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How Do You Know If You Have Piriformis Syndrome Or Sciatica?

Written by: Nick Jack
Category: 2014
on 17 August 2017
Hits: 21889

This is a question I am often confronted with in our rehabilitation program as we see so many clients who have been misdiagnosed and consequently mistreated. Many back related injuries and chronic pain conditions share many symptoms that are very similar to other injuries, and in the case of Piriformis syndrome and Sciatica the similarities in symptoms and pain is very close. However these two injuries are very different, and the approach to treating although similar in some regard, will have some key elements that are significantly different. This article we are not telling you how to diagnose but help you become aware of what your symptoms may be telling you, what the triggers of your pain may be and what exercise solutions you can use to help correct this problem once and for all. The common theme both injuries do share, is that they are in over 90% of all cases caused by postural imbalance and movement dysfunction. To quote Dr Evan Oscar in his book about Common Hip & Shoulder Dysfunction - "Osteoarthritis, more accurately described as degenerative joint disease, is just one manifestation of poor movement strategies, it is not simply a process of getting old." And like Dr Oscar I have found in over 12 years of working with all ages, and many different injuries, that those who improved stability and movement had less injury, less pain, and could not only prevent problems, but correct them once the right program was adopted. This article we hope to share some of those secrets and help you get rid of your pain for good.

First We Must Define Sciatica & Piriformis Syndrome

1: Sciatica

Sciatica is refers to pain, tingling, and/or numbness felt along your sciatic nerve. The sciatic nerve runs down the back of the thigh, down the shin to the toes, and can be traced back to the nerve roots that exit the spine at L4/5 and L5/S1. The pain felt in your butt and legs is when the sciatic nerve is being pinched. This usually occurs in your lumbar spine (lower back). For example, a disc bulge or herniated disc which would be the most common back injury we see may irritate anyone of the five sciatic nerve roots that comprise your sciatic nerve, which in turn sends symptoms shooting down your sciatic nerve. This is where people may think they have piriformis syndrome, when in fact it is a problem coming from somewhere else. The key to eliminating this comes down to finding the cause of the nerve pinch which you will find is related to postural and movement dysfunctions. Bone spurs can be a potential cause of this problem but in many cases it is postural and movement related.

2: Piriformis Syndrome

The main difference between these two conditions is the location of the problem. The piriformis muscle is not located in your lumbar spine, instead it is located in your butt underneath the big gluteal muscles. It is located right near the sciatic nerve, which is where the problem begins.  When the Piriformis begins to overworks, (due mainly to instability of the hip and pelvis, more on this later), it begins to thicken and shorten, developing trigger points but even worse it may compress the large sciatic nerve. The compression feels like a deep aching pain in the butt or a radiating sharp nerve pain that extends along the middle of the rear thigh, the exact same symptoms of sciatica we just looked at. You can see how it can be easily assessed as sciatica when in fact it is a different problem all together.

How Can You Find Out Which One You Have?

As I said in the introduction the purpose of this article is not to diagnose your problem, but to show you how easy people can be actually treating the wrong condition by being fooled by symptoms. To get a correct diagnosis you will need to consult a therapist or Doctor skilled in looking for these problems. Diagnosis of both conditions should involve a review of the patient’s medical history, a physical examination looking for movement dysfunction and instability and possibly even x-ray or MRI. A good therapist will often be able to correctly make a diagnosis by using a process of elimination. Your goal should not to just get out of pain but to find out what the cause of the problem was in the first place and devise a plan to remove it or change it. The corrective strategy may vary quite a lot, but you will find that there is some common threads to both conditions which I will now explain.

Why Hip Dysfunction Is Common To Both Problems?

Today's modern medicine when it comes to chronic pain is to look at the area in pain and get rid of it. Our approach to treating pain is that it is a real inconvenience and that there must be some kind of pill, tablet or medical intervention to just get rid of it. While all the while being completely ignorant to WHY the pain is there in the first place. This how a relatively simple problem that could be easily corrected using simple exercises and drills, grows to be a very big painful injury needing a lot of time and money to correct. We must move beyond treating symptoms and begin looking at treating the cause of the problem.

Below is two videos I encourage you to watch that explain firstly why the lack of hip mobility and pelvic stability is the true cause of most painful conditions like sciatica and piriformis syndrome and the second video explains how a vicious cycle of pain can continue for months, even years if you continue to ignore the cause of your problem and do not adopt a corrective program that will stabilize and strengthen your body.

In one of our previous articles Are Your Tight Hips The Cause Of Your Back Pain Or Knee Pain? I discuss how hips are often to blame for many of the injuries we see. Our sedentary lifestyle leading us to sit too much contributes to developing tight hips that can then force the spine to flex on itself in turn creating spinal injuries like a disc bulge. Or it can cause the hips to limit movement that inhibits the gluteal muscles from functioning correctly, in turn winding up the piriformis muscle to compensate and pick up the workload. In both injuries here tight "STIFF" hips were the cause of the problem. Note that the pain was not in the hips itself, but instead in the lumbar spine for a disc bulge, and in the buttocks for piriformis syndrome. Treating these areas without addressing the hips is a waste of time.

Not all times however is the hip stiff and tight from short tight muscles needing mobility. Some cases it is the exact opposite, too loose and unstable. The instability creates a new strategy of stabilizing by the body in order to protect the hip from dislocation. This is where movement patterns are altered creating a false stiffness on movement that leads to excessive movement again in the spine or in the lower limbs that force compensation at muscles like piriformis.

Again you need to know what type of hip problem you may have in order to use the correct approach. For if you start loosening a hip that is too unstable, you will create more problems and more pain. Here is how we would do this.

You Must Assess Your Joints & Movements

There is a lot of assessments and tests that I may use to be 100% certain on what approach I am going to use and guide me on exercise selection. It is very difficult here to give you a black and white "do this, do that" approach, and to keep this article relatively short I have removed a lot of these tests, so instead I will give you some of our easiest and most effective ideas on what to look for. To see the complete assessments with detailed instructions of each test, exercises, stretches and step by step programs if you have sciatica are covered in our Back Pain Secrets Program, and all the tests and assessments, exercises, stretches and programs for Piriformis Syndrome are covered in our Piriformis Syndrome program. Click here to go straight to the shop to find out more or on the image below of what program is relevant to you right now.

 

Simple assessments for hip mobility involve looking at both flexibility and movements. You cannot just rely on flexibility assessments alone for they will not show instability or weakness when you stand up. In the book Vital Glutes by John Gibbons he makes a great quote -"Tight muscles show themselves lying down, whereas weak muscles show themselves standing up".

This is something we keep in mind when completing the assessment to not get fooled by what might look as good flexibility when doing the simple stretch assessments. Below is 5 simple assessments that will guide me on where to start.

Test 1 - Hip Mobility & Flexibility

This is quite simple to do and will tell us if there is limited range of movement at the hips. This is often very limited if you have knee pain as well, and for someone who sits too often. I like to use a swissball to assess this as featured in the picture below but if you have a partner you could do the lying test. You should be able to achieve 120 degrees of motion completing this test. If your heel does not touch your butt, you have a serious flexibility problem. Potential for knee problems is quite high with a positive test here.

How To Do The Swissball Quad Stretch:

  1. Begin in a sprinters start position with the foot and ankle of the leg to be stretched on the ball.
  2. Slowly rise upward draw your belly button inward and roll your pelvis under so that your back flattens to increase the stretch.
  3. You may place one hand on the ball or a chair for support.
  4. If you cannot sit perfectly upright without discomfort you have tight quads. Make a note of difference between right and left too.

Test 2 - Hip Rotation

This test I often see more of a problem with for piriformis syndrome than herniated disc bulge or sciatica problems. This test is best done using a partner but you can also do the one featured on the right.

How To Do Lying Hip Rotation Stretch

  1. Lying supine with one arm outstretched raise the leg on the side of the arm that is outstretched.
  2. Place the foot behind the back of your knee.
  3. With a partner holding you down or your other hand reach across drawing your knee across your body to the point you feel a comfortable stretch.

Tightness on these two previous tests indicates that you have lost range of motion and need some corrective mobility drills and stretching to help improve this. If however you do not find these hard this indicated your problem is more to be with stability which we will test shortly. In both cases stability and a lack of strength will need to be used, just some people will need to spend considerable time improving their mobility first before executing exercises whereas others will not.

The last thing I might test to rule out piriformis syndrome is the foam roller trigger point test. If this is extremely painful you have definite proof of over activity with the piriformis muscle.

You will find tons more information about stretching in our this article Mobility & Flexibility Which Comes First & Why

Test 3 - Glute Function

Now we are up to looking more at strengthening and stabilizing. And we have to look at the glutes very closely for in both cases of sciatica and piriformis syndrome there is always some gluteal dysfunction present that exacerbates the muscle imbalance and movement compensation. The longer this remains the worse things will get. The tight hips you are trying to loosen from the previous tests will just tighten right up again if the glutes do not do their job. You have to find out if you have adequate activation and put a plan in place to correct this.

There are many different ways to test this, but I find the glute test in the video below to be one of the easiest to do that does not give pain.

  1. Lie on your stomach and bending one knee to 90 degrees, lift the thigh a little off the floor.
  2. You should be able to get a strong contraction of gluteal muscle to do this and be able to hold the static contraction for 60 seconds.
  3. If this position places too much strain on the hamstring or lower back, or the leg starts shaking, then this is a sign you are unable to recruit the gluteal muscles sufficiently to hold this position.

The other test I like to use is the Bridge. It is common for the gluteal muscles to become lengthened (chronically stretched), reducing the tension in the range around hip extension. The bridge or hip extension  exercises targets your butt muscles very well in this position.

How To Do The Bridge

  1. Lie on your back with knees bent, feet and knees hip-width apart
  2. Squeeze the gluteal muscles and lift hips until you have a straight line running through knees and hips to the mid-back. Leave the shoulder blades on the floor
  3. Hold the position, focusing on using the gluteal muscles, for 10 seconds in total.
  4. Place the hips back down, maintaining neutral spine build up the length of hold gradually to 30 secs, and three repeats (sets)

I would also encourage you to read our article on How To Strengthen Your Glutes to see more detailed tests and exercises to enhance this function. The bridge

Test 4 - Bending

Now this test is CRITICAL if you suspect you have a herniated disc injury causing sciatica. It can be very difficult for the pirifromis sufferer too as there is significant hip range of motion required. It is usually in this pattern of movement that a back injury was created in the first place and as a result and repeated poor movement of this and the pain symptoms can be amplified. This is also a hamstring range of motion test and any nerve impingement may give a fake reading of tight hamstrings, so you may want to test the hamstrings in a lying position to rule this out. The unique thing with standing up tests are that they are testing more than just mobility for this is also a stability assessment. This is where we can see the person who passed all the flexibility tests with flying colors appear extremely stiff and tight due to their failure to correctly stabilize the lumbar spine or pelvis during movement. This one movement pattern can correct all the things we have been doing individually so far if you can execute perfectly and be able to progress with loads and to single leg stance. In the gym world this movement is known as the deadlift and is the king of all gluteal and postural corrective exercises. It is also the one that can absolutely ruin your back if you get it wrong.

You MUST learn how to do this and you must learn how to do this with load or you are only ever a short step away from going back to pain. The two videso below help to explain this.

How To Do The Bending Test

  1. Standing with feet parallel and shoulder width apart, stick your bottom out (arching your lower back) and reach behind you to hold a piece of your skin in the middle of your lower back.
  2. Bend forward from the hips while maintaining the arch in your low back and skin between your fingers until you feel a comfortable stretch in your hamstrings.
  3. If you bend to far or round your back you will lose the curve in your low back.

Normal: Able to maintain neutral spinal curve and approximately 45deg flexion at the hip. Struggling to do this indicates you move too much through the spine and not through the hips and just about any day to day task that involves you bending over is a potential risk until you correct this. Tying your shoelaces, vacuuming the carpet, picking the shopping bags up are all potentially going to aggravate your injury and the sciatic nerve.

Below is a video of exactly what we look for in a bending actions

Test 5 - Single Leg Squat

This last test we see massive problems in Piriformis Syndrome sufferers. If the bending action is the risky movement for a herniated disc then single leg exercises are the risky movement with piriformis people. This exercise demands the hip to act as a hip rotator and stabilizer at the same time. It needs to lock the head of the femur into the socket, creating a very tight and stable hip joint during gait. This prevents the ball and socket joint from rattling around during walking and running, but maintain adequate mobility for the leg to swing through. The reason this is risky for most is that their lack of glute strength and stability of the hip itself is so faulty that the piriformis muscle has no choice but to work excessively hard to prevent hip dislocation and even begins to take over movements of the glutes. If you think about how often we need to stand on one leg, walking for instance, you will see how easily this pain can escalate from mild to extreme very quickly. Again this is so much more than a simple one joint strength or stability test. Multiple joints and muscles are on the job and this movement requires perfect timing and alignment for it to be completed pain free.

Watch the videos below to see what we look for when assessing this movement. As with the bending movement I would rate this as a much more useful exercise to end up using. If you can master this and be able to do this with loads or at high speed the chance of injury is very small. You just cannot beat learning to move.

Read our article on Single Leg Squats to see more detail about this extraordinary exercise.

What Is Next?

Well as you can see the test results can take you in many directions.

  1. If you found you were very stiff and tight you need to start working on flexibility and mobility drills to improve your joints range of motion.
  2. If you found that your problem was with bending or single leg stance then your problem is much more stability and movement based.
  3. Pain with bending indicates back related problems
  4. Pain in the butt region indicates more piriformis related problems.

You could also fail all of these tests and be either piriformis or sciatica patient. Are you confused now? I hope not, but you can see how it is so easy to misdiagnose this problem, and also mistreat the problem. You must assess what your body needs and use strategies to improve it. You cannot rely on a therapist or a doctor to do this for you, you MUST find what exercises you need to do and you must start doing them. These injuries can be corrected and they definitely can be prevented.

You will find many great ideas in the articles below

4 Best Exercises For Piriformis Syndrome

Bulging Disc Exercises & Effective Long Term Solutions

Conclusion

Chronic pain can take a real toll on someone's life both physically and mentally. And both sciatica and piriformis sydnrome can wreak havoc on daily activities and escalate into crippling injuries. The days of treating symptoms and just trying to get rid of pain are over. We must be smarter in how we approach injuries like these and provide people with proven programs and methods that not only remove the pain, but remove the underlying cause of the injury. The information in this article gives you great insight as to how injuries like these are born and why we must consider other joints like the hip in their role of forcing compensation and pain into other areas.

Below is a great Free Report you can get by clicking the image that can guide on your journey to living pain free.

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