Why “Piriformis Syndrome” is a Real Pain in My Ass

Recently there was an article brought to my attention (thanks Carrie) published in Mensjournal.com written by a very well-meaning physical therapist regarding “sciatica” and how to “fix” it. It was a short article written for the public, so I can’t get too mad at the guy for leaving it as a pretty simple article that didn’t get too technical. In fact, he started off really well with his intro paragraph:

“You've probably heard of sciatica in reference to mysterious leg pain. Technically speaking, sciatica is just a term used to describe any type of irritation of the sciatic nerve. The sciatic nerve is the longest and widest nerve in the human body, and is responsible for the activation of several leg muscles as well as sensation to the back of the leg. Based on the size and functions of the sciatic nerve, sciatica can end up looking like a lot of different things. More importantly, its causes can also be varied.”

I was encouraged by him enlightening readers that sciatica can actually have several causes and indicating that it is more of a catch all term for any radiating neural pain along the sciatic nerve distribution. However, things started to go south after this in the next paragraph when the author stated:

“One of the most common culprits, and the one I would like to focus on here, is piriformis syndrome.”

For some reason we as physical therapists have developed this unhealthy relationship with the piriformis. We seem to blame this little tiny muscle for all sorts of nasty problems that our patients are dealing with. The author goes on to state:

“In some people, the sciatic nerve actually pierces straight through the middle of the piriformis. When the deep hip rotators become tight, they basically compress this nerve like a bandage, irritating and decreasing the function of the nerve. This is when sciatica symptoms — tingling, numbness, and pain — can kick in.”

The piriformis gets quite the bad name, but is this really justified, and does it really contribute this much to sciatic nerve related problems? The author is correct in stating that in some people (17% according to this research study) that the sciatic nerve pierces through the middle of the piriformis muscle. However, we have no current evidence to suggest that this is really of clinical significance, and with it only being 17% of the population he seems to be neglecting the plethora of other individuals that deal with sciatic pain that don’t fall into this anatomic variant category. In addition, since this is a normal anatomic variation why would we think that it increases the likelihood of having sciatic problems…and if you’ve had this anatomic variation since you were born why did it wait until you were 62 years old to start giving you issues??? Maybe, just maybe, this anatomic variation has absolutely nothing to do with your likelihood of developing sciatic pain.

The author goes on to state in the next paragraph:

“The deep hip external rotators, like the piriformis, get tight for a variety of reasons, one of which is overuse. This happens when big muscles, namely the glutes, aren’t engaging when you run or lift and the smaller deep hip rotators have to help out.”

Yet, he has no evidence to date to support his statements. We are in fact extremely unreliable at assessing if a muscle “isn’t engaging” properly, or if there is an alteration in the onset timing of muscle activity. In fact, there is quite the inter-individual variation between muscle onset timing with even simple movement such as the prone hip extension. There are in fact, a variety of ways to move “correctly”. Additionally, we know that the gluteal muscles are extremely important in supporting stance while walking. Simply put if the gluteal muscles are not “engaging” when we walk or run we would have significant difficulty maintaining upright posture and movement as demonstrated by this study.

Next, the author again goes on to state some dubious claims:

“To treat piriformis syndrome, you need to take the pressure off the sciatic nerve by activating the glutes. Step one is releasing the hip flexors (which are often tight in men, and prevent the glutes from engaging) and putting the pelvis in the optimal position. Next, you want to stretch them. And finally, activate the pelvic floor and hip adductors, which ensures proper pelvic stability and allows the glutes to engage properly. This three-step process will put you on the road to sciatica relief.”

Again, we are unsure of how to exactly change the “activation in the glutes”, and definitely unsure of how this will “take pressure off of the sciatic nerve”. Furthermore, I am unaware of any evidence at all to support that on average men have a tougher time activating their glutes due to their poor hip flexor length??? The author at this point it reducing his view of pain to a completely biomechanical viewpoint that hangs completely on the un-justified Janda upper and lower crossed syndromes. Greg Lehman has done quite a good job here at describing how these syndromes have not been validated and should be used with extreme caution.

To take things a step further, the author advocates for performing hip flexor and piriformis “releasing” exercises with a lacrosse ball stating that they will help to put the pelvis in a more “optimal position” so the glutes are no longer inhibited. Yet, we know that exercises in fact don’t change the long term resting position of joints, AND it is quite hard to justify that laying down on your stomach with a lacrosse ball in you groin will put any pressure on or “release” you psoas muscle that is several inches deep behind your intestines coming off of the anterior portion of your lumbar spine….not to mention he started off by talking about how the sciatic nerve pierces the piriformis in a subset of people so why would “releasing” this muscle even matter if the nerve is stuck within it?

I want to reiterate that the author seems like a very well-meaning clinician. However, I also want to encourage readers to consume information with a very skeptical eye and try not to shove so much biomechanical hokum down your patient’s throats just because it sounds good and “seems to make sense” at face value. Pain is so much more complicated than a tight muscle, or even a nerve that pierces straight through a muscle. The piriformis has been demonized for far too long and I wanted to give it a little redemption. I’m growing tired of patient’s coming to me sure that their piriformis is the cause of all their pain because that’s what their personal trainer, previous PT, sister, chiropractor, massage therapist, etc told them. As I tell my students, “muscles are not usually the driver of a problem. Muscles tend to be the employee rather than then employer. They are simply doing or feeling what the driver of the problem is telling them to.”

Hell, maybe the reason your patient’s gluteal area feels tight isn’t because the piriformis caused sciatic pain, but instead because irritation to the contributors of the sciatic nerve caused nociception that then lead to increased perception of tightness in the area. Maybe the increased nociception even lead to interneuron signaling that encouraged a small increase in resting tone in the piriformis due to its close proximity to the nerve. The reality is that we don’t actually know and making definitive statements like the author did in this article put the horse way before the cart.

As usual, thanks for listening to the rant,

Jarod Hall, PT, DPT, CSCS

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