What a Pain in the Rear

PAIN MANAGEMENT: Pyriformis Syndrome

Pain in the rear end is really a pain!  Pyriformis syndrome is a condition characterized by abnormal tension or spasm of a muscle in the buttocks called the pyriformis muscle. The tensions in the muscle may lead to irritation of the sciatic nerve.

The pain from pyriformis syndrome is most often felt in the hip and buttocks.

The pain from pyriformis syndrome is most often felt in the hip and buttocks.

The pyriformis muscle is attached to the sacrum and the thigh bone (femur)  and assists in rotation of the leg outward. Pyriformis syndrome can mimic sciatica, which is a totally different disease caused by a herniated disc(s) or bone spurs putting pressure on the large nerves which exit the spine.

The pain from pyriformis syndrome is most often felt in the hip and buttocks. However it can radiate into the lower spine and back of the leg like true sciatica.  It can also be associated with weakness, stiffness, and numbness and tingling like sciatica.

Pyriformis syndrome has two general causes: overload and biomechanical.  Overload, or overtraining, is associated with sports that require significant running, change of direction or weight bearing activities.

Overload can also be caused by exercising on hard surfaces (concrete), exercising on uneven ground, exercising after a long period of inactivity, prolonged sitting, or increasing exercise intensity or duration too rapidly.

Biomechanical causes of the syndrome include, poor running or walking mechanics, poor posture or sitting habits, tight or stiff muscles in the lower back, hips and buttocks, and running/walking with toes pointed out.  Spinal problems such as herniated discs or spinal stenosis (narrowing of the spinal canal) can also lead to pyriformis syndrome.

Diagnosis of pyriformis syndrome requires that spinal causes be ruled out, since they can be the primary source of pain, or cause pyriformis syndrome.  During the physical exam your doctor will evaluate the spine, hip joints and pelvic muscles.  In true pyriformis syndrome the physician can feel a painful, tight pyriformis muscle with deep pressure on the buttocks.

Treatment follows the same process as any other soft tissue injury.  Immediate treatment within the first 72 hours involves rest, ice, compression, elevation and referral to the appropriate specialist (R.I.C.E.R).

After the first 72 hours following an injury, gentle and progressive mobilization techniques can begin.  Massage is a very effective technique for reducing spasm, removing any scar tissue and enhancing the healing process.

The rehabilitation phase begins once the pain is sufficiently reduced.  The goal is to restore and improve upon the baseline flexibility, strength, and endurance of the pyriformis muscle.  If pain persists after using R.I.C.E.R., physiotherapy and rehabilitation, trigger point injections may be needed to reduce any residual spasm in the muscle.

A trigger point is a small area of intense muscle contraction or spasm in part of a muscle.   Activation of a muscle with a trigger point, or direct pressure causes intense pain, which can radiate to other parts of the body.  Trigger point injections involve depositing a solution containing an anti inflammatory agent into the trigger point.  This breaks the cycle of intense spasm and pain, facilitating rehabilitation.

Proper Warm up Increases Blood Flow

Prevention is the key to prevent recurrence of symptoms, and there are some basic steps one can take to avoid re-injury.   Prior to any vigorous exercise, one should perform a thorough warm up of all muscles that will be used in the athletic activity.  A proper warm up increases blood flow to and elasticity of the muscles and tendons involved in the activity.

Muscles must also have adequate rest and recovery after any vigorous physical activity

Muscles must also have adequate rest and recovery after any vigorous physical activity

“Prehab” is the concept of training muscles to prevent injury.  Strengthening and conditioning muscles of the hips, lumbar spine, and buttocks will prevent pyriformis syndrome and other soft tissue injuries.

Increasing muscle flexibility is very important for preventing muscle “pulls.”  Flexible muscles are able perform strenuous activities without being over stretched.   Non-flexible muscles can be more easily stretched past their limited range of motion, leading to strains and pulls.

Unfortunately, adults lose flexibility with increasing age and this process is worsened by a sedentary life style. However, with only modest effort, flexibility can be maintained with a simple daily stretching regimen.  This may include yoga or Pilates.

Muscles must also have adequate rest and recovery after any vigorous physical activity. Without adequate time to heal and recover, muscles are prone to injury with subsequent strenuous physical activity.

If you think you have symptoms of pyriformis syndrome, schedule an evaluation with your physician.  A comprehensive approach, which often includes specialty evaluation by a pain specialist or orthopedic specialist, can be tailored for the individual to optimize treatment and prevention.

Dr. Gayles

Dr. Gayles

ABOUT THE AUTHOR

Dr. Richard Gayles is a graduate of the University of Michigan Medical School.  After obtaining his medical degree, Dr Gayles completed a residency in anesthesiology at The Johns Hopkins Hospital in Baltimore, Maryland.  Subsequently, he held the post of visiting registrar at St. Bartholomew’s Hospital in London.  Upon his return to the United States, Dr. Gayles completed a fellowship in chronic pain management at the Cleveland Clinic in Cleveland Ohio.  Dr. Gayles is an Aviation Medical Examiner (AME) and a multi-engine instrument rated pilot. His interest in aviation led him to recently join Angel Flight, a volunteer organization which transfers chronically ill patients across country via private aircraft.

To contact Dr. Gayles call 321-784-8211, or log on to YourPainInstitute.com.

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