Piriformis Syndrome For Runners: Diagnosis, Symptoms, and Treatment

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Are you experiencing an aching soreness in your glutes or shooting pain down the back of your leg?

Piriformis Syndrome can be a real pain in the a$$.

It can be tricky to accurately diagnose due to the long list of symptoms, including glute, hip, and hamstring pain.

Piriformis Syndrome can occur due to direct trauma to an area or, like most running injuries, when your training demands exceed your body’s training tolerance.

Piriformis Syndrome is not as common as other running injuries, such as Runner’s Knee or ITB Syndrome, but still boasts an incidence rate estimated between 1% and 3%.

This article will provide up-to-date science regarding Piriformis Syndrome, giving you the tools to help evaluate and treat this problematic injury.

In this article, we will be looking to answer the following:

  • What Is Piriformis Syndrome?
  • Piriformis Syndrome Diagnosis
  • Piriformis Syndrome Symptoms
  • Causes of Piriformis Syndrome
  • Can You Run With Piriformis Syndrome?
  • Effective Piriformis Syndrome Treatment – 4 Exercises To Try

Let’s jump into it!

What is Piriformis Syndrome?

The piriformis is a small but mighty, stabilizing muscle that lies deep within your glutes. The piriformis runs from the base of the spine to the outside of the top of the femur.

piriformis muscle anatomy on body

It plays a critical role in running motion, involved with external rotation, abduction, and partial extension of the hip.

The sciatic nerve originates from your lumbar spine and passes under your piriformis muscle, down the backs of your legs, and down to your toes.

Piriformis syndrome is a condition of sciatic nerve entrapment near the ischial tuberosity (sit bones.)

sciatic nerve running through pelvis and lower back

There are more women diagnosed with piriformis syndrome than men, with women accounting for 85% of cases.

Piriformis syndrome typically develops in two ways.

  • The first is following a heavy impact or trauma to the buttocks, e.g., falling onto a hard surface, which can cause damage to the piriformis and lead to tightening and spasms.
  • The second is repeated overuse of the piriformis muscle, e.g., an increase or change in running volume, that causes it to fatigue and become damaged, resulting in muscle spasms and shortening of the muscle.

For 15% of people, the sciatic nerve passes through the piriformis, possibly leaving these individuals more susceptible to piriformis syndrome.

Piriformis Syndrome Diagnosis

To get an accurate diagnosis for you, check with a medical professional.

Due to the complicated causal nature of piriformis syndrome, the diagnosis is primarily clinical and will look to exclude other possibilities.

A practitioner is likely to perform stretching maneuvers that will look to irritate the piriformis muscle.

Additionally, applying manual pressure around the sciatic nerve may help reproduce the symptoms and confirm the diagnosis.

sports massage therapy for piriformis syndrome

These movements include:

  • Freiberg – A practitioner will look to produce forceful internal rotation of the extended thigh
  • Pace – A practitioner will engage the piriformis by creating resisted abduction and external rotation of the thigh.
  • Beatty – While lying on a table, a practitioner will reproduce glute pain by getting a side-lying patient to hold a flexed knee several inches off the table.
  • FAIR – flexion, adduction, internal rotation manoeuvres
lower back pain from piriformis syndrome

Piriformis Syndrome Symptoms

The most common findings in runners with piriformis syndrome are:

  • Pain and tenderness in the buttocks, or more specifically between the sacrum and the top of the femur – the area the piriformis muscle runs through.
  • Pain, tingling, or numbness in the lower back, down the back of your leg, through your hamstrings and calves.
  • Buttock pain and sciatica-like pain worsens with prolonged sitting.
  • You experience pain or aggravation when the hip and leg are positioned to put tension on the piriformis muscle. For example, lying on your side and abducting your leg will likely cause pain.

When running, you may feel pain in your buttocks during the stance phase of your stride; the pain might worsen when you run fast and go up and down hills.

3 Main Causes of Piriformis Syndrome

There are no universally agreed-upon criteria for piriformis syndrome, so the exact cause can be hard to pinpoint.

However, the mechanism of piriformis syndrome is sustained pressure between the sciatic nerve and the piriformis muscle of the hip.

But what causes sustained pressure?

Here are the 3 key causes:

#1: Muscle Trauma

Over 50% of cases of piriformis syndrome are a result of blunt force trauma to the piriformis area.

That inconspicuous fall when running on the trail can lead to inflammation of soft tissue, muscle spasms, or both, with resulting nerve compression.

Trauma may also be a result of a surgical procedure.

#2: Overuse

The most common risk factor in runners is usually down to a sudden increase in training volume.

Not allowing your body adequate time to rest and repair after a training run will lead to accumulated stress.

Overuse of the piriformis muscle over time will increase tension within the muscle, leading to possible nerve compression.

If you are new to running, increase your volume slowly. If you are a seasoned runner, check for recent inconsistencies or spikes in your training.

A different form of overuse can result from prolonged sitting. Spending multiple hours per day sitting on a hard surface can aggravate the sciatic nerve.

#3: Muscle Weakness

Following on from “Overuse” is muscle weakness. They are inherently linked as any weakness in the piriformis and glute muscles will be exacerbated by sudden increases in training volume or intensity.

The core and glute muscles play a vital role in the stability of the hips, pelvis, and lumbar spine. If these muscles are too weak, the piriformis will have to work overtime in an effort to provide stability to the hip.

If you’re constantly sitting all day, whether it be in an office at your desk or during your commute, your glute and hamstring strength can decrease over time.

Can you run with piriformis Syndrome?

trail running in mountains with sunset

Most of the time, you can continue running with piriformis syndrome.

The likelihood is that if you’re suffering from recent direct trauma or highly acute piriformis syndrome and you feel pain when walking or as soon as you start running, your body could probably do with some rest.

Continuing to run with piriformis syndrome may slow the healing process and prolong the course of the injury.

If the symptoms are mild and don’t deteriorate with exercise, then a reduced volume of running is certainly possible.

Effective piriformis Syndrome treatment: 4 Exercises To Try

Piriformis syndrome rehabilitation is not clear-cut for each individual

Typically a mild case of piriformis syndrome can be successfully treated within 2-4 weeks, with more severe cases lasting 6-12 weeks or longer.

As always, recovery is rarely a linear process, so you can expect occasional flare-ups along the way. This does not mean you’re back to square one.

lower back and glute pain for runner in park

If the cause of the pain was a result of direct trauma, then rest is recommended for the first week or two while the inflammation in the area settles.

You can then gradually increase your running, as long as it doesn’t excessively aggravate the pain.

However, rehab looks slightly different if it was caused by overuse and overtraining.

In order to ensure a seamless return from injury, it is crucial to address the body’s training tolerance and muscle weakness.

If you increase your strength, your tolerance will increase, and the risk of aggravation and re-injury will decrease.

This is a gradual process; weekly, you will slowly re-introduce load to the affected area. What you can do on week four would likely be too much on week one.

foam rolling piriformis muscle

Key parts of the rehabilitation program will be:

  • Soft tissue and joint mobilization – Massaging your piriformis muscle can help ease the tension, which may help reduce the pain and discomfort caused by piriformis syndrome. This can be done using a foam roller or seeing a qualified Sports Massage Therapist.
  • Stretching program – Stretching can be especially effective at reducing tightness in the piriformis muscle and subsequently reducing compression on the sciatic nerve.
  • Strengthening program – Increasing strength will gradually increase tolerance, easing symptoms and protecting you from re-injury.

Here is an example of what a progressive rehabilitation program may look like.

Phase one of exercise rehabilitation:

Phase one will feature low-load muscular activation piriformis syndrome exercises and stretches.

Exercise 1: Supine Piriformis Stretch

Begin with holding the stretch for five seconds and gradually progressing over time to 60 seconds.

Don’t be overly aggressive with this stretch; this may put too much stress on the already irritated piriformis.

Repeating for 5 sets of 5-60 seconds.

Exercise 2: Side Lying Abduction

lying on side raising leg up in air

This piriformis syndrome exercise will strengthen your hip external rotators.

Lie on your side, keep your hips forward, and raise your top leg to 45 degrees. Go slowly, raising the leg for 5 seconds and lowering the leg for 5 seconds.

Try 3 sets of 10 repetitions.

Phase two of exercise rehabilitation:

Phase two will slowly increase the load experienced by the piriformis muscle.

Exercise 3: Resistance band clamshell

Phase three of exercise rehabilitation:

Heavy compound strength exercises or plyometric work.

Exercise 4: Bulgarian split squats

This will be a real test for your quads and hip external rotators. It’s a great movement that will also require proprioception from the other leg.

Try 3 sets of 10 repetitions.

Photo of author
Ben is a qualified Personal Trainer and Sports Massage Therapist with a particular interest in running performance and injury. He has spent the last 9 years working with runners at his clinic in Brighton. Ben is a keen runner and avid cyclist. Evenly splitting his time between trail running, road biking, and MTB.

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