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What Causes Piriformis Syndrome & How To Break The Vicious Cycle Of Chronic Pain

Written by: Nick Jack
Category: 2014
on 25 November 2020
Hits: 3357

One of the most confusing and frustrating injuries to rehabilitate is piriformis syndrome. The symptoms of this problem often mimic other injuries and can easily lead to incorrect treatments of the underlying problem as people attempt to relieve their pain. Unfortunately the longer this condition is left untreated at the source the more chronic the pain becomes forcing the body to compensate around the pain. This compensation sets off a chain reaction of other problems that create an ongoing vicious cycle as the body continues to try to avoid pain. Rest is one of the worst things you can do and often rapidly increases the severity of the pain and this is where many people are left feeling desperate and lost as to what to do next. Many of my previous articles relating to piriformis syndrome have focused on corrective exercises and strategies to resolve the problem. But, by far the fastest way to combat this is to identify the original cause or pain trigger and remove it. This article I will show you exactly how to do this and find an answer to this once and for all.

Why You Must Identify & Eliminate The Cause If You Want To Find A Long Term Solution

The piriformis muscle lies deep within the buttocks, covered by the massive gluteal muscles (your butt). Its job is to externally rotate the hip when it is extended, and abduct the hip when it is flexed. This muscle is important in lower body movement because it stabilizes the hip joint and lifts and rotates the thigh away from the body. This enables us to walk efficiently by allowing our body to shift weight from one leg to another without compromising stability.

If you have trouble stabilizing your leg in a single leg stance there is likelihood that the Piriformis muscle will become overworked, short and tight.

This muscle is located right near the sciatic nerve, and when it overworks 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. Occasionally numbness and tingling can continue to the calf and toes. These symptoms can be accompanied by low back pain and worsen after prolonged sitting.

At first this injury often starts out as a small ache and a bit of stiffness in the hip or lower back. Most people ignore and keep pushing through with what they are doing thinking it will just go away. As time goes in it begins to get more painful and last longer and it is at this point that the chain reaction of multiple problems is already in full motion. The longer you take to identify the pain trigger the worse this will get.

Take a look at the picture below to see how this vicious cycle is created and how easily it takes a hold of your body.

 

We will walk through each of these steps to help you gain a better understanding of what to do starting with the most important one, identifying the original cause.

Get a Diagnosis from a Doctor First

It is important to get a correct medical diagnosis before you do anything, as you need to be certain it is truly a piriformis syndrome problem and not a herniated disc. Even though these two injuries are similar with symptoms they differ in terms of treatment. The worst thing you can do is self-diagnose by watching You Tube videos and use exercises that may exacerbate your problem.

See this article for more detail on this – Do you have piriformis syndrome or a herniated disc?

To get a correct diagnosis you will need to consult a therapist or Doctor skilled in looking for these problems. Diagnosis 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 the diagnosis by using a process of elimination.

If you have established that it is piriformis syndrome what do you do next?

Finding Your Pain Trigger

This first step is the most important part of the rehabilitation program and if you can get this right you will have taken a big step forward to correcting your problem for good. Recognizing and avoiding the pain mechanism is essential to a pain free life. By understanding your pain trigger you can begin to avoid placing your hip in positions that create more damage and pain. But how do you find your trigger?

The simple answer is to TEST and ASSESS.

Try to observe what movements or positions you repetitively use during the day. During my initial consultation with people one of the first questions I ask is what makes your body feel good? And what makes your body feel worse? I try to get them to be aware of what position their body was sitting, lying, or standing in prior to the onset of severe pain. There may be no actual pain in the position or movement you were using at the time, but if there is an escalation in pain straight afterwards this is a clue as to where the pain trigger lies.

With piriformis syndrome the pain trigger will often be linked to sitting, running, and any activity that requires stability in the single leg stance. When the injury first starts the pain is often quite minor, and only a small ache that goes away with some rest. As time goes on the pain becomes more severe and can severely limit daily movement and even sleep.

Some pain triggers are easy to see whereas others are more complex as compensation hides the true weakness.

Watch the video below to see an explanation of what to look for, and watch the second video to an explanation of how over-using glute exercises will create piriformis syndrome.

 

Here are some things I regularly see as repetitive actions that lead to creating the injury in the first place.

  • Poor bending technique
  • Sitting on a wallet in a back pocket
  • Sitting with legs crossed
  • Sitting on the edge of the chair with pelvis tucked under
  • Excessive stretching with Yoga poses
  • Standing on one leg with hips
  • Poor running technique
  • Poor technique in the gym
  • Excessive hill running
  • Excessive glute strengthening
  • Excessive abdominal training

It is not unusual for me to see a person continuing to do these actions when I first meet them, even though it may be causing them pain.

The very first thing you must do is identify your pain trigger and eliminate this movement or action from your daily life. Failure to do this will result in a poor treatment outcome and set off the first chain reaction of problems being hip stiffness and pelvic instability.

In very rare cases this injury can be due to a severe knock such as receiving a knee into the butt during a football game but in most cases it is poor movement strategies and lack of stability behind the problem. And until this is addressed you will never find a long term solution.

Hip Stiffness & Pelvic Instability

This is one of those times you are confronted with the chicken and the egg scenario. Is the hip stiffness due to poor movement, or is the poor movement the cause of the hip stiffness?

Usually it is the poor movement strategies adopted from the repetitive pain triggers that forced the hips to create stiffness, as they body had to find a way to protect other joints like the pelvis and lumbar spine from further damage. Sometimes poor coordination and lack of strength contribute to the problem, but either way the end result is the hips will respond with stiffness.

 

The hips are designed to be very mobile and withstand both direct loading stresses and large rotational forces with weight-bearing activities, whereas the pelvis is more concerned with stability in order to preserve neutral alignment of the spine and lower limbs.

This constant interaction between these two joints can very easily be disrupted by poor movement strategies or inactivity. When this happens we often see a loss of hip mobility first, and pelvic weakness following almost instantly. Restoring the muscles involved in these regions back to normal takes more than just a hip flexor stretch and some planks. In some cases it is the hip flexor stretching causing all the trouble!

The hips are a real concern for they will steal work from the abdominal stabilizers and the glutes at the same time as they go into workaholic mode. It is not hard to see how easily back and hip problems worsen when the hips are taking over work that they are not designed to do.

Below are some videos with great ideas for improving hip mobility.

 

And with regards to core function and hips stealing work from the abdominal muscles I suggest to read our recent article on lower abdominal training to see a detailed explanation of how this works.

Pelvic stability becomes much harder when hip stiffness is present and compensation is inevitable. Instead of providing mobility for the legs to lower to the floor the hips do the exact opposite, they contract and stiffen. Every time the hips try to fire up to create the stiffness in the spine they move the pelvis into anterior tilt and as a result of this you lose your lumbar spine stability. Lack of stability of the pelvis will make it extremely difficult for the glutes to perform their role as they need the assistance of the pelvic stabilizers to position the hips in the right place in order to fire.

This brings us to the next problem being weak glutes.

Glutes Weakness From Muscle Inhibition

When the hips become tight they will begin to inhibit the function of the glutes, and when this happens is when the problem escalates very quickly.

The glutes are pivotal to our ability to control the single leg stance used in walking and running, they are the biggest muscles in the body, and are often referred to as the engine room for sporting performance. These muscles are very misunderstood and regularly abused in many gym training programs that often create gripping problems leading to piriformis syndrome and bulging discs.

It is important to understand the different roles the glutes must perform for you to appreciate how to train them correctly and avoid causing more problems.

 

There are three distinct heads of the gluteus medius muscle that perform a unique role as the body moves:

  1. The posterior fibres - These fibres contract at early stance phase to lock the ball into the hip socket. The posterior fibres therefore essentially perform a stabilising or compressing function for the hip joint.
  2. The middle/anterior fibres - These run in a vertical direction, help to initiate hip abduction. The glutes work in tandem with other muscles around the hip in stabilising the pelvis on the femur, to prevent the other side dropping down.
  3. The anterior fibres - These allow the femur to internally rotate in relation to the hip joint at mid-to-end stance phase. This is essential for pelvic rotation, so that the opposite side leg can swing forward during gait. The anterior fibres perform this role with TFL.

The glutes need to stabilize the hip, act as a hip rotator, and lock the head of the femur into the socket, creating a very tight and stable hip joint when we walk. This prevents the ball and socket joint from rattling around during walking.

When our glutes work correctly they provide optimal hip extension for walking, running and jumping, and also when we lift heavy objects off the ground. At the same time they act as a gross stabilizer by providing external rotation of the hip when we stand on one leg. The piriformis muscle acts a tiny assistant to the much larger and more powerful gluteal muscles to provide added stability to the hip.

You must be very careful with strengthening of this muscle group and use exercises that are focused on improving movement such as deadlifts or single leg deadlifts. Beware the workouts that encourage you to squeeze the glutes hard and try to posterior tilt the pelvis as this will make your problem worse. The anterior pelvic tilt is the key to glute strength and improving muscle timing and joint control.

Below is a free checklist you can download to help you with this.

 

Once the glutes have become inhibited and begin to lose strength it forces the piriformis muscle into hyper-drive to assist with hip stability. And when this happens is when your pain goes to a new level.

Piriformis Muscle Over-works Touching the Sciatic Nerve

When the glutes are disabled from poor positioning and muscle inhibition the body is forced to find a way to make up for the loss of its largest muscle group. The piriformis is normally just the assistant to the glutes but now it is left on its own to take control of the hip function.

The biggest problem with the piriformis muscle is where it is located within the hip joint. It is located right next to the sciatic nerve, which comes from the spinal cord and is the largest nerve in the body. 

When the Piriformis overworks it begins to tighten up and develop trigger points from over-use. Worse still is that like any muscle that becomes inflamed it swells in size. Now due to its close proximity to the sciatic nerve it begins to compress the nerve. The compression feels like a deep aching pain in the butt or a radiating sharp nerve pain that extends along the back of the leg in the hamstrings. Occasionally numbness and tingling can continue to the calf and toes.

This constant pain can disrupt all daily activities and your ability to sleep at night causing more stress to the body as it is unable to effectively repair any damage to the body. This is bad enough, but things are about to get much worse as the weakness created from the sciatic being compressed begins to create more compensatory movements.

These new movements your body creates to avoid pain now start to create a new set of injuries!

New Injuries Begin to Surface

As the body constantly tries to avoid pain and develop alternative movement strategies other joints are more exposed to potential danger as they are forced into compromised positions.

The body is very smart and can anticipate pain before you even move. It can instantly rearrange and change motor programs and movements to protect itself from immediate harm. It does not question if a movement is good or bad or try to predict future problems, it is only concerned with the task at hand safely and efficiently with the tools it has at its disposal. This is a good thing in a life and death situation as it can save your life. Long term side effects are irrelevant if you do not survive this current situation so the body is designed to only think about what is happening in the immediate situation.

The joints most exposed are the lumbar spine and the knees as these two joints are above and below the hips. Both of these joints are primarily concerned with stability whereas the hips are more concerned with mobility.

Now we know that the hips are using stiffness to protect the joint from further movement greatly restricting range of motion with daily activities. To find the lost range of motion from the hips the body will require the lumbar spine and knees to sacrifice their stability to give you more freedom to move. This is where you begin to see the evolution of herniated discs in the lower back and patella-tracking problems with the knee.

To avoid using the hips with hip extension that uses the glutes and hamstrings a person will use either one of these faulty movement strategies.

  1. Bending of the spine
  2. Excessive use of the knees with a squatting pattern that keeps a straight spine

These are secondary problems to the original problem but over time will become much bigger and more painful than the piriformis syndrome.

Faulty Movement Patterns Encoded Into the Nervous System

If compensatory movements are not identified and corrected early they can evolve into permanent motor programs. And if this happens it can take considerable time and effort to change back to a more functional and optimal movement pattern.

The poor technique becomes encoded into the nervous system as a permanent motor program once the person exceeds a certain threshold of repetition. This is known as a motor engram and is stored in the spinal cord. Paul Chek claims it takes 500 reps to learn a movement but as many as 5000 to change one!

This is why it is so important for beginners to spend time to learn good technique when exercising and never cut corners to simply get fit. The video below provides you with a ton of ideas of how to improve your movement skill with the bending pattern which is often the most dysfunctional when it comes to piriformis syndrome.

 

In the book “Movement” by Gray Cook he makes a note of how many things a beginner to exercise may have to contend with when learning how to move correctly. The brain will be firing multiple commands that are operating in the background such as;

  • Avoid positions that are restrictive
  • Avoid unfamiliar movements
  • Avoid pain and stress
  • Compensate and substitute where possible
  • Compromise movement quality to gain movement quantity where needed
  • Conserve energy where possible
  • Do not rely on positions of weakness or instability
  • Take the path of least resistance
  • Seek comfort and pleasure

In the case of a person with piriformis syndrome the body will choose quantity of movement over quality of movement. If he/she does not have adequate stability or strength to handle a task requiring stability of the hips and pelvis the body will create an alternative form of stabilizing in the form of stiffness. Unfortunately this stiffness will rob his joints of the necessary mobility required for efficient walking and general movement and change all other movements with similar timings and positions.

“The brain does not question if it is good or bad motor program, it will simply choose the program it knows the most and use that to produce movement”.

Due to the length of this article already being too long I have not gone into great detail as to what corrective exercises you can use. I encourage you to download a copy of the detailed program I put together a few years ago to help people assess and correct their injury at the source.

Do You Need Help Putting Your Corrective Plan Together?

Due to the complexity of this condition it is impossible to have a one size fits all program that works every time. You need to assess your condition and then use the results of those tests to determine what is needed for your body. This article I provided some of those tests, and basically the process of working through this injury but understand to keep the article to a reasonable size I have left a lot of exercises and stretches out.

You can get all the tests, exercises and stretches in a detailed video and book format below. Without a doubt the most detailed of all of our programs, as it is so difficult to work with. We had to document over 200 programs and real life case studies in order to put this program together. Included is over 60 different exercises along with 25 different assessments to identify where to start. This has been simplified down so that a person who has no gym background or equipment can still execute this program effectively. Most of the people who completed this program were everyday people, not gym junkies or athletes, although there were many runners and a few dancers who helped us put this program together.

My advice to you is to read this article and then go straight to our online shop and get your copy of the full program because this article cannot explain exactly what you need to do. I just don't have enough room on the page to explain it, and it is easier in video to show you than with text. For more information about what is inside this click here on the images below.

  

Summary

There is no doubting that piriformis syndrome is one of the toughest injuries to work with once the pain has set in. I hope the information in this article can help you see how the injury was created in the first place and more importantly where to look for correcting it for good. The sooner you can begin this process the better to avoid any compensatory problems from manifesting into bigger problems to joints elsewhere that can take a long time to restore back to normal.

The most important step to address in this entire article is the first one, finding the pain trigger! This really is the key to success with getting rid of this problem for good.

For more ideas and information on specific topics I may not have covered in detail be sure to check out our INDEX PAGE on the website that has over 300 of our best articles. These are all sorted into categories for quick reference so you can find what you are after more easily. You can also subscribe to our FREE fortnightly newsletter by clicking here.

If you do need specific help with your exercise program please feel free to reach out to me for help and we can set you up with your individualised program.

About The Author

Nick Jack is owner of No Regrets Personal Training and has over 15 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specializes in providing solutions to injury and health problems for people of all ages using the latest methods of assessing movement and corrective exercise.

References:

  • Movement - By Gray Cook
  • Corrective Exercise Solutions for the Hip & Shoulder - by Evan Osar
  • The Psoas Solution - by Evan Osar
  • Diagnosis & Treatment Of Movement Impairment Syndromes - By Shirley Sahrman
  • Low Back Disorders - by Stuart McGill
  • Knee Injuries In Athletes - by Sports Injury Bulletin
  • Anatomy Trains - by Thomas Meyers
  • Motor Learning and Performance - By Richard A Schmidt and Timothy D Lee
  • Assessment & Treatment Of Muscle Imbalance - By Vladimir Janda
  • How To Eat, Move & Be Healthy by Paul Chek
  • Scientific Core Conditioning Correspondence Course - By Paul Chek
  • Advanced Program Design - By Paul Chek