An aching soreness in your butt, shooting pain down the back of your leg. Irritation with every step when you run, sound familiar? These are the classic symptoms of piriformis syndrome. A stubborn and troublesome injury.
That can cause sciatica like pain. Pain that can radiate from your butt around your hip or all the way down your hamstrings and even into your lower leg.
Piriformis syndrome is tricky to diagnose, so statistics on its frequency are hard to come by. At best, it appears to account for no more than one to three percent of all running injuries.
One study of over 2,000 injured runners seems to have included it in the larger category of “sacroiliac injuries.”
Accounting for about one percent of injuries. Some cases may have also been misdiagnosed as gluteus medius pain, which accounted for just over three percent of injuries in the study.1
In any case, rare as it may be, piriformis syndrome is a real pain when you have it. So, what can you do about it?
Anatomy of Piriformis Syndrome
The piriformis is a small, narrow muscle that runs from just above your tailbone to the head of your femur. It helps externally rotate and abduct your hip. But it’s not the only muscle that does so. The gluteus medius and gluteus minimus are bigger, more powerful muscles that perform essentially the same function.
The piriformis (as well as these lesser glute muscles) also serve to stabilize your hip when you firmly plant your foot on the ground. Like during the stance phase of running.
If the piriformis is a weak, small, and seemingly unimportant muscle, how could it cause so much trouble? The piriformis does have one unique anatomical feature. Its proximity to the sciatic nerve. The sciatic nerve is the longest nerve in the body. Running from the base of your spine all the way down to your foot. Fore more, please read, Overcoming Sciatica.
As you might guess from its name, the sciatic nerve is also the source of the pain pattern we call sciatica. Aching or burning pain that radiates down the length of the sciatic nerve.2
The sciatic nerve passes right next to the piriformis. In fact, in somewhere between seven and 21% of the population, the sciatic nerve actually passes through the piriformis muscle.4
As a result, any aggravation or irritation of the piriformis muscle is likely to aggravate the sciatic nerve as well. Potentially causing localized pain in the piriformis region and sciatica pain down the back of the leg.
Piriformis Syndrome And Sciatica
It’s important to differentiate sciatica and piriformis syndrome in runners. Sciatica is a pain pattern. More of a symptom than an injury. Several things can cause sciatic nerve pain. The more common is a herniated disc in the lower back.
But piriformis syndrome is another one. Pain along the sciatic nerve is not the only symptom of piriformis syndrome. Nor should a lack of sciatic nerve pain be a reason to rule out piriformis syndrome.
According to a 2003 review study in the scientific journal Clinical Orthopaedics and Related Research, some of the key symptoms of piriformis syndrome include hip pain between the tailbone and the head of the femur, pain with hip flexion or internal rotation, and tenderness over the piriformis itself.
The pain will often get worse with sitting or squatting.3
One specific test for piriformis syndrome is the FAIR test. Which stands for flexion, adduction, and internal rotation. 4
Stretching the piriformis directly, as shown below, can also reproduce symptoms.4
When you run, the piriformis’ role as a hip stabilizer means that piriformis syndrome will cause pain during the stance phase of running. Because increasing stability is needed at higher speeds, the pain will likely get worse as you go faster.
Treating Piriformis Syndrome In Runners
Perhaps due to its rarity in athletes and its commonality among the general population, there are plenty of studies on treatment approaches for sedentary people. But relatively few among athletes. Among the general population, symptomatic relief is the primary focus.
Typical treatments involve physical therapy modalities like ultrasound, stretching, and injections of numbing, anti-inflammatory, or muscle relaxant medications.
One study, published in 2010 by Jason Tonley and other researchers at several clinics and universities in Los Angeles, describes a different approach for athletes.5
Tonely et al. note that though hip muscle weakness has been noted in numerous studies on people with piriformis syndrome, hip strengthening exercises are almost never included in standard physical therapy routines for the injury. Further, Tonley et al. propose that the piriformis becomes aggravated when it is overworked as a result of weakness in the other muscles that abduct and externally rotate the hip.
Improving Hip Muscle Strength
To bolster their argument, the authors cite research showing that hip muscle weakness is associated with a number of other hip and knee injuries. And even cite another study which found that including hip strength exercises in a rehab program for piriformis syndrome seemed to speed recovery.
To demonstrate how such a program might be put into practice, Tonley et al. outline how they used a hip strengthening program to treat a recreational athlete with the typical symptoms of piriformis syndrome.
Though it’s only a case study, Tonley et al.’s rehab program is still a good place to start for treating piriformis syndrome in runners. Their biomechanical argument is sound and the link between running injuries and hip muscle weakness has merit.
Tonley et al.’s rehab program can be augmented by other treatments advocated in other scientific papers, like massage, stretching, and injection of medications.
Please read The Relationship Between Hip Strength And Running Injuries for more.
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Aggressive Treatments For Piriformis Syndrome
If your piriformis syndrome does not abate after the stretching and strengthening program (per above), there are some second-line treatments you can try. Several scientific papers describe injecting lidocaine and corticosteroids directly into the piriformis to decrease pain and inflammation.3,4
This may be particularly helpful if you have sciatica type pain. Since inflammation of the piriformis is a known cause of sciatic nerve irritation. Though it’s important to note that these treatments were generally on sedentary people, not athletes.
Soft tissue manipulation techniques like massage, Active Release Technique, and Graston Therapy have been used by some runners to loosen up a tight piriformis muscle. Some runners even roll on a lacrosse ball or a baseball as a home remedy to get the same effect.
Though there’s been no formal research on the efficacy of any of these soft tissue techniques. Pushing too hard on the piriformis could cause further irritation of the sciatic nerve, so consider this before getting overzealous with soft tissue therapy.
In rare cases, surgery is helpful when piriformis pain is long-standing and does not respond to any other interventions. This is something you’ll have to discuss with a trusted doctor who has experience working with athletes.
Cross Training While Injured and During Recovery
Aqua jogging is a form of deep water running that closely mimics the actual running movement. Your feet don’t actually touch the bottom of the pool, so it is zero impact and safe for almost any type of injury. In my experience, the only time to avoid aqua jogging is when you have a hip flexor injury, which can be aggravated by the increased resistance of the water as you bring your leg up. Because aqua jogging closely mimics natural running form, it provides a neuromuscular workout that, in addition to aerobic benefits, helps keep the running specific muscles active. The same can’t be said for biking and swimming. The only downside to aqua jogging is that you need a pool that is deep enough to run in without touching the bottom. If you’re lucky enough to have access to a pool of this size, aqua jogging should be your first cross training choice.Aqua Jogging Workouts For Runners
If you're interested in aqua jogging to rehab your injury, then the absolute best way is to use one of my favorite programs, Fluid Running.
Medium Effort Workouts
Hard Workouts
Return To Running
Since piriformis syndrome is so poorly studied in runners, there aren’t any good return to running programs that have been scientifically validated. Still, as your hip strength improves, you can see how your piriformis reacts to running.
You’ll likely find that your tolerance for distance and speed increases linearly along with your hip strength. As with most injuries, no pain is a lot of gain.
You can carefully and gradually work your way back towards your usual running routine. But be aware that it can take several weeks for a hip strengthening program to fully kick in. Even when you are doing the stretches and strengthening exercises every day.
