Blog Talk – Piriformis Syndrome (Episode 2)

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.

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© 2018 and Beyond. ALL BLOG CONTENT at duncansportspt.com by Lori Duncan PT

36 Comments

  1. Ron on March 22, 2018 at 5:13 PM

    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

    • Lori Duncan DPT, MTC, CPT on March 24, 2018 at 4:58 AM

      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!

      • Ron on March 24, 2018 at 1:45 PM

        Hi Lori,

        Thank you that helps a lot.

        I look forward to your next blog talk 🙂

        Ron

  2. Ron on March 25, 2018 at 5:44 AM

    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

    • Lori Duncan DPT, MTC, CPT on March 31, 2018 at 6:49 AM

      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.

  3. Sydni on March 26, 2018 at 11:48 AM

    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!!!

    • Lori Duncan DPT, MTC, CPT on March 31, 2018 at 6:51 AM

      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.

      • Sydni on March 31, 2018 at 8:01 PM

        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!

        • Lori Duncan DPT, MTC, CPT on April 3, 2018 at 7:54 PM

          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.

          • Sydni on April 6, 2018 at 1:36 PM

            Got it. How long do you recommend the stretch be held? Thanks!!!



          • Lori Duncan DPT, MTC, CPT on April 16, 2018 at 12:37 PM

            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.



  4. Martin on March 29, 2018 at 3:43 AM

    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

    • Lori Duncan DPT, MTC, CPT on March 31, 2018 at 6:55 AM

      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!

      • Martin on April 16, 2018 at 5:11 AM

        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.

        • Lori Duncan DPT, MTC, CPT on April 16, 2018 at 12:46 PM

          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.

  5. Ron on April 1, 2018 at 10:53 AM

    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

    • Lori Duncan DPT, MTC, CPT on April 3, 2018 at 7:53 PM

      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.

      • Ron on April 4, 2018 at 7:52 AM

        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

  6. Jan Hamburg on April 26, 2018 at 7:29 AM

    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

    • Lori Duncan DPT, MTC, CPT on April 29, 2018 at 4:07 AM

      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.

  7. Jan Hamburg on April 26, 2018 at 9:09 AM

    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.

  8. Liz Wood on May 1, 2018 at 4:24 PM

    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)

    • Lori Duncan DPT, MTC, CPT on May 16, 2018 at 6:23 AM

      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

  9. Darryl on May 15, 2018 at 1:47 AM

    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?

    • Lori Duncan DPT, MTC, CPT on May 16, 2018 at 6:25 AM

      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.

  10. Ron on May 18, 2018 at 11:07 AM

    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

    • Lori Duncan DPT, MTC, CPT on May 19, 2018 at 7:15 PM

      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.

  11. Ron on May 20, 2018 at 10:32 AM

    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

  12. Ashish Tagalpallewar on May 31, 2018 at 5:21 AM

    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

    • Lori Duncan DPT, MTC, CPT on June 4, 2018 at 11:14 AM

      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!!

  13. Lori on June 5, 2018 at 7:32 PM

    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

    • Martha on June 18, 2018 at 11:56 AM

      Can these exercises work if my MRI sates L4-L5 moderate to severe right sided neuralforminal stenosis? I really do not want surgery.

  14. Martha R on June 18, 2018 at 11:58 AM

    Can these exercises work if my MRI states moderate to severe neuraforaminal stenosis at L4-L5?

  15. Jargal on June 28, 2018 at 8:42 PM

    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!

    • Lori Duncan DPT, MTC, CPT on June 29, 2018 at 7:03 PM

      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.

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