Not a day goes by in practice that I don’t have a patient tell me they have pain in their lower back and pain in their buttock on the same side. Patients will almost always say the pain in their buttock is from a “tight piriformis”. So, what have they done to mitigate said “piriformis” pain? They of course have Googled buttock pain and had seen a plethora of pictures and videos illustrating how to get rid of their “piriformis” pain by stretching. What a great idea! In many cases pain from a muscle should be stretched. What would you say if I told you 95% of the time this was not only the wrong diagnosis but also the wrong approach to fixing the pain and in fact was causing more harm than good? Unfortunately, in the last week alone I’ve seen 2 patients, one a 22-year-old and the other a 53-year-old, who fell into the “piriformis” pain trap and actually significantly worsened their symptoms! The crux of the problem lies in the fact that the piriformis is in the vicinity of the pain but is NOT THE CAUSE OF THE PAIN! In most cases, the cause of the pain is a disc related injury such as a bulge or herniation that is pressing on the associated nerve root and referring pain downward into the buttock. In essence, these individuals are suffering from sciatica due to a disc injury. The actual injury is in the lower back and the symptom is the pain in the buttock.
The typical presentation of a true piriformis issue is pain in the buttock, yes, but presenting with pain on movement not at rest. Runners, walkers and stop and go athletes such as tennis players can develop true piriformis issues because the muscle is being used frequently and strenuously during their athletic endeavor. The job of the piriformis is to steady the head of the femur (ball of the hip) into the hip socket (acetabulum) and create external rotation (outward rotation) of the thigh bone (femur).
External rotation can be performed actively if you simply rotate your foot and leg outward away from your body. As such, patients with acute piriformis injuries or strains with have pain with walking (as the muscle contracts to steady the femoral head in the acetabulum) and the side of injury will often present with a foot and leg rotated away from the body. This pain is typically relieved by sitting and taking weight off of the affect side. Stretching and other soft tissue modalities such as Active Release and massage are beneficial at resolving the issues.
The glaring mistake made in the over-diagnosis of piriformis issues, when sciatica from a disc bulge is actually the cause, is the symptom presentation of the patient. In the majority of cases of individuals with buttock pain from sciatica and disc bulges, pain is most common and most painful when sitting and relieved by movement. When a disc is bulging, sitting typically will cause more load on the disc causing it to bulge further toward the nerve. The added pressure on the nerve will refer pain into the buttock causing the deep aching pain disc patients often complain of when sitting at work, sitting on a couch or driving in their cars.
The correction to this problem is NOT STRETCHING!! If you take the advice of the online “experts” and stretch the piriformis while lying on your back and crossing your legs and pulling your knees to your chest or sitting and crossing your legs and dropping your chest to your knees YOU ARE MAKING THE PROBLEM WORSE! Again, the buttock pain ISN’T from a muscle that needs to be stretched its from your lower back and sciatic nerve! If you stretch your back you will push the disc out further and WORSEN YOUR SYMPTOMS! Which is what both my 22 and 53-year-old patients did. They stretched over and over again based on the suggestions of the online “expert”. In doing so, both patients increased their frequency and intensity of pain by causing the disc to bulge further out placing more pressure on the nerve! Once I convinced them (yes, I have to actually convince some of my patients the online “experts” are often incorrect) their symptoms were not piriformis related but in fact disc related, they both agreed to follow my protocols to fix their back pain with proper exercises. Both patients are fortunately already improved and will make full recoveries. We’ve worked on proper movement, proper sitting postures, staying away from back breaker core work and back breaker stretches and utilizing proper exercises to fix disc related injuries and sciatica related symptoms.
So, if you are having buttock pain sitting at work, sitting on your couch or in the bleachers of your child’s sporting event or driving that resolves/improves when you stand up and walk around you are most likely having a sciatic related issue from a disc bulge NOT a piriformis problem. Please don’t waste your time and effort and potentially worsen your pain by stretching the piriformis! By learning my exercises for disc bulges and sciatica you can get better quickly and resume a normal, pain-free life and most importantly you’ll PROTECT YOUR BACK!