your pain worse and avoid sitting on your wallet. Listening to your symptoms and determining what aggravates and relieves your pain can make a big difference. Focus on minimizing the activities and movements that bring on your pain.

 

Exercises and stretches for piriformis syndrome

Exercise is often the mainstay of treatment for piriformis syndrome. Remember to listen to your pain when performing these exercises. If your pain level reaches 5-6/10 or greater (on a 0-10 pain scale), please stop the exercise and rest before continuing to the next exercise/routine. If the pain continues, and does not resolve within 24 hours, you should contact your physical therapist or MD. 

All exercises will be listed in order of progressing difficulty based on expert opinion. However, you may find different exercises harder than others. This emphasizes the importance of an individual approach specific to your needs and goals at Health Loft. 

The beginner phase of exercises is intended for those who have not begun any exercise treatment for piriformis syndrome. The first phase typically will take 1-3 weeks, but your progression and needs may vary. Perform each exercise for 12-15 repetitions and three sets, 1-2 times per day. Do not attempt to perform all the exercises listed; instead, pick around 3-4 for each phase. If you can perform 15 repetitions easily, consider adding a resistance band to increase the difficulty. Isometric exercises should be held for 10 seconds and completed for 10 repetitions per set. Stretches for all phases should be held for at least 30 seconds for 3 sets.

  • Glute sets (isometrics)
  • Supine piriformis stretch with affected leg’s knee brought towards opposite shoulder
  • Supine hip abduction isometrics
  • Sitting hip external rotation against gravity
  • Supine bilateral bridging
  • Side lying clamshells

The intermediate phase of exercises is intended for those who have successfully completed the beginner exercises and are progressing with rehab. Continue with the same sets, stretch hold time, and repetitions and add a resistance band as appropriate. 

  • Bodyweight squats
  • Side lying hip abduction
  • Supine piriformis figure four stretch with affected leg crossed over unaffected leg
  • Prone hip extension
  • Fire hydrants in quadruped
  • Step ups and step downs
  • Hip hikes
  • Side step-ups

The advanced phase will follow with exercises performed for 12-15 reps and 2-3 sets with stretches held for the same duration. However, consider adding more resistance holding small weights or changing the color of the resistance band to increase the demand. If you make the exercise harder, 8-12 repetitions may be more appropriate. 

  • Hip extension and abduction in standing
  • Pigeon pose piriformis stretch 
  • Standing piriformis stretch with affected leg placed on chair or stable surface while leaning body forward
  • Kneeling hip thrusts
  • Lunges
  • Fire hydrants in standing
  • Monster walks
  • Split squats
  • Single leg bridges

 

How to sleep with piriformis syndrome

There is no one single sleeping position when it comes to dealing with piriformis syndrome. You will need to utilize a trial and error approach to see what is most comfortable to you and what position minimizes your pain the most. Below are some sleep positions you may find beneficial. 

If you prefer side sleeping, bend your knees and place a pillow between them. It is recommended that you sleep on the unaffected side to relieve pressure from your buttock. This position may also help reduce pressure on your spine. If you like sleeping on your back, place 2-3 pillows your knees so that they are slightly bent. Although sleeping on your stomach is usually worse with back pain, it may be more comfortable when dealing with piriformis syndrome because you are avoiding lying directly on your buttocks. The key is to see what position works best for you. 

 

How to sit with piriformis syndrome

Finding a good sitting position can be as difficult as finding your best sleeping position.  You will have to experiment to find what positions and padding do not cause additional pain. However, avoid sitting on your wallet or anything in your back pockets. Additionally, avoid crossing your legs because this will stretch the piriformis and may cause irritation. 

If you sit a lot at work or during your typical day, try to get up and move around every 15-30 minutes or at least once an hour. Avoid staying in the same posture or position for prolonged periods. You should also use a chair with back support and a soft chair cushion. Your feet should be placed flat on the floor and your elbows resting on armrests at approximately 90 degrees. 

For an individualized treatment plan to assist you with piriformis syndrome or any other type of hip or buttock pain, consult with one of our physical therapists in Chicago, IL (virtually via our telehealth platform or in person) by calling us at (312) 374-5399 or by scheduling an appointment online. Remember to also check out our Facebook, Instagram, and Twitter pages for more fun facts and articles on nutrition, physical therapy, and exercise!

 

REFERENCES

  1. Hopayian, K., & Danielyan, A. (2017). Four symptoms define the piriformis syndrome: an updated systematic review of its clinical features. European Journal of Orthopaedic Surgery & Traumatology28(2), 155–164. doi: 10.1007/s00590-017-2031-8
  2. Tonley, J. C., Yun, S. M., Kochevar, R. J., Dye, J. A., Farrokhi, S., & Powers, C. M. (2010). Treatment of an Individual With Piriformis Syndrome Focusing on Hip Muscle Strengthening and Movement Reeducation: A Case Report. Journal of Orthopaedic & Sports Physical Therapy40(2), 103–111. doi: 10.2519/jospt.2010.3108
  3. Revord, J. (n.d.). Symptoms and Diagnosis of Piriformis Syndrome. Retrieved from https://www.spine-health.com/conditions/sciatica/symptoms-and-diagnosis-piriformis-syndrome
  4. Cass, S. P. (2015). Piriformis Syndrome: A Cause of Nondiscogenic Sciatica. Current Sports Medicine Reports14(1), 41–44. doi: 10.1249/jsr.0000000000000110
  5. Boyajian-Oneill, L. A., Mcclain, R. L., Coleman, M. K., & Thomas, P. P. (2008). Diagnosis and Management of Piriformis Syndrome: An Osteopathic Approach. The Journal of the American Osteopathic Association108(11), 657. doi: 10.7556/jaoa.2008.108.11.657
  6. Derman, P. (n.d.). 3 Little-Known Tips for Sleeping with Sciatica. Retrieved from https://www.spine-health.com/blog/3-little-known-tips-sleeping-sciatica
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