How to Fix a Problematic Piriformis

Introduction:

Piriformis syndrome, otherwise known as sciatica, is a prevalent dysfunction in physical therapy. As a result, the piriformis tends to be the go-to muscle to blame when we experience common symptoms of lower extremity numbness, tingling, pain, and weakness. The typical treatment includes medication, stretching, and strengthening when these problems occur. Unfortunately, although these interventions may provide short-term relief, they're genuinely only addressing the symptoms and not the source of the pain. This article will teach you a redefined approach to improve your outcomes when working with piriformis syndrome.

In this article, we'll address the following topics:

• Anatomy and Biomechanics of the Pelvis
• Piriformis Hierarchy 
• Intervention Intention
• Three Strategies to Address the Source

If you're more of a visual learner, skip the reading and click the video below to watch the same topics discussed:

 Anatomy and Biomechanics of the Pelvis

Before reviewing the anatomy and biomechanics of the pelvis, we need to recognize the label we subconsciously create by calling the dysfunction "piriformis" syndrome. When we blame a singular muscle as the problem, it creates a tunnel vision approach to our assessment and treatment. This is when we become either consciously or subconsciously hyper-focused on one specific area while neglecting the rest of the body. As a result, we often miss other critical contributing factors to the overall problem. In our case of "piriformis syndrome," the sciatica-type pain is usually multi-factorial. Therefore, we need to remove the label to make sure we see the entire picture clearly.

Now that we're removing the blinders, let's identify the significant structures within the posterior-lower pelvis. Some primary muscles include the glute max, piriformis, and the gamellus superior/inferior, and quadratus femoris. These muscles will all create an external rotation bias when they contract in an upright position (think lower degrees of hip flexion). The action of the muscles is familiar information in the physical therapy world, but the 3-dimensional effect is frequently overlooked. The impact from the external rotation is going to be compression on an already compressed area of the body. This compression will be the true source of the patient's symptoms. 

Piriformis Hierarchy

The Piriformis Hierarchy is a chart that I created to help guide you through the piriformis syndrome process. At the top of this hierarchy is the overall problem or source of pain from this syndrome — compression. As you move down the chart, you'll find two sub-categories 1) posterior pelvic tilt and 2) anterior orientation. Let's take a deeper look at how each sub-category influences compression.

Sub-Category #1: Posterior Pelvic Tilt

A posterior pelvic tilt is a posturally driven pattern that will cause poster-lower pelvis compression. I usually refer to these presentations as the "no butt syndrome." These individuals have the appearance as if they "don't have a butt." I hate to break it to you, but they do have a butt. However, the posterior pelvic tilt creates a "J" shaped posture, which "hides" their glutes as they tuck under their spine. As discussed in the Performance Redefined Course, this type of presentation is frequently seen in our narrow ISA's.

Biomechanically speaking, the external rotators of the pelvis are going to be in more of a concentric bias as a result of their posture. This concentric bias compresses the pelvis and moves it towards a counter-nutated sacral position. As a result, these individuals tend to be better at achieving external rotation, flexion, and abduction of the femur.

How do we fix this posture that's contributing to our patient's pain? First, we need to provide them with what they don't have. As we mentioned, they have excessive posterior-lower compression. So, they don't have any expansion. Expansion biased exercises will help in two ways:

1. Move the tissue towards an eccentric bias
2. Increase the amount of posterior-lower pelvis space

These benefits of introducing expansion will begin to relieve the patient of their sciatica-related symptoms. Furthermore, there are three expansion-based exercise examples at the end of this article. 

Sub-Category #2: Anterior Orientation 

 An anterior orientation is also a posturally driven problem with an accompanied dominant pattern. We can define anterior orientation as the whole body shifting forward as one unit. It will not have the ability to dissociate or have the necessary relative motion at the pelvis. We see this pattern occur for many reasons, but some may include: stability, internal rotation compensation, or a result of habitual postures. An anterior orientation is usually seen with a wide ISA but can also be observed as a compensatory strategy in a narrow ISA. Let's dive deeper.

As the entire pelvis shifts forward as a unit, the whole body and center of mass follow it. Here's the thing, if we allow the continual forward momentum, we'll fall. So, how does the body maintain its upright posture? Compression! Specifically, the compression of the external rotators within the posterior-lower pelvis. This compensatory compression keeps the body upright by shifting the forward-biased pelvis back! So, with this sub-category, we continue to see compression as the main problem, but the occurrence for a slightly different reason.

Intervention Intentions

When selecting your intervention, you always need to ask yourself what your intention is. Unfortunately, in traditional physical therapy, the purpose of our piriformis syndrome interventions tends to get lost. For example, one of the classic treatment choices is stretching. The problem with stretching is that it's more of a symptoms-based approach instead of treating the source. When you stretch a muscle, you may provide short-term relief, but it does not address the root cause as to why the compression is happening in the first place. In other words, the "tightness" that you're stretching was an effect of poor movement patterns, postures, poor habits, etc. Fix the source, and you'll permanently fix the pain. 

Risks VS Rewards

A quick outline on choosing interventions is that you should always weigh the risks versus rewards. In some instances, it's beneficial to prescribe a high-risk exercise with high rewards. In other circumstances, it's more helpful to prescribe a low-risk, high reward exercise. A good clinician knows the proper time to employ which strategy. As a general rule of thumb, when dealing with nerve pain, it can be very irritable for the patient. Take this into consideration when choosing the best exercise for your patient. 

Hip Shifting Activities

The three interventions that we'll go over all have the same thing in common — hip shifting. Hip shifting is powerful because it will begin to address the source of the pain while providing relief for your patients. Often, your patient results in this overall compressed state at their posterior-lower pelvis because they cannot rotate when they walk or perform exercises. Hip shifting begins to eccentrically orient the tissues as the sacrum shifts away from the innominate bone. Additionally, because the patient is moving back, they create expansion or space to move into as they go through their movement.

90/90 Positioning

90/90 positioning is gaining popularity in the rehab world for exercise selection. We need to understand introductory hip flexion biomechanics to understand the benefit genuinely. We cover this in great detail in the Performance Redefined Course, but I'll provide the cliff note version here. We have an alternate pattern of external (0-60°), internal (60-90°), and back to external rotation (>90°) during hip flexion. When we are around 90°, the pelvis will naturally expand the posterior-lower pelvis from our internal rotation bias at this point. So, working on hip-shifting activities in this position can be a great way to increase exercise intensity while opening up what needs to be expanded. 

 Three Strategies to Address the Source

 1. Side-lying Hip Shifting 

 The side-lying hip shift or adductor pullback is a great starting point for your patient. This low-risk, high reward exercise places them in a side-lying position which tends to be favorable for this population. The wall acts as a reference to ground the feet and changes this exercise to a closed-chain movement to emphasize the pelvis moving on the femur. As the pelvis moves back, we will begin to expand the symptomatic side. To coach or perform the side-lying hip shift, read the steps below or click the video to watch the exercise demonstration.

• Start in a side-lying position with the symptomatic side up and the asymptomatic side down, and place your feet on the wall.
• Place a foam roller between your feet and a small ball between the knees.
• Get grounded through your mid-foot/heel with a slight emphasis on your inner heel.
• Perform a slight pelvic tuck (don't over tuck)!
• Gently push your symptomatic knee down into the ball to feel a small amount of your inner thigh.
• Maintain your pelvic tuck, inner thigh, and feet on the wall as you inhale and drawback.
• You should feel a "back" pocket stretch.
• Repeat for 5-10 breaths.

2. 90/90 Hip Shift

 The 90/90 hip shift is a progression of the side-lying position. In this position, we will now be moving against gravity which will increase the intensity and difficulty. Additionally, in this position, the posterior-lower pelvis naturally expands from the IR bias we have at 90° of hip flexion. To coach or perform the 90/90 hip shift, read the steps below or click the video to watch the exercise demonstration.

• Place your feet on a box, bench, or object to align you at 90° of hip flexion and 90° knee flexion.
• Place a ball between the knees to keep the pelvis and femur in a neutral position.
• Move into a slight pelvic tuck and gently press your heels down into the box (imagine you're trying to bring your heels to your butt).
• While maintaining the previous step, shift the asymptomatic side towards the ceiling and the symptomatic side back towards the ground.
• Inhale as you drawback (symptomatic side).
• Repeat for 5-10 breaths.

3. Split-Stance Deadlift

 The split-stance deadlift is the most challenging of the three and is a higher risk, higher reward exercise. The higher risk results from loading the movement and requiring a successful hinge. The higher reward results from the increased expansion capabilities in the posterior-lower pelvis when the technique is correct. To coach or perform the split-stance deadlift, read the steps below or click the video to watch the exercise demonstration.

• Begin in a split stance position with your asymptomatic side in front of the symptomatic side
• You may place your symptomatic side on a slant board in an elevated toes position to improve hinge mechanics, but it is not required.
• Place a ball between the knees to improve hip shifting mechanics.
• Hold a KB on the asymptomatic side and gently reach towards the symptomatic foot as you hinge back and weight shift towards the symptomatic side.
• Inhale as your hinging, move the asymptomatic knee forward and draw the symptomatic knee back.
• You should feel a deep stretch on the symptomatic glute.
• Repeat for 5-10 breaths.

Conclusion:

Hopefully, this article has created a paradigm shift in your piriformis syndrome thought process. First, we want to avoid tunnel vision treatment to ensure that we aren't missing other critical components. Next, we unlock the potential to find and treat the true source creating the patient's pain. Finally, once we understand the source, we get them expanded where they're compressed and get them moving!

To dive deeper into these concepts, I encourage you to check out the Performance Redefined Course. Upon completion of the course, you will have a massive boost of confidence in comprehending, assessing, and coaching movement!