Blog Talk – Piriformis Syndrome (Episode 2)
March 21, 2018 / /
Piriformis Syndrome. Blog Talk. Episode 2
If you don’t do anything else except read this ONE SENTENCE:
Throw away that tennis ball and stop stretching!
Episode 2 is dedicated to another popular Blog Post: Piriformis Syndrome: It’s Not About the Tennis Ball . It gives visual life and explanation to the original blog post and reviews some glute exercises you can try. You must find the Good Glutes (Max, Med and Min) to truly heal this syndrome.
Blog Talk is A Video Podcast of Physical Therapy, Healthy Movement and Patient Stories.
© 2018 and Beyond. ALL BLOG CONTENT at duncansportspt.com by Lori Duncan PT
Hi Lori,
I had written to you a little over a year ago. I think your advice is always spot on and I think glute activiation is critical in preventing other injures as well as piriformis syndrome. I have suffered with sciatica or pseudo sciatica on and off for over a year. A year ago, I had thought it was due to PS, but after only brief relief from visits with, doctors, accupunturists, chiropractors and spinal specialists my condition would always come back. Even after doing the glute exercises you suggest, my condition still resurfaced, which led me to believe that my case was disc related. About 6 weeks ago when suffering a flare up, my daughter who is also a PT suggested that I see a McKenzie therapist. After 2 visits per week for 6 weeks of intense Mckenzie protocol exercises for a bulging disc, I have been pain free for about a week now. However, my therapist did tell me I had some lingering muscular issues with my glute med and min, possibly due to compensating from limping with pain, or from compressed nerves preventing the muscles from firing efficiently, but she wasn’t certian. I know there are still some muscle issues because I can tell those muscles are different on my left side(bad) versus my right side(good). She feels I would greatly benefit by starting to strenghten those muscles going forward. It seems like there’s no sure way of diagnosing the source of sciatic pain. MRI’s are usually not helpful, and glute med/min spasms can also mimic sciatica by referring pain down the leg. My question is: how does one know if the condition is caused by disc, the piriformis or other glute muscles, and if the glute med/min are the culprit, will activation exercises on the those delay healing? I know those muscles don’t compress the sciatic nerve like the piriformis but they can still spasm and refer pain down the leg.
Thank you and I really enjoy hyour blogs,
Ron
Hi Ron,
Glad you got relief. GREAT question. This is why you need a good PT or other medical professional to be thinking and constantly evaluating the symptoms. Piriformis syndrome (without spinal involvement) truly does resolve once the good glutes are found. Additionally, PS does not hurt so bad you can’t get up from the floor. So, if someone is not starting to have pain relief after a few weeks with glute work, then the spine must be considered. For herniations and stenosis. The glute min/med usually refer to the outside of the leg, not down the back of the leg. So, that’s a cue for those. Again, it’s why I encourage people to have good PT in their corner. Hope that helps!
Hi Lori,
Thank you that helps a lot.
I look forward to your next blog talk 🙂
Ron
Hi Lori,
One more question if you don’t mind. Doing the clamshells, and fire hydrants feel great during and after, yet I cannot do a single legged glute bridge on my affected side without a “cramping” in the left buttock. I assume that is the gluteus maximus. Any suggestions for that?
Thank you,
Ron
Clams are more of the side glutes, single leg bridge requires the back glute. Try double bridging and march your knees to train the glute to activate and not cramp.
My PT, my pain doc, and my PCP all told me to stretch that piriformis muscle, as well as well-meaning friends. So, just to clarify, are you saying don’t EVER do those stretches for piriformis syndrome? Throw out the pigeon pose and the ankle over the knee one? I have been thinking those stretches are my problem, but until today when reading your blog posts, not one doctor has said to NOT stretch. Definitely going to try NOT doing them. But, is there ever a time when you should do them? Is there a good hip or glute stretch I should be doing instead?Thank you so much for taking your valuable time to write this blog and reply to comments and questions!!!
Hi Sydni,
I am not a fan of figure 4 stretching EVER. It doesn’t control the pelvis rotation/alignment. A safe glute stretch is to sit in criss, cross legs one foot in front of the other. Tall spine and lean forward. You should feel that in your glute of the leg that is in front.
Ok. I’m not sure I understand. Is there a youtube I could look up or pictures? I found a yoga criss cross pose or is it more like sitting Indian style? As far as the stretch part, should my spine curve when going down for the stretch or stay straight? Thanks again!
Hi,
I don’t have a youtube of this. Just sit in legs crossed, tall spine (not rounded) and lean forward. Make sure pelvis is level on the ground.
Got it. How long do you recommend the stretch be held? Thanks!!!
Hi,
Sorry for the delay. Vacation! A stretch should feel comfortable. So, if can be 15 seconds to 1 min. Just make sure it feels good.
Hi Lori,
Really interesting article and video. I’ve been rolling on balls and stretching like a mad man – although not on an apple! That’s hilarious! I think I’ll give it a rest now.
Do you see any cases of a piriformis related issue without the sciatic nerve pain? I don’t have too much nerve related pain – some occasional burning but that was towards the side of the hip. My main complaint is just a general tightness and light spasming across the butt. And when I run (and sometimes when I walk), I get a dull ache approximately to the left of my tail bone (it looks to me like the area the piriformis attaches to the sacrum.
It started a year ago after a hill run and I really messed it up doing jumping lunges not long after that. Since then, I’ve done all kinds to try and kick this. More recently glute work but mixed in with core and stability work which included lunges and I think this is what kicks off that ache near my sacrum.
So I’m wondering if I’m just not activating enough glute strength yet, despite all the glute work! And I think you mentioned avoiding lunges if the glutes weren’t 100%.
How do you know when you’re recruiting enough glute to perform glute demanding exercises? I have buns of steal at the moment from all the work but it doesn’t seem enough!!
Keep up the good work.
M
Hi Martin,
Thanks! Are you sure your spine is cleared? Meaning, if you think you have really strong glutes and you’re still having pain, is that nerve/pain signal coming from your spine? Or, if you just take out lunges, does it feel better? You may just not be performing those correctly. The back glute is the main driver of the lunge and extends the knee straight. If you think the front leg is the driver, it will have the back hip behave strange. Hope that helps!
Lori, many thanks for your reply.
I’ve had my spine checked by a PT and Chiro (they pressed and poked around that region) and they both didn’t have any concerns.
Taking out lunges doesn’t get rid of the symptoms, it just causes a flare up. And since reading your other article on lunging, i was doing it completely wrong – it seems like such a simple movement but I was using the front leg as the driver, exactly what you said.
I can deadlift and squat without any flare ups and this seems to help for some reason. Perhaps the increased load is forcing the joint to become more stable? I have no idea!
Thanks again for your time.
Hi Martin,
Well, pressing and poking is different than imaging. My only point is that if you are not getting relief, then you need to look in a different direction for the true cause. Sounds like your glute max works better than your glute med/min from the exercises above. And, work on that lunge :). Work on clams and some glute med/min stuff.
Hi Lori,
I thought you and your followers might find this interesting. I was watching a PBS show on chronic pain issues presented by a PT. He had a very interesting perspective on sciatica, and a protocol pretty much identical to yours for piriformis syndrome. He said something that I found very interesting, and not knowing human anatomy that well, I don’t know how accurate it is but it made a lot of sense. He said the only cause of sciatic pain that starts in the glute region and radiates down the leg, is from the piriformis due to it overworking and becoming enlarged because of other glute muscles, mostly the gluteus medius, either being injured or not activated and out of balance. He said it’s impossible for any mechanical structure in the spine to produce these symptoms because there are only nerve roots at the spinal level and not the entire sciatic nerve. He also stated that a technology, MRN(Magnetic resonance neurography) confirms this as it shows the sciatic nerve being squeezed by the piriformis in all cases where patients complained of pain radiating from the glutes to the knee and below. I would be happy to post the link to this here, but wouldn’t want to do so without your permission. He is very much in agreement with you on how to treat piriformis syndrome, but I am wondering/skeptical on the accuracy of him stating that sciatica originating in the gluteal region cannot come from a spinal issue such as a bugling disc.
If he is correct, I think everyone suffering with sciatica, will greatly benefit from following the exercise you have posted here in your Blog Talk.
Thanks,
Ron
Hi Ron,
I’m glad to knows someone else is thinking on the same lines. He thinking is a little “off” like you think. Sciatica is just a general term to state the sciatic nerve is irritated. Either that irritation comes from full compression at the sciatic nerve (at the level of the piriformis) or one of the nerve roots that feeds the sciatic nerve. Either way, it’s sciatica.
Thanks Lori,
I didn’t do a great job explaining his thinking. The way he explained it was, if there is pain along the entire sciatic nerve, that can only come from the piriformis, as that is the only structure that would compress the actual sciatic nerve. Structures in the spine only can compress nerve roots so that would elicit pain only to specific regions(I think he called them dermatomes). So for example, a compressed nerve root at L5 would only refer to the L5 regions, not everywhere like in the glutes and entire leg as the piriformis would do.
It’s an interesting theory and seems to make a lot of sense.
Ron
Lori
I enjoyed your video and have begun the clamshell and hydrants. I have had this condition for over 10 yrs. and have tried everything. Sitting on the tennis made me sore as hell and the pigeon felt good while doing it but no improvement noticed. Sitting is uncomfortable .
I will begin with 30 of each exercise morning and evening. No more stretches and tennis ball. Your theory makes sense as I am quite weak on the left side which is worse than the right. When I sit, I feel like I am on the coccyx bone.
Should I ice after? How soon to increase the clamshell and hydrants?
Thanks so much. This all makes sense to me.
Jan
Hi Jan,
You can ice if you want. It can sometimes help with pain. And, it’s fine to start with 10-15 reps of each exercise at first. You should increase the reps to 20 when you can hold good quality and feel a good healthy “burn” in your glutes. I’m glad this makes sense to you and I hope you get relief soon.
I am trying Loris method. When should I begin to feel the improvement. I have had this so long I don’t remember sitting comfortably.
I’m going to try these exercises. My problem started 8 weeks ago slightly higher than glutes just when I got up from standing, improved with physio but then started to flare up again but no sciatica. Then I slipped on a wooden floor but actually can’t say my symptoms were aggravated at that time. Since then more problems sitting and getting up but with sciatica in my lower calf above the ankle mostly. Comes and goes – had some relief yesterday with McKenzie prone position but physio keeps telling me my back feels ok and it’s piriformis. I’ve been given the standard 4 or versions of, stretch, and pilates bridges which I feel are not great (I’ve done bridges in the past at the gym and find they aggravate my back). I am mostly ok walking or lying in bed (occasionally leg aches) but sitting and getting up is the worst and I do feel that tightness in the glutes (had it around 5 years ago but not as bad or long lasting as this)
Hi Liz,
I disagree with your physio from your symptoms. Piriformis syndrome will NEVER feel higher than the glute. It does sound like something happened at your spine. THAT SAID…most people heal their symptoms (ie. herniation) with PT and without any surgical intervention. I would ensure you are adding core stability. Do not like bridges for piriformis or spine when aggravated.
If you haven’t watched Blog Talk – Piriformis Syndrome…I give a few good glute exercises. And, on Youtube, I have a short core video for few ideas. https://www.youtube.com/watch?v=Q-RmGzx-gpQ&t=17s
Hi Lori, I have done these before and felt a massive improvement when I walk but then it just gets worse again do you know why this could be? Also I have a lateral pelvic tilt my hip is hiked on the side of the pain will this effect it in anyway? Should I concentrate on fixing the pelvic tilt first or fix the piriformis first?
HI Darryl,
I would get someone to help you with the pelvis first. Could be the pelvis is truly “off” or you could just have a dysfunctional muscular patterning causing a change to the pelvis. But, if the pelvis is not stable, then everything that attaches to it does not activate correctly.
Hi Lori, I find your blogs so interesting and accurate. I enjoyed this one very much as well as the one you did on Disc and spine issues.
I am curious on your opinion on trigger points. Do the glutes get trigger points and not function efficiently which can cause the piriformis to have to overwork? I have been to a massage therapist many times for trigger point therapy in the glute and hamstring area, and I feel terrible the day after, but then feel really great after a couple of days. It seems to last for about a 4-6 weeks, then then I start to notice the muscles are not as efficient and need more therapy. There is so much information regarding them online, and a lot of disagreement on how to best address them. Are trigger points real, and if so, how do you think its best to treat them? Massage therapy, foam rolling, moist heat, all the above, none of the above, etc?
Looking forward to your next blog 🙂
Ron
Hi Ron,
Trigger points are real. But, just having them released is not the answer. Trigger points exist because of poor muscle activation. So, if you get them released, you need to quickly activate (in a good way) that muscle. Foam rolling? Not a fan. Moist heat? Sure, can help, but not treating the cause. It’s fine to get them released, but if you continue to get them then no one has addressed the “why” of your pain.
Hi Lori,
Thanks so much. The source of my problem is overuse mostly caused by biking, ellipticals and tennis. I can really feel my gluteus medius being strained and overworked especially biking in high gears(I need to stop doing that I knwo) . I struggle doing a side plank on the affected side. A few months ago I had a therapist work on the trigger points, then she gave me some excellent glute activation exercises similar to yours but using resistance bands. I felt so good, but whenever I feel healthy I think I am all set and stop training the glutes and then overdo other activities and fall back to where I was. I need to really stay on top of this.
Ron
Hi Lori,
Awesome blog and Glad to hear people’s reaction in above replies.
I am facing this problem from last 2 year approx. and I am just fed up as its affecting my social life. Pain is in the hip area and from last 6 months pain started to grow in full leg. I am not sure it is a sciatica nerve issue or Piriformis disorder. I gone through the MRI scan and report says “1. MRI study of the lumbosacral spine reveals mild non-compressive disc bulges at L4-5 and L5-S1 levels 2. Screening of the rest of the spine has not revealed any significant abnormality”. I have only taken Ayurveda medication all over the course and also gone through “Panchkarma” treatments (Basti). I am not sure If you are aware of the terminology or not. But I want you to have all the details. Treatment was also included of normal Yoga Poses and Oil massage therapy.
Please guide me which therapy/Medication I should try to get over this problem.
Thanks in advance
regards,
Ashish
Hi Ashish,
I would stop the yoga (stretching) for now until you can get your deep abdominals, glutes and scap muscles to fire. You need core stability!! The full core is glutes to shoulder blade muscles. If your symptoms are starting to run down your leg, I would also see a PT in your area to ensure you are not getting any motor loss (weakness associated with nerve compression). That can be a sign you need to see the MD.
But, strengthening your core is good no matter what!!
My piriformis is so tight and painful I can’t even do these excerciseswithout stretching first. I have switched to 2 yoga poses, child pose and downward dog instead of the opposite leg assist cross over. Sad to say I have to slowly work into even child pose 🙁 I am miserable
Can these exercises work if my MRI sates L4-L5 moderate to severe right sided neuralforminal stenosis? I really do not want surgery.
Hi Martha,
They might, but a better set of low-load exercises are ones I describe in this video. Here’s the link.
https://youtu.be/ydl337yl_nU
Can these exercises work if my MRI states moderate to severe neuraforaminal stenosis at L4-L5?
Hi Lori,
I’m so glad to find your video on piriformis muscle stretch. I wish the sound could have been better as it’s very low. I’m not a native speaker of English thus it’s not easy to fully comprehend your advice. I really want to start doing the exercises. Thank you!
Hi Jargal,
Yes, some people hear it fine and others not. Since then, I bought a GoPro so the sound is more consistent. Make sure your YouTube settings are to HD and the volume is up high! Hopefully that helps. Find your good glutes, not that silly piriformis.
Hi Lori, would it be normal not to feel pain when doing the exercises, but to have symptoms seem worse shortly after finishing, maybe at first? Wasn’t sure if I might be doing them wrong or if just starting out might cause some irritation if the muscles are out of shape. I slept basically sitting up on one glute during a couple of months of cancer treatment and now I have had what sure seems like lingering PS. Just trying to figure out if I should expect some escalation at the beginning or if that’s a sign I don’t have it quite right. Just a little gun shy after months of flare ups.
Hi Aaron,
Sorry for the delay. The commenting feature on the blog was glitchy and I didn’t see this. No, you really are looking for glute activation exercises that do NOT cause any irritation. Sometimes just squeezing the glutes together (glutes before hamstrings) is a good place to start.
Hi Lori,
I am curious of your opinion on this. I had a pretty severe case of PS over a year ago, and through PT I was able to clear it up. I felt 100% for almost a year, but recently I had a few brief bouts of PS. It seemed to come out of nowhere and only last about 30 seconds, but I could really feel the muscle spasm and pain radiate down my leg. It was quite severe but then it would disappear for days at a time without me doing anything for it. Then it happened again. It’s happened about 4 times in the past two weeks but never lasting over 30 seconds.
What I am curious about is, after doing a little more research on PS, I have found several interesting articles saying that experts in this field have found that there are actually 2 types of PS. Short PS and Long PS, and treatments for both are different. You should never stretch the muscle if your symptoms are due to long PS, howerver it’s good to stretch them for short PS. One such article was from the National Academy of Sports Medicine (I don’t know if this is a good organization or not).
I’d be curious on your thoughts on this.
Thanks,
Ron
Hi Ron,
I’ve never heard of long and short, but I can deduct that it deals with true hypertrophy of the muscle vs just acute overuse. In general, stretching is never the answer. Ever. Only true glute activation. It’s still a VERY misunderstood diagnosis, especially in the world of fitness. Find your real glutes, PS goes away. It’s really that simple.
Hi Lori,
Just a follow up to Ron’s comment…there are several sites that suggest that there are, in fact, two different issues. One is that your piriformis has become too long and is irritating the nerve. The other is that your piriformis is short due to injury. The suggestion is that you can test for it by stretching the piriformis. If you don’t feel any stretch, your piriformis is very likely long. If you feel tightness in the stretch, your piriformis is very likely short. If your piriformis muscle happens to be tight (short) and has hypertrophy, wouldn’t it benefit from stretching (to release some of the tightness) and glute work (to reduce the hypertrophy)? I completely agree with you that stretching, tennis balls, etc. won’t solve the problem, but I would have thought that stretching could help in coordination with the glute work. Any thoughts on that?
Thanks,
Jesse
Hi Jesse,
That is really more of an old thought – taut vs stretched. And, it truly is not usually a length issue (the piriformis is a deep muscle and hard to isolate in stretch. No, the figure 4 does not isolate it). It is almost always an overactivation issue. So, if it’s over activated…why? I get that there is a lot of poor (and very old) thought processes about this syndrome, but once people stop stretching and start activating the glutes, this syndrome goes away. HOpe that helps!
Said to my wife today “I need to ask you a funny question…can you please grab my butt.” She confirmed what I thought I could feel on my own…that my right glute and even my right hamstring had noticeably atrophied compared to my left side. This likely started because I had some pain in my upper right hamstring since May and had babied it a bit. To make up for it, my guess is that my piriformis took on most of the load, resulting in my current situation of piriformis and sciatic pain. I’ve been doing clamshells and fire hydrants the past week and can already feel my glute taking on some of the load it had previously given up.
Hi Lori,
I was intrigued to see your article/video as it suggests that tennis ball rolling is not helpful.
I have had PS for a couple of years and after some research now perform daily glute and back exercises, but what I really found helpful in getting rid of the pain was rolling on a tennis ball!
Now I roll on a tennis ball every night for a few minutes before bed. I have found that if I do that, I dont wake up in the middle of the night with pain through lying on the affected side, Just wanted to share my experience as maybe different things work for different people?
Hi Mike,
Thanks for your comment. If you have to roll on a tennis ball every night, then you have not healed your PS. Promise. Although it gives you symptom relief (short-term) it is only kicking off the blood flow and neurological feed to that nerve for a moment. When you truly heal PS, you never feel again. And…Rolling a nerve on tennis ball is never a good idea. Seriously..find your glutes!
Thanks for the quick response Lori.. will try the other exercises you mention as only doing the bridge for my glutes at the moment
Good day Lori.
First off, my apologies for arriving here and bringing this back up two years after it was posted.
About 2 1/2 years ago I began experiencing a burning pain in what my rudimentary google skills suggested was my piriformis. My PCP diagnosed PS and had me doing some stretching exercises. Over the course of 2-3 weeks doing these stretches the symptoms changed to the point that I was unable to sit, stand, or walk for longer than 3 or 4 seconds without excruciating pain. An MRI revealed a herniated disc at L5-S1 for which I underwent a series of three epidural streroid injections, the last of which was on March 1, 2018. Since that time I have always had a dull ache in the piriformis region but over the last week this dull ache has grown to severe pain that manifests when sitting, transitioning between a seated and standing position, and when I stand without putting weight on the affected side. During the two years since the injections I have also been regularly visiting a chiropractor for maintenance adjustments in an effort to prevent a repeat of the total incapacitation I experienced initially.
I go through all of that because I have one very ignorant question. What do you mean when you suggest making sure the spine is “cleared”? I suspect that my problems originated with the herniated disc, but I’m not sure if the injections and subsequent chiropractic care constitute clearing. Ultimately, based on reading yuour blogs about PS, I’m not sure if I would be better served by seeking out a physical therapist or returning to the pain management clinic and exploring the option of further injections.
Is that too broad a question?
Hi,
That is not an ignorant question. That’s an important one! If you have had spine issues in the past you want to make sure that it is not your spine contributing to the symptoms. Meaning, true sciatica stems from a problem at the spine (L3-S2). PS is just an aggravator to the sciatic nerve and mimics those sciatic symptoms. I would stop getting “adjusted” at the chiropractor and look for a good PT to help you stabilize and truly find the good glutes! DO NOT get an injection or surgery. Happy to help if you need. [email protected]
Hi Lori,
I have been suffering with what I think is PS for over a year. At one point it was so bad I couldn’t sit, lay down or stand comfortably. I have the pain on both sides but the left side is typically worse. Now I can lay down fairly well and can even sit a little better until recently. I had an MRI and they didn’t see any problems with my spine. I can seem to do exercises fine but then the next day or so it get real sore. Sometimes the pain comes up into my lower back. With everything going on I have stopped going to a massage therapist and someone doing dry needling. It was starting to help. I have a couple of questions: 1) How often should I do these exercises. 2) Are there any exercises that should be avoided.
Thank you for any help you can give.
Hi! I have been having this pain for about a month now, started after a long day gardening, I was sitting bent over for way too long. Since then I have had pain in my hip that radiates along my back at the top of my glute. Of course I have been stretching which I’m now reading may be hurting more than helping. I’m going to try your recommendation on glute exercises but had one question – thoughts on regular ol’ exercise? I like to do workout videos but wonder if all the squats, burpees, etc… will help or hurt. Also, I just bought a new mountain bike – ok to ride or give it a rest for a bit?
Hi Emily,
If squats don’t bother you they should be ok. I would avoid burpees or fast movements until you feel your pain is gone. Work on glutes, core. Mountain biking should be ok, but I my rule is: “If it hurts, stop for the moment.” Hope that helps!
Can you share a few of your testimonials please?
Here is a linke to my website with testimonials…www.duncansportspt.com