Boyd W. Haynes, MD
As a busy Sports Medicine Physician, I often see patients for ailments which other physicians may not encounter very often. That’s because athletes have a way of injuring muscles that many people have never heard of, because of the demands that they place on their body while playing or competing. The Piriformis Muscle is one of those and in this article, I will describe it, how it is injured and effective ways of treating it when injured.
In the gluteal (buttocks) region of the body, there lives a muscle that is tucked away deep in the pelvis called the Piriformis (Latin for pear-shaped) muscle. This muscle is one of six lateral rotator muscles that help rotate the femur (thigh bone) one way or another. To help you visualize its role, imagine sitting in a chair with both feet on the floor. If you lift your right leg and place the right ankle on the left knee, with your right knee facing outward, that motion is allowed by the Piriformis and other lateral rotators. The Piriformis is also important because it helps us ambulate without falling down, by allowing us to shift weight from one foot to another while walking or running.
The Piriformis Muscle lies next to and in some people, can intersect one of the main nerves which travels from the spine to the leg, the sciatic nerve. When everything is functioning normally, these two coexist peacefully, each minding its own business. However, sometimes the Piriformis Muscle rubs against the sciatic nerve repeatedly, which irritates and inflames the nerve. The inflamed sciatic nerve then causes pain in the buttocks. It may also cause pain, numbness and tingling in the leg, also referred to sciatica. This is known as Piriformis Syndrome or PS.
Competitive runners, rowers and bicyclers often develop the condition, as do soccer players, but it can occur in anyone who exercises frequently and who utilizes the piriformis muscle repetitively. Symptoms can be worsened by sitting in a car or chair for long periods of time, climbing stairs or by running.
When I see patients complaining of sciatica, I must first determine whether the sciatica originates from the spine or from the Piriformis muscle, because the symptoms are the same. 80 year-olds typically have spine-related issues and 25 year-old runners typically have PS, but not always. I will ask many questions about your activities, when the pain is worse, better, etc. A physical exam, watching you walk and getting you to rotate your leg and hip to trigger symptoms will be important to my diagnosis. I will get x-rays to rule out arthritis or bone spurs of the spine, which could be causing the problem.
Conservative treatment will include activity modification, OTC anti-inflammatory medications, ice/heat therapy and possibly oral steroids. Physical Therapy plays a huge role in rehabbing folks with PS. Often there is a gait imperfection or abnormal body mechanics which need to be corrected. A misaligned pelvis can often be the root of the problem. Strengthening and stretching exercises are key, as well as core strengthening. Orthotics may also be helpful and may be ordered to correct leg length abnormalities or foot issues. Massage, ultrasound and other modalities may be employed by the Physical Therapist. Using a foam roller or tennis ball for self-massage is also recommended.
Conservative treatment usually clears up the problem; however, some folks present with a tougher case. I may order an MRI or CT scan to confirm my diagnosis and to rule out hidden spine issues. I can inject a corticosteroid into the Piriformis muscle under x-ray or ultrasound guidance. We can also use PRP (Platelet Rich Plasma) therapy which is usually very effective.
Rarely do I see cases that do not improve with these treatments. Surgery can be done to relieve the nerve compression and tends to be successful when performed.
As with many ailments, prevention of PS is much preferred over treating the condition. Performing warm ups and stretches before sports or activities is helpful. Using proper form is crucial and having the appropriate footwear for the sport is important. Keep running or exercising on hills or uneven surfaces to a minimum. Increase exercise intensity gradually, at no more than 10% per week. If you are a competitive athlete, get a sports coach who is trained in identifying and modifying gait abnormalities and work to perfect your form before injury becomes an issue.