Piriformis Syndrome: 4 Mistakes That Block Your Recovery

You're listening to the Restoring Human Movement Podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. Hey everyone, it's your co-host, Sebastian, with the Restoring Human Movement Podcast. Thanks for joining the show with me today. Remember, look back on the old episodes. We have endless episodes on hip and groin, low back, sciatic nerve, knee conditions in runners, and even shin splints, and so on. We have so many episodes that are going to give you a lot of value if you're an active person, especially a runner. Now, today I'm covering a topic of piriformis syndrome today, and I'm going to cover four mistakes that people make when dealing with piriformis syndrome, so hopefully you guys can get over the hump a little sooner and get back to your activity.

Also know that if you guys are looking for help directly, we have consultations available on our telehealth and in-person platform. We actually are licensed in various different states, and believe it or not, we can actually help people through telehealth more effectively sometimes than you can even in person, especially if you're unable to make your way in. So we are specializing in telehealth and watching you move and making good suggestions. So contact us below. Now, piriformis syndrome, the biggest mistake that people do make is that they get misdiagnosed. Now, I'm not going to say that piriformis syndrome is actually super common.

It's not. It's actually fairly rare, but it doesn't mean you can't diagnose it if you don't find it. So the diagnoses that people tend to get stuck with instead of the correct one of piriformis syndrome is usually sciatica or lumbar radiculopathy. Now, I'm going to cover these each in their own turn because there is some semantics that are a little bit incorrect associated to it. Now, sciatica is actually not really a technically diagnosis. I mean, technically, yes, it is. It does have an ICD-10 code, which is a international diagnostic coding system brought up brought on by the I'm not sure if it's the insurance, the medical medical associations, but it has a diagnosis, but it is not actually a condition in itself.

It is a condition created by another condition. So it's not really the hierarchy, the highest condition you're treating. Sciatica, all it means is leg pain. Leg pain can be from piriformis syndrome or compression on the sciatic nerve as it travels through the piriformis muscle bellies on some people, not others, or underneath them on some people, not others. It can also be created by disc herniation pressure on a nerve root as it exits the lumbar spine. It can also be from lumbar stenosis, foraminal stenosis or central stenosis, which also creates closure onto the nerve root, which then creates leg pain too.

So all of these things can create sciatica. Sciatica in itself is not really a good or accurate diagnosis. Now, piriformis syndrome, there are ways to test it to figure out that it's not the other things. I wouldn't say back pain is necessarily the dead giveaway that it's not related to the spine because a lot of people who have lower back pain can actually have leg pain, but also people with piriformis syndrome can also have leg pain, back pain too. If you look up online on Dr. Google and you search lumbar radiculopathy, you'll see that there's a black and white chart, which has S1, L5, L4, and so on all over it.

It's a, it's one that is pops up on every lumbar radiculopathy search. And you'll see that different pain presentation locations down the leg are present with different lumbar nerve roots that are affected. The caveat to this is the sciatic nerve actually includes L4, L5, and S1. So technically it can be all three of those, but the most common location is the S1 presentation, which usually includes the back of the hip, the SI joint, the back of the hamstring, the calf, the bottom of the foot, and even the side of the foot. L5, as you see on the chart, actually includes when in the hip has similar types of scenarios.

It's going to be the SI joint area. It's going to be the piriformis area or deep glute, but then it starts to migrate to the side of the thigh, the side of the shin, different part of the foot, and so on. So notice that both of these things, a piriformis syndrome and lumbar radiculopathy, both have deep buttocks pain. And I spoke with a industry expert, Michael Shacklock, about nerve conditions, specifically sciatica or leg pain. And I said, do you need to have all these locations that are in this picture? And he said, no, it can actually be only calf or only hamstring or only buttocks. So when you have pain only on the buttocks area, everybody thinks it's piriformis syndrome, but it's not.

It can also be a lumbar radiculopathy. So I'd say the most common reason for buttocks pain and even pain down the leg or sciatica is going to be some form of pinched nerve in the lower back, whether from a disc or some closure from arthritis or old disc height issues and so on. But there are people who actually have compression at the piriformis. Now, there's a specific test that you could do. It's a modified slumps test, which helps give insight of where the compression of the sciatic nerve may be happening. Now, to my understanding, you can't actually 100% identify it, but it gives more information to believe that it's actually the sciatic nerve.

And the way we do this is actually we would turn the hip so it actually doesn't contract the piriformis muscle, but it actually elongates it so it squashes the nerve. And if you turn it first before doing the remainder of the test and it lights the person up, then it may be more piriformis syndrome based versus actually being a lumbar radiculopathy in isolation. But also, too, you can have multiple compression points because a nerve that has sensitivity or swelling in it from compression in one location can also create compression in another. So I know it's as clear as mud, but the long story short with this is make sure you do have someone actually examine you, because if you don't, you may be misled about exactly what's going on with you.

And a skilled provider can, within 15 minutes, beyond reasonable doubt, tell you where your problem's at if you have piriformis syndrome or some type of back condition. And by the way, an image doesn't always show this. An image will not always show piriformis syndrome, nor will an NCV or an EMG and so on. So usually a physical examination with someone directing you about how to differentiate different parts of the test and we cluster that information together is used the best thing to do. We a lot of times, again, do this on telehealth. It is a little sloppier on telehealth with nerve testing, neurodynamic testing, but in person is always the best.

And it's very, it does take a little bit of effort on the practitioner's part to learn this type of protocol. It's not always taught in school. The second mistake people make is they think the piriformis muscle is weak and they start strengthening it. The thought is that some of these muscles that are tight and to have a lot of tone with it are overworked is that they're actually weak too. I see a very common thought process with that, with hip flexors, where people start to strengthen their hip flexors or psoas or iliacus muscle or TFL, these small ones, because they're always feeling tight and they have pain in them, but it's not always correct.

Sometimes muscles that are actually tighter, creating compression on this case, the sciatic nerve with the piriformis, is more so that they're being overworked. They're not actually weak. They're just tired. And when you unravel this a little bit more, you can see that there's other tissues of the hip or the core or the leg that are not actually doing their job that are much bigger. If you think about the piriformis muscle by design, look how small it is. It's tiny. It's not supposed to be doing a ton of work. It's actually more so, we believe, it's more of a rotator cuff muscle of the hip, so it just helps centrate the ball socket, creating enough compression in the socket to perform high-quality movement.

It's a stabilizer. It's not really a prime mover. So if you make it do other jobs that it's not accustomed to doing, it will get tight fatigued and start speaking out at you and make you create compression onto the sciatic nerve, creating leg pain and so on. So don't necessarily think it's weak. Think about what it's maybe compensating for. Most of the time, it's for a weak glute max muscle or a weak leg in general. Like if you've had an old knee injury and your quad is a little bit weaker on that side, then that would be probably the target point that I would take for most people. The third thing that people make a mistake on when trying to resolve this condition is they try to work that tissue or only the hip in isolation.

So there is this phenomenon that happens when people have low back disorders that their glute max muscle turns off. They call the term slang, the slang term for it anyways is glute amnesia, but it's almost like the glute max forgets to work. And this is why a lot of physical therapy-based exercises are very glute, glute, glute, glute, glute, glute, glute, right? I think you only need one or maybe two glute exercises, glute max specifically, to get the activity back. But sometimes it requires a precursor step. And the way we tend to find this is that when we start giving someone a really simple glute exercise, let's just say a clamshell.

This one's for the glute medius more in particular, but say you're doing a clamshell and they don't actually feel the glute working. They feel their piriformis muscle tightening. They feel their TFL tightening. They start to feel their back. And no matter the way that your physical therapist or personal trainer coaches this, it doesn't really matter. It's still kind of crummy. Another example is a glute bridge. You know why it's called a glute bridge? Because it should be very easy to get the glute to work. But if you start feeling your hamstring or your deep butt cheek, the piriformis area or TFL or low back, then these are reflections that the glute max is really not working well and it may be forgetting to work.

Again, what they've observed is that precursor steps sometimes can help out with glute facilitation and getting it to come back online. So instead of just trying to kill the exercise and overcoach it and wonder why it's not working, sometimes reverse engineering this a little bit more and getting the core to turn on first is the first step. And that may be more of intra-abdominal pressure cueing, which is a hidden core function. It's like a secret deep core muscle, but it's not a muscle. It's a function. It's pressure. Or even bracing can work. Or even doing something like a really hard ab exercise prior can really help out to turn the glute on.

I would, I would, there was one time I was teaching a workshop where we were doing, this was with a bunch of clinicians. And so I was demonstrating an exercise again called a glute bridge. And so I had the person doing up on stage and after about a minute or so, he was calmly talking to me and I said, you know what, let's just try something else. And because I was trying to get his glute to turn on. And so later after we broke off into groups and we circled back again, he came back and he said, can I ask you why you stopped that exercise? I said, cause I could tell it's not going anywhere. And he said, how so?

I said, after a minute and a half of doing or so, you should be a little bit more tired. So there's other tissues helping out. What we ended up doing was we did a core exercise prior to it, went back to the glute exercise again, the bridge. And then within 30 seconds, he was dying because we added that we had a band on it originally. So knowing expected outcomes of the exercise is important. And if you're not doing, you're not getting the right outcome from the exercise because it's taking too long or you have other tissues involved, then maybe reverse engineering that get your support system, like your core back first, and then proceeding forward in the exercise.

And this is what we do again in our telehealth, we observe if people are having trouble with that or not. And then we help them reverse engineer and stick plugs into the holes in their program, which brings us to number four, holes in their program. People oftentimes don't realize how lopsided their personal training programs are, their lifestyles are, their physical activity. The easiest thing to do is plugging a hole in a program. And this is a strength coach named Dan John. He has a great podcast. If you want to listen to a great strength coach that can make things really complicated, but chooses to make things simple, he is one of them.

And one of the basic Dan John principles is plugging a hole in the program. So there's five basic movements that everybody should have in their repertoire. And they should all generally be kind of the same intensity, weighted, challenges, and so on. So there's a push, a pull, a carry, a squat, and a hinge. And then there's a last category, which is everything else. We'll start, we'll stick on the first four right now, because I know that it's super common that when people have a condition like piriformis syndrome, they tend to have a missing part in their program. And so I ask him, what do you end up doing in your, what are you doing with your exercise right now?

What do you, what do you choose to do? What do you like? And they say, well, I really like pushups and pull-ups and bench press and incline press. And I choose to do like squats or single leg squats and lunges, reverse lunges and so on. And I, and I, so I say, so do you ever do any deadlifting at all? And they said, nah, ever since I hurt my back, like 10 years ago, I stopped doing that. And I said, so what do you do for your hip dominant pattern? What's your hip pattern? And they say, bridges. And I say, so you're doing weighted squats, you're doing back squats and you're doing bench press, both very heavy.

You're doing pull-ups, very heavy. And you're doing regress, a severely regressed hip hinge pattern. There's a hole in your program in the hip dominant category. And how do you really expect the glute max to work well if you're not really training it for strength? So we need to fill that category for them. And then a lot of times when people do that, they feel a lot better. But the problem is that a lot of times people are apprehensive of doing that because remember, the brain remembers. And they had a past injury when they were deadlifting and they said, ah, I don't want to do that anymore. They also, in this scenario, the person also has a hole in their, in their carry aspect of the program.

So we need to fill that one as well. A sled push, a farmer's carry, a waiter's walk, a rat carry, like all those would count for this. And probably the hardest hole to plug is going to be the hip hinge because they're going to be a little afraid of it. They may have a little pain with it. And our job as good coaches is to find a version, interrupt scheme, and a weight, which is more acceptable to their body's tolerances at the moment. Now, you may be wondering like, why would we do a deadlift if it hurt the person? We don't have to do a barbell deadlift. A hex bar deadlift is great. We can also do a kettlebell one, very heavy kettlebells.

We can do swings. And remember, a deadlift is just part of a hip dominant pattern category. We don't need to choose a deadlift and also times changing how the deadlift is used or what ranges you go through is another aspect to how we can change it as well. So we have a bunch of videos on this on our YouTube channel, which I'll put a link in the description for the podcast, which is all free, by the way. But if you're looking for more specific things to do, again, you can reach out to us for our one-on-one sessions. Or remember, we do have online programs as well. We put together programs on low back and hip conditions on our website, and I created them all.

We recorded videos. They are not videos that are available on YouTube because they're a little bit more specific. And it even includes a lot of the stretches and modifications that we would make for each one of the lifts too. So if you guys are interested in that, just check it out and I'll see you guys next time on the podcast.