The Piriformis syndrome: severe pain in the buttocks, legs and back
February 4, 2018
If you experience pain in the buttocks that radiate to the back of your thigh, you may be suffering from piriformis syndrome. Alicia Filley, a fitness and health expert, explains the causes of this condition and what you can do to help with buttock pain.
- What is the piriformis syndrome?
- What causes are there?
- Can the Piriformis syndrome be diagnosed with a test?
- Is there any therapy for this type of sciatic pain?
What exactly is the cause of Piriformis syndrome?
The piriformis muscle lies in the deep layer of the hip muscles below the gluteal muscles. This muscle attaches to the anterior surface of the sacrum, passes through the greater ischiadic foramen, and attaches to the greater trochanter of the thighbone. The piriformis is used as an outer rotator for an extended hip and as an abductor for a bent hip.
The sciatic nerve is the biggest nerve in the human body. It has its origin in the spinal cord at the level of the 4th lumbar vertebra to 3. Kreuzwirbels. This nerve is in close proximity to the piriformis muscle, and in most people its exit point is in the pelvis just below the piriformis muscle. But surgical observation and examination of corpses show that these two muscles are different in 22% of people. (1)
In short, something in their own right
Our training word expert Katharina Brinkmann has developed the first program that deals with this disease decidedly. Not only did Katharina compile the most important information on background and genesis, but she also developed a training concept specifically tailored for the Piriformis syndrome, which presents simple and effective techniques that help you stretch the shortened muscle, strengthen the pelvic girdle, and correct posture problems , This will teach you how to treat the Piriformis syndrome yourself, so that your pain will soon be a thing of the past.
Sciatica and piriformis
Piriformis syndrome is an irritation of the sciatic nerve caused by inflammation of the piriformis muscle. The symptoms are a sharp pain in the buttocks or a strong nerve pain that can radiate to the middle of the back thigh. Occasionally, a numbness and tingling sensation that can reach into the calf and toe.
Piriformis syndrome, stretching exercises In addition to these symptoms, lumbar back pain may also occur and become worse during prolonged sitting. Since the symptoms of the Piriformis syndrome are similar to those of a disc herniation in which an intervertebral disc presses on the sciatic nerve, a thorough medical examination must always be performed to exclude it.
However, diagnosing a disc disease, which is common in older cyclists and cyclists, can not rule out the possibility that piriformis syndrome is the cause of the pain.
In California, researchers studied 239 patients suffering from sciatica that was not related to the disc. (2) Many of these patients had previously undergone surgery on the lumbar spine because the cause of the pain was a herniated disc.
In the group of patients examined here, however, the pain was only slightly or not relieved by the operation. 42% of people who were eventually diagnosed with piriformis syndrome complained of lumbar back pain. Since an exclusion diagnosis is often made, the actual frequency of piriformis syndrome in the population is difficult to determine.
Test for the detection of piriformis syndrome
Unfortunately, there is no test to definitively detect piriformis syndrome. One way to determine the cause of sciatica pain is to reproduce the pain. If lifting the straight leg, the so-called Straight Leg Raise Test (SLR), leads to a positive result, it can generally be assumed that the pain comes from the spine or the sacrum rather than from the piriformis muscle ,
In this test, the person is in the supine position, the legs are stretched. The examiner raises the leg of the painful side. If the person being examined feels pain in the sciatica, the SLR is positive. It should be noted, however, that in the California study, 41% of people diagnosed with piriformis syndrome had a positive SLR test score on the first visit.
The FAIR test
If the pain is reproduced with the FAIR test (English: For flexion, adduction, internal rotation of the hip), on the other hand, is more likely to be a Piriformis syndrome. In the FAIR test, the affected person lies on the non-painful side and positions the aching leg with a 60-degree hip flexion, knee flexion, hip adduction, and internal rotation. (1) The examiner pushes the knee down, causing the piriformis to stretch that compresses the sciatic nerve.
Examination may cause tenderness over the piriformis muscle, which feels like a sausage-like hardening. The following changes in posture may occur: rotation of the sacrum to the painful side, misalignment of the sacroiliac joint and rotation of the lumbar vertebrae. If the person is in a back injury, the aching leg may be slightly outward due to the shortened piriformis muscle. Below the piriformis a delayed nerve conduction velocity can occur, especially if the affected person is in the FAIR position.
Therapy against the piriformis syndrome
Piriformis syndrome is an early stage inflammatory response to congestion, trauma or postural damage. If the piriformis is severely inflamed, it causes the sciatic nerve to become trapped. Treatment with non-prescription non-steroidal anti-inflammatories relieves pain and reduces inflammation. In addition, it is recommended to treat the pain with other conservative agents, eg. B. rest, compression and cooling of the painful area.
Treatment for Piriformis syndrome
When the disease progresses, it leads to a cycle of muscle spasms, pain and compensation by the posture. At this stage, the patient is usually referred to a physiotherapist. Ultrasound and ice spray can be used to treat inflammation and reduce muscle spasms.
Problems with the soft tissue can be treated manually, eg. B. by myofascial trigger points to release tension. With sport exercises and stretching, the shortened muscle is then stretched, the pelvic girdle strengthened and posture changes are corrected. In a 10-year study, researchers from New York found that physiotherapy administered 2-3 times a week for up to 3 months leads to an improvement of 60-70% in most patients.
Although the symptoms usually occur on only one leg, the painless leg should be treated in any case. The New York study found that overexertivity (43% of 876 patients) and one injury (18% of 892 patients) are the most common causes of piriformis syndrome. As part of the said studies, the nerve conduction of the symptom-free leg was also investigated in the patients with piriformis syndrome.
Measures against the piriformis syndrome
The examination results were significantly worse compared to a control group without piriformis complaints. Since over-exertion and injuries usually always occur on both legs, the treatment should always be carried out on both sides.
If conservative measures are unsuccessful, it is possible to administer an injection for piriformis pain. In the Californian study mentioned, the scientists used to inject anesthetics and corticoids into patients suspected of having piriformis syndrome.
If the symptoms disappeared completely or almost completely, this was considered confirmation of a Piriformis syndrome. Patients who returned symptoms in less than 1 week were referred to a surgeon for follow-up. If it persisted for more than 1 week until the symptoms returned, the patients were given up to 2 more injections every 4 weeks. If the pain was not completely eliminated even after these additional injections, these patients were also referred to a surgeon for follow-up.
68% of the 239 patients examined were diagnosed with piriformis syndrome. Of these, 23% were completely symptom free after 1 or 2 injections. In 37% injections caused longer-term pain relief (longer than 6 months) before the symptoms recurred. However, no physiotherapy had been performed following the injection treatment. This explains why the symptoms returned.
Operation in Piriformis syndrome
In surgery, the tension on the tendon of the piriformis is released, so that the sciatic nerve is no longer compressed. It also investigates whether the sciatic nerve has scarring or tissue adhesions that could cause irritation. 59% of the patients who had been referred to a surgeon as part of the Californian study were extremely satisfied with the outcome of the surgery. Even after a long time (more than 2 years after surgery) patients reported very good results in 62% of the cases.
For the operation, which used to be a major procedure (with a similar size to a hip replacement), today only a 3 cm long incision is needed. As a result, surgery today no longer marks the end of a sporting career. Most of them can resume their usual daily activities after only 2 weeks, and soon start training in deep-water running or swimming.
Small muscle, big problem
Functionally, releasing the tension of the piriformis also affects the biomechanics of the hip, as the piriformis is a fairly short external rotator and weak abductor. How can it be that such a tiny piece of muscle causes such severe pain in the buttocks? The course of the piriformis syndrome is influenced by both internal and external factors. Internal factors are z. B. the anatomical position of the piriformis in relation to the sciatic nerve, postural disorders such. Due to a different leg length, an infection in the muscle, myositis ossificans, and a tumor.
The piriformis syndrome in runners
Runners experience overuse due to external factors, such as As a too large Laufpensum, too fast extension of Laufpensums or a bad running technique. Even terrain differences, worn shoes or running on sloping surfaces overload weak muscles. When the primary muscles of the hip tire, the smaller accessory muscles like the piriformis have to work harder to maintain the shape. This compensation work for the stronger musculature strains the piriformis. Also, a forceful impact on the buttocks, such as a fall or a blow, can lead to injury of the piriformis and trigger an inflammatory response.
A good rule of thumb is to extend the running time by no more than 10% per week. It is important to remember that you are constantly changing the direction of travel on the track or on sloping roads. The functional difference in length of the legs that results when walking on a sloping surface creates additional stress on the pelvic muscles.
From a leg length difference of 1 cm, the orientation of the pelvis is impaired. In such cases you should ask a physiotherapist for advice on whether a shoe lift is advisable. If you want to make sure that your muscles can easily cope with any external factors that may occur, you should definitely provide more core strength in the pelvic girdle muscles.
Power is important
Endurance athletes, especially runners, are known to like neglecting the strengthening part in their training. Many believe that they are already building up enough strength by practicing their sport. Running is exactly the opposite. Endurance runners, who take longer running pens, even lose muscle power in the legs.
In New York, fitness experts at 8 men and women examined the strength of the hip muscles before and after a 2-hour run. The abduction power decreased by 17% in the men and by 12% in the women and the adduction power by 18% and 17%, respectively, while the flexion force of the hip decreased by 19% in both men and women.
In a descriptive analysis, researchers from Minnesota examined the hip strength in runners who suffered from a running-related injury. They found in 30 recreational runners a clear relationship between a weak hip muscles and a running injury. The musculature of the injured leg was noticeably weaker than that of the healthy leg.
In a control group with uninjured runners, there was no difference in hip force between the two sides, as was the case in the experimental group. Although this is not evidence of a causal relationship, it does make it clear what an important role the hip force plays in the context of injury prevention.
Hip strength as a prevention against the Piriformis syndrome
More hip force can therefore also lead to better performance. In a joint project, scientists from Spain and the United States investigated endurance runners for the effect of a sports-specific, periodic strength training program on shortening the stride length.
18 sub-elite runners were randomly assigned to each of 1 of 3 training groups. During the 8-week training program, subjects completed either a periodized or unperiodised strength training program or no additional strength training.
For training sessions conducted at competitive speeds, the running distance was repeated up to 20 times, measuring the stride length in relation to the speed (SLG). A comparison of the SLG scores of the first and last third repeats showed that the scores for athletes who had completed a run-specific, periodized strength training program did not decrease between the first and last runs.
By contrast, the SLG score in the runners of the other two study groups dropped significantly. The biggest decrease was recorded by the group who did not do weight training. So the longer you can delay muscle fatigue, the more consistent your stride, and the better your performance.
By training specific muscles for specific forces, you can avoid having to resort to the accessory muscles instead. This will give you better results on your running track and avoid injuries.
Alicia Filley lives in Houston, Texas, and is Vice President of Eubiotics: The Science of Healthy Living, which advises individuals seeking to improve their health, fitness, or athletic performance through training and nutrition.