Getting a leg up

Has this ever happened to you? Suddenly, you feel pain in the lower portion of your back and the upper portion of your buttock, and (sometimes) the pain runs down your leg. It hurts. It restricts movement. And it doesn’t seem to go away. Sometimes, the pain is worse than others, but typically, it remains constant. The terms sciatica and piriformis syndrome are commonly used to describe this condition. While the conditions are similar – they both affect the same general body areas – they differ concerning causes, symptoms, and treatments. Below I describe each condition and recommend exercises and stretches that can help.

Anatomy

The piriformis muscle locates in the gluteal (butt) region underneath the gluteus maximus muscle (largest butt muscle). This flat pyramidal-shaped piriformis muscle is one of the six lateral hip-rotator muscles – the name derives from Latin, meaning “pear-shaped.” The piriformis starts from the front part of the sacrum (lower spine) and attaches to the second, third, and fourth sacral vertebra (spine portion between your lower back and tailbone), and from there, it’s connected to the upper thigh bone surface.

The piriformis is responsible for laterally (outward) rotating the thigh (femur) bone during hip extension. To visualize this movement, lift one leg and cross it over the other while sitting so that your outside ankle is resting against the other knee. The piriformis muscle is also a prime mover for thigh abduction (moving the leg away from the body) during walking. This thigh abduction moves body weight to the opposite side of the foot being lifted. Without this, we would fall while walking.

The sciatic nerve roots originate in the lower back, specifically the lumbar (portion between the diaphragm and the tailbone) and sacral parts that fuse to create a single, large nerve in the pelvic cavity. The sciatic nerve exits the pelvis at the ischial tuberosity and runs under and through several muscles, including the piriformis. The sciatic nerve enters the back thigh, moves through the large thigh muscles, and finally ends at the knee, giving rise to nerve fibers running down the leg.

Piriformis syndrome symptoms and causes

Piriformis syndrome represents a clinical condition termed sciatic nerve entrapment (a nerve becomes trapped or ‘stuck’ between other body structures) at the ischial tuberosity level (see image, above). While there are multiple factors contributing to piriformis syndrome, the clinical presentation is pretty consistent, with individuals reporting pain in the buttock (gluteal) region that may “shoot,” “burn,” or “ache” down the back of the leg (often mis-termed “sciatic” pain). In addition, numbness in the buttocks and tingling sensations along the sciatic nerve distribution are not uncommon.

Other symptoms indicating piriformis syndrome include pain (sometimes intense) while sitting, standing, or walking for more than 20 minutes; intense pain with sitting or squatting; paresthesia (pins and needles, numbness, burning, tingling, or itching sensations) radiating from the sacrum down the back of the thigh, usually stopping above the knee; and pain when standing up from a seated or squatting position.

The primary causes of piriformis syndrome include inflammation, overuse, sitting for prolonged periods, piriformis muscle strain, spasm, or changes resulting from hip or buttock trauma.

Sciatica symptoms and causes

Sciatica, also known as lumbar radiculopathy, is commonly called a “pinched nerve.” Radiculopathy represents an injury or damage to nerve roots in the area where they leave the spine, which may be caused by a bone spur or a herniated disk pressing on the nerve.

Sciatica often presents as pain in the lumbar back region, mainly on one side. Individuals describe pain as burning, tingling, heaviness, numbness, skin crawling, or itching sensation.

Sciatica is most often caused by a herniated disc or spinal stenosis (spaces in the spine narrow and create pressure on the spinal cord and nerve roots), which results in irritation or compression of one or more spinal nerve roots in the lower spine. Spondylolisthesis, where one or more spinal bones (vertebrae) slip forward and out of place, is another cause of sciatica pain.

Treatment options

Successful piriformis syndrome or sciatica treatment depends on being able to address the underlying causes of each condition. It is crucial to rule out conditions with similar presenting symptoms, including sacroiliitis (sacroiliac joint inflammation, lumbar radiculopathy (nerve root inflammation other than the sciatic nerve), and bursitis (fluid-filled sacs caused by inflammation that cushion the bones, tendons, and muscles near joints). A specialist likely will conduct X-rays of the lumbar region and a thorough spine physical examination. If true sciatica presents, you should see a specialist for a proper diagnosis before embarking on home treatments.

Get after it

Because an accurate sciatica diagnosis often leads to specific treatment options, I am focusing my recommendations to piriformis syndrome.

On the first presentation of piriformis pain, stop doing strenuous activities. Depending on the severity of the pain, rest can be helpful, along with taking appropriate analgesics (medication to relieve pain) for the first day or so. However, most research suggests staying active tends to be most beneficial (strong level of evidence). Too much sitting causes the hip flexors to tighten, resulting in piriformis tightness and increased pain (strong level of evidence).

Analgesics are divided into two categories: Acetaminophen (Tylenol being the most common) helps relieve pain by changing the way the body recognizes pain or discomfort; and non-steroidal anti-inflammatory drugs — NSAIDs — which include Voltaren, Advil, Motrin, Celebrex, and Aleve. Acetaminophen and NSAIDs reduce fever and relieve pain caused by muscle aches and stiffness, but only NSAIDs can reduce inflammation (swelling and irritation). Acetaminophen and NSAIDs are usually well tolerated, but NSAIDs and, to a lesser degree, Acetaminophen, should not be used by those taking blood-thinning medication or those who have a bleeding disorder, bleeding in the stomach/intestines, or peptic ulcers; those who have liver or kidney disease; and those who use alcohol regularly. Chronic alcohol use, plus NSAIDs (and, to a lesser degree, Acetaminophen), is associated with an increased gastrointestinal bleeding risk.

Acupuncture (see Health Yourself, “Get Poked-Does Acupuncture Work?“), epidural steroid injections, spinal manipulation, and traction represent other therapies proven somewhat effective (moderate level of evidence) in relieving piriformis syndrome. However, stretching and whole-body movements have proven most helpful (strong level of evidence) in preventing and alleviating general hip tightness and reducing piriformis syndrome pain development.

Stretching the truth

The following stretches and exercises can ease pain or soreness associated with tight piriformis muscles and help alleviate pain caused by piriformis syndrome. If you feel any exaggerated pain during these movements: STOP.

The first three stretches below are variations of the same exercise performed in different positions.

Seated piriformis stretch

1. Sit on a chair with knees roughly level with hips
2. Cross your left ankle over your right knee
3. Gently press on the left knee to open the hip
4. Keep your back straight and lean forward until feeling a stretch in the gluteal area
5. To increase the stretch, rotate the upper body toward the left knee
6. Hold for 30-60 seconds, relax
7. Swap legs and repeat on the other side

Standing piriformis stretch

1. Standing near a wall with feet hip-width apart for balance if needed, cross your ankle over the opposite knee
2. Bend the supporting leg slightly, drop hips down and slightly back, lean forward with a straight back, lower your chest toward the raised leg
3. Hold for 15-30 seconds, release.
4. Switch sides and repeat

Supine (lying) piriformis stretch

1. Lie down with knees bent and feet on the floor
2. Cross right leg over left knee
3. Place hands under left knee on upper thigh, lift legs, pull to body
4. Keep shoulders and upper back on the floor
5. Hold for 30-60 seconds
6. Repeat with the other leg

Seated spinal twist

1. Sit on the floor with both legs straight, torso upright with a straight back
2. Bend the left leg and cross it over the right thigh
3. Place the left foot flat on the floor next to the right thigh, pull the left foot as far in toward you as possible
4. Rotate right shoulder toward left knee using arm(s) to gently pull around to achieve stretch in hips and glutes
5. Hold for 30-60 seconds, release
6. Switch sides and repeat

Spine lumbar twist stretch

1. Lie supine with your legs straight and arms extended out to the sides to form a T
2. Bend the left leg and draw the knee toward you, placing your right hand on the left knee
3. Gently pull left knee across your body, twisting hips and lowering leg toward the floor
4. Keep shoulders and upper back stationary
5. Hold for 30-60 seconds, release
6. Switch sides and repeat

Glute bridge, feet externally rotated

1. Lie down with knees bent and feet flat on the floor, hip-width apart, and arms at hips
2. Turn feet outwards
3. Push down on heels, bringing hips up in a bridge position
4. Contract glutes and hold for 5 seconds, then slowly return to the starting position
5. Repeat 10 times

Knee-to-chest stretch

1. Lie supine with legs stretched out
2. Bring the right leg up as far as possible toward the chest
3. Pull the knee toward the opposite shoulder
4. Hold for 30 seconds
5. Repeat with the other leg

Bird-dog stretch

1. Get on hands and knees with hands stacked under your shoulders
2. Lift one leg from the hip up off the ground until the leg is fully extended
3. Lift leg up as far as possible, keep the leg straight
4. Slowly lower to the starting position
5. Repeat 10 times
6. Switch sides and repeat

Closing thoughts

Pain during stretching is rarely good and usually indicates that you are trying to stretch too rapidly or moving into an unnatural position. Stretching should not be painful, but expect some mild discomfort. If there is pain while stretching the piriformis, try easing off and waiting until the muscle relaxes to increase the depth of the stretch.

The good news is that the piriformis is easy to stretch and usually responds well. Therefore, a few weeks of concerted effort can restore the piriformis muscle to its ideal functional ability and reduce or eliminate piriformis syndrome pain.

References:

• Dart, R.C. “The use and effect of analgesics in patients who regularly drink alcohol.” The American Journal of Managed Care 2001 Dec;7(19 Suppl): S597.
• Deville, WLJM, et al. “The test of Lasegue: Systematic review of the accuracy in diagnosing herniated discs.” Spine 2000;25:1140.
• Ertem, U., et al. “YouTube as a source of information on piriformis syndrome exercises.” The Turkish Journal of Physical Medicine and Rehabilitation 2022;69(1):15.
• Hicks, B.L., et al. “Piriformis syndrome.” 2023 Aug 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. PMID: 28846222.
• Kaur, J., et al. “Pudendal nerve entrapment syndrome.” 2023 Aug 21. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. PMID: 31334992.
• Kirschner J.S., et. “Piriformis syndrome, diagnosis and treatment.” Muscle Nerve. 2009;40(1):10.
• Koes, BW, et al. “Diagnosis and treatment of sciatica.” BMJ 2007;334:1313.
• Miranda, H., et al. I “Individual factors, occupational loading, and physical exercise as predictors of sciatic pain.” Spine 2002;27:1102.
• Probst, D., et al. “Piriformis syndrome: A narrative review of the anatomy, diagnosis, and treatment.” PM&R 2019;11 Suppl 1:S54-S63.
• Vroomen, PCAJ, et al. “Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: A systematic review.” Journal of Neurology 1999; 246: 899.