“That deeeeeep pain in the rear keeps happening after I run!” says the client. “I can’t seem to stretch where it hurts.”
Can you relate? But what is it?
Your butt? Sciatica? or something else?
The most common culprit is piriformis syndrome.
The piriformis is a small pizza slice-shaped muscle that lies deep under the gluteus maximus and is responsible for external rotation of the hip and pelvic stabilization.
It can be a real pain in the butt.
It can cause symptoms like pain, numbness, burning and tingling which may or may not extend down the length of the leg to the toes.
Many of the runners I see who come in with this pain, have been told by their doctor (or self-diagnose) they have sciatica, when it's often piriformis syndrome.
Because compression of the sciatic nerve by a tight piriformis muscle can cause pain to radiate up to the low back or down the leg, most people, even doctors, associate this pain with sciatica. Symptoms can overlap and it’s kind of a ‘same difference’ situation, but it does matter in regards to our massage treatment.
The difference between sciatica or piriformis syndrome is where the compression occurs.
Sciatica is a compression of the nerve at the lumbar vertebrae. This can be caused by spinal rotation, vertebral disc compression or asymmetrical pelvic rotation and typically, but not always, sends pain, tingling and numbness down the entire length of the leg. In many cases of sciatica, there will also be pain in the buttocks.
Piriformis syndrome is caused when the piriformis, which lies on top of the sciatic nerve, gets too tight and spasms, causing it to compress the sciatic nerve, like a kink in a garden hose. Pain is often centered in the middle of the glutes and can be tender to the touch and/or painful upon sitting. In some cases, the spasm will pulse in the glute.
What causes the piriformis to tighten up?
There are many reasons the piriformis will tighten and cause dysfunction.
Excessive amounts of sitting - This can cause the piriformis to stretch and compress the sciatic nerve. Also, it can cause pelvic instability because the glutes, piriformis and other muscles become underactive. This can lead to the piriformis going into spasm after running because you're asking it to perform under stress (running) when it's not prepared to. Think pop-quiz in high school.
Excessive internal rotation of the femur - When your foot turns in like a pigeon into internal rotation it causes the piriformis to lengthen. Remember, the piriformis is an EX-ternal hip rotator so too much internal rotation will cause it to lengthen too much, and over time, become overactive trying to hold that lengthened position. This often leads to trigger points or nodules of pain in a muscle.
Poor pelvic floor/core control - Having a strong pelvic floor and core stability is more than having 6 pack abs. And as a runner, core stability is a must in order to reduce the risk of many types of running injuries. If you have a weak core, it causes the other muscle groups to "pick up the slack." This causes them to work harder and will eventually lead to fatigue and overactivity.
Additionally, piriformis dysfunction often times also results in tight adductors (the inside of your thigh), like adductor magnus, sartorius, gracillis, as well as the deep six (a group of external hip rotators) and of course gluteus medius and tensor fascia lata (hip flexor).
Your physician or physical therapist can assess to differentiate between true sciatica and piriformis syndrome and give you an official diagnosis. As a massage therapist, I can’t diagnose, but we can work together to solve the issue regardless of an official diagnosis.
Treating Piriformis syndrome - Luckily, piriformis syndrome is relatively easy to treat, in most cases. Here are 4 simple and effective ways you can get rid of piriformis syndrome.
Ice - sitting on a bag of frozen peas can help to reduce inflammation and swelling, which in turn can take some pressure off the nerve. Just remember not to over do it. Inflammation is your body's way of healing so a little inflammation is a good thing.
Stretching - One of my favorite yoga stretches for the piriformis is pigeon pose. This effective pose will target not only the piriformis, but the glutes and deep hip rotators. However, if your piriformis is tight because of too much internal rotation, it’s far better to stretch the adductors to take some stress off the piriformis.
Foam rolling - Using a foam roller, ball or other tools to target trigger points in the muscle or relieve stress on the attachment points at the sacrum or the greater trochanter of the femur can help relieve pressure on the nerve as well.
The mistake that many people make is using the wrong tool. Many times clients will use the hardest tool they can find, like a lacrosse ball, when a tennis ball is more appropriate for your first time. They think the more pressure the better, right?
Like massage, you need to work within your body's pain tolerance level. You also only need 30-60 seconds of sustained pressure to get relief. More than that makes an already irritated muscle even more irritated and can cause more issues, including nerve damage.
You also want to be careful not to compress the nerve itself. If you're unsure of how to use a tool, just ask, I'll be happy to give you a demonstration.
Massage - If stretching and foam rolling isn’t enough or you just don't want to do the DIY method, it might be time to see a professional. A licensed massage therapist can get into areas a foam roller cannot or help stretch you in ways you cannot do alone to ease piriformis pain. If you're ready to take that step, you can book your next appointment here.
Once the soft tissue dysfunction is removed, strengthening the glutes, core and hip flexors is recommended for lasting results. I suggest a corrective exercise specialist, personal trainer or physical therapist for specific exercises to strengthen weak muscles which will keep this problem from ruining your next run.