Piriformis Syndrome (Buttocks Pain) Treatment with Physical Therapy in New York City

What is Piriformis Syndrome (Buttocks Pain)?

Piriformis syndrome is the clinical term used to describe a  pain in the buttocks that often radiates down the back of the leg, mimicking sciatica.   That’s because it occurs when the piriformis muscle (located within your buttocks area near your hip joint) irritates or compresses the sciatic nerve.  All of us use our piriformis muscle for everyday movements involving hip rotation such as walking and running, where it helps with pushing off the ground, maintaining our balance on uneven surfaces and simply holding up our posture while standing.

In New York City your piriformis muscle is constantly being put to work due to the city’s pedestrian-centric lifestyle. As New Yorkers, whether we’re standing on swaying subway cars, navigating crowded sidewalks, or going up and down stairs, our piriformis muscle is essential for efficient push-off, hip stabilization, and the quick adjustments needed for daily functioning in the city.  Unconsciously the piriformis muscle consistently supports our balance, agility, and the movement required to thrive in the energetic rhythm of New York City.  Since the piriformis muscle plays a critical role in hip rotation when it spasms, tightens, or becomes inflamed, it can put pressure on the sciatic nerve, leading to pain, numbness, and tingling known as “piriformis syndrome”..

How to Sleep with Piriformis Syndrome (Buttocks Pain) 

Piriformis syndrome (the buttock pain radiating down the leg) can make it hard to get a good night’s rest due to pain intensification when lying down and difficulty finding comfortable positions. Be mindful at night laying in the bed there are few distractions (unlike in our daytime life) thus it’s natural to be more aware of piriformis muscle pain as it kind of has the ‘spotlight’, making it feel even more pronounced. There can also be a slight decrease in blood flow to nerves during sleep due to reduced movement, coupled with increased stiffness from inactivity  and creates its own little ‘perfect storm’ for the worsening of nerve related pain.

In fact the constant pain makes even falling asleep difficult and leads to frequent awakenings, creating a cycle of pain and sleeplessness.  Having said that, to get to sleep try placing pillows between the knees when side sleeping or under the knees when back sleeping (a supportive mattress and pillows are also important).   

Think of the piriformis muscle as a highly irritable muscle that doesn’t like being squashed or stretched in certain ways. Sleeping on your side without a pillow can sometimes put your hip in a position that “agitates” the piriformis muscle. The pillow helps alleviate piriformis syndrome pain by acting like a gentle spacer and thereby optimizing hip alignment keeping your hips happier and less likely to irritate the piriformis muscle (and the nearby sciatic nerve).  This allows the piriformis and hip muscles to relax and help break the pain-tension cycle making it easier to fall asleep and stay asleep with less pain. 

If you prefer sleeping on your back, try placing a pillow under the knees to optimize spinal and pelvic alignment.  Elevating the knees like this gently flexes the hips and knees, effectively reducing the normal inward curve of the spine in the lower back region promoting a more neutral pelvic position. This adjustment will reduce strain on the muscles surrounding the hips and buttocks, creating a more relaxed environment for the piriformis muscle and minimizing potential sciatic nerve irritation.

Why Piriformis Syndrome (Buttocks Pain) is Effectively Treated with Physical Therapy

Physicians ranging from pain management doctors, chiropractors, orthopedic surgeons and more offer care for piriformis syndrome; and treatments like rest, NSAIDs (ibuprofen), muscle relaxants, and injections are also used. Know that at the end of the day it’s physical therapy that is the cornerstone and most frequently recommended and sought-after treatment for piriformis syndrome.  This is because physical therapy directly focuses on stretching and strengthening the piriformis and surrounding muscles, relieving tightness, improving flexibility, range of motion, and restoring proper function of the muscle. 

Additionally, in treating you we may use manual techniques like massage to release tension, and provide you with the tools (foam roller) and education for long-term care and preventing recurrence.  After a thorough assessment we tailor a protocol to your individual needs encompassing piriformis syndrome education, pain management, and flexibility and strength building –   that work together to deliver lasting improvement.  Let’s take a closer look:

Patient education empowers you in not only understanding your condition but in learning self-management skills like exercises, how to use tools like foam rollers and how to self-apply pain relief techniques.  Equipping you with strategies for injury prevention and relieving any flare-ups increases your confidence, control, and ability to manage your recovery journey. For example, through education you will learn how to improve sleep with piriformis syndrome applying pain management techniques and guidance on optimal sleeping positions. Learning how to relax at night will also reduce the anxiety and stress that commonly accompanies piriformis syndrome leading to more restful nights.

Pain and inflammation management techniques (hands-on manual therapy). You’ll receive soft tissue mobilization and massage to release tension in the piriformis and surrounding muscles along with joint mobilization to improve mechanics. Joint mobilization for piriformis syndrome treats any stiffness or restricted movement in the hip and sacroiliac joints that might be contributing to the pain and immobility. Restoring joint mechanics can reduce compensatory strain on the piriformis muscle, relieve muscle spasms, tension, and pain while improving posture and the effectiveness of other treatments like stretching and strengthening (therapeutic exercises).  For example there are what are called, “Nerve glide exercises for sciatic nerve mobility” that involve gentle, controlled movements such as supine leg raises with ankle movements.

The supine leg raise with ankle movement is performed by lying on your back, bringing one knee to your chest, straightening the leg towards the ceiling with a slight bend, and then alternating between pointing your toes towards your nose and pointing them down. This gentle movement helps to improve the mobility of the sciatic nerve, reduce irritation caused by the piriformis muscle, and promote better blood flow to the nerve. Once pain is under control, we’ll focus on improving flexibility. This involves guiding you through specific stretches, including techniques like reciprocal inhibition and post-isometric relaxation, both of which cause the piriformis muscle to relax, allowing for a deeper stretch of it and surrounding tissues.

Strengthening these muscles supports hip function and reduces strain on the piriformis muscle. If and when the time is right in your recovery, we’ll work on muscular endurance through walking. In treating piriformis syndrome, walking can accelerate your recovery journey as a low-impact activity that not only improves overall cardiovascular health but helps maintain mobility and strengthen supporting hip muscles. 

This approach reduces tension and pressure on the sciatic nerve, relieves pain, and improves overall hip function and proven effective with the following research:

• A Journal of Orthopaedic & Sports Physical Therapy case report on treatment for piriformis syndrome centered on strengthening hip muscles and correcting movement patterns, contrasting with traditional methods that emphasize stretching and soft tissue mobilization of the piriformis itself.   The study proposes that by strengthening hip muscles, particularly the gluteus maximus, and retraining movement, strain on the piriformis muscle can be reduced, thereby alleviating sciatic nerve compression. The described intervention successfully allowed a patient to return to sports without pain and also resolved associated low back pain.  -“Treatment of an Individual with Piriformis Syndrome Focusing on Hip Muscle Strengthening and Movement Reeducation”, A Case Report, Journal of Orthopaedic & Sports Physical Therapy

• “Physical therapy including muscle strengthening, sciatic nerve gliding exercises, and hip stretching, show positive correlations with pain improvement” – “The Effect of Physical Therapy in the Treatment of Piriformis Syndrome: A Narrative Review”  National Journal of Clinical Orthopaedics

What Causes Piriformis Syndrome (Buttocks Pain)?

Piriformis syndrome occurs when muscle spasms, tightness, or inflammation of the piriformis muscle (located deep in the buttock) irritates or compresses the sciatic nerve, resulting in pain that can radiate down the leg.  

• Muscle imbalances can also place stress on the piriformis, increasing the likelihood of it compressing the sciatic nerve.

• Trauma to the buttock or hip from falls or accidents can directly injure the piriformis muscle. 

• Overuse from repetitive activities like running or extended sitting strains the muscle, making the piriformis muscle prone to tightness and spasms and contribute to an externally rotated leg and foot on the affected side.

Pinpointing the exact cause of Piriformis Syndrome is difficult because more often it’s a combination of potential triggers rather than a single event, and there is an overlap of its symptoms with other conditions causing similar pain, such as sciatica from a disc issue.  The subjective nature of pain and the vast array of potential for compensatory movement patterns (how the pain alters our daily movements), contributes to the difficulty in determining the precise cause of any individual case. What we do know for certain in all cases is that all roads lead to the piriformis muscle in some way aggravating the sciatic nerve.  For this reason it is usually sensible to treat the entire region of the piriformis muscle and its surrounding structures – and here’s a closer look as to why.

A comprehensive approach increases the likelihood of addressing the underlying problem, even if the precise trigger isn’t known.  Treating the entire region allows us to also treat contributing factors such as the surrounding hip rotators, gluteal muscles (other buttock muscles), connective tissues, and not just the piriformis muscle itself. This broader approach can help to normalize muscle tone, improve joint mechanics in the hip and sacroiliac joint, and improve any compensatory or altered movement patterns that may have developed.

Is Piriformis Syndrome  (Buttocks Pain) Permanent?

If left untreated or insufficiently treated some people can experience piriformis syndrome on a long-term basis and the agitation of the sciatic nerve can become chronic.  Continuous and repetitive strain or trauma to the piriformis muscle, persistent poor posture, untreated muscle imbalances can cause a person to be susceptible to chronic pain and potentially permanent nerve damage.  

Additionally, Piriformis Syndrome can become a recurring issue for some individuals, where symptoms flare up depending on their activity levels or certain movements. 

• Vehicle Drivers and Delivery Drivers: Extended periods of sitting, often with vibrations from the vehicle, can put constant pressure on the piriformis muscle.  
• Office Workers and Desk Jobs: Similarly, long hours of sitting, especially with poor posture or inadequate ergonomic support, can contribute to muscle tightness and nerve irritation.
• Construction Workers and Laborers: Jobs involving heavy lifting, repetitive bending, twisting, and awkward postures can strain the muscles in the hips and buttocks, including the piriformis.
• Athletes and Fitness Instructors (depending on the sport/activity): Jobs that require repetitive hip movements, such as running, cycling, rowing, or certain types of dance or weightlifting, can overwork the piriformis muscle.  
• Jobs Requiring Extended Standing: While sitting is often cited, jobs requiring extended standing, especially if combined with poor posture or uneven weight distribution, can also contribute to muscle imbalances and piriformis issues.

In these professions, the repetitive stress, sustained postures, or physical demands can repeatedly irritate or tighten the piriformis muscle, leading to recurring episodes of Piriformis Syndrome. 

Is Walking Good for Piriformis Syndrome (Buttocks Pain) ?

Since walking involves gentle movement and increased blood flow to the pelvic and hip region (the affected area) it promotes loosening muscles thereby reducing stiffness and improves flexibility and overall healing.   However, excessive walking or improper form can exacerbate symptoms, particularly if the piriformis muscle is severely inflamed or spasming.  Walking thus can be ‘high risk’ if you’re not under professional supervision and guidance.   For this reason proceed with caution, moderation, gradually increasing duration and intensity and with proper form and avoiding overexertion.  Warm-up stretches before walking and cool-down stretches afterward are also important to incorporate in any self-guided treatment for piriformis syndrome. 

How Long Does it Take to Recover from Piriformis Syndrome  (Buttocks Pain) ?

Even under a tailored treatment plan recovery for piriformis syndrome varies widely depending on the severity of the condition and adherence to the recovery protocol.  Generally speaking, mild cases might see improvement within a few weeks, moderate cases might see improvements in 1-2 months, but chronic cases could require several months.  Having said that, everyone recovers at their own pace, and this can be influenced by age, overall health, and even slight differences in the body’s structure. Being patient and sticking with your physical therapy protocol consistently is the key to a lasting recovery.

Can piriformis syndrome (Buttocks Pain) cause foot drop (inability to lift the front part of the foot, causing the toes to drag while walking) ?

There is research showing that in rare and severe cases piriformis syndrome can lead to foot drop.   Since the sciatic nerve controls the muscles in the lower leg and foot, extended or extreme compression by the piriformis muscle results in weakness or paralysis of the foot’s dorsiflexion muscles (that help you lift the front of your foot up towards your shin), causing foot drop. Foot drop is not a typical symptom of piriformis syndrome but note the early signs are subtle changes in gait, such as scraping the toes while walking, and perhaps the need to lift the leg higher to clear the foot when walking up stairs or when walking from the street, up the curb and to the sidewalk. Sometimes this is accompanied with a feeling of weakness in the foot or ankle when trying to lift it, along with possible numbness or tingling in the top of the foot or lower leg.  Some people also experience an increase in tripping or stumbling.

How should I sit to avoid piriformis syndrome (Buttocks Pain)?

As a guideline, minimizing pressure on the piriformis muscle when sitting is about maintaining awareness of your posture. Sit with both feet flat, knees at a right or 90-degree angle, keep your back straight back and weight distribution even.   Know that slouching, leaning, or crossing your legs can all tighten the piriformis muscle. Site in a chair with good lumbar support and consider a cushion or wedge to elevate your hips slightly (avoid extended sitting on hard surfaces).  It also helps to take frequent breaks to stand, stretch, and walk around at least hourly.  It’s important that your workspace is ergonomically sound and we have a page on our site dedicated to our services on all matters, “workpalce wellness”.  We can come into your home office or workplace, assess and optimize chair height, desk arrangement, monitor placement, and keyboard/mouse positioning to minimize strain and promote neutral posture.   It’s important to be mindful of your posture in all sitting situations, including driving and watching television.  

How to diagnose piriformis syndrome (Buttocks Pain) ?

We diagnose piriformis syndrome through a comprehensive evaluation, starting with a detailed patient history to understand symptom location, intensity, and triggers.  We’ll inquire about past injuries, daily activities, and medical conditions. This, combined with a thorough physical examination, including palpation of the piriformis muscle, and range of motion assessments helps identify muscle tightness, spasms, and sciatic nerve involvement.  The diagnosis relies on a combination of symptom assessment, physical findings, and the exclusion of other possible conditions, as there is no single definitive test for piriformis syndrome.

How painful is piriformis syndrome (Buttocks Pain) ?

Piriformis syndrome pain can vary wildly, from dull or mild buttock aches to sharp shooting sciatica-like leg pain that worsens with extended sitting, walking, or stair climbing.  In severe cases the pain can make daily life unbearable interfering with work, exercise, and simple tasks. 

Tingling, numbness, and weakness can also accompany piriformis syndrome pain, which may intensify at night due to extended fixed sleeping positions that may compress the sciatic nerve for longer periods. Also be mindful at night laying the bed with few distractions we’re more aware of piriformis muscle pain sensations, making them feel more pronounced. There can also be a slight decrease in blood flow to nerves during sleep due to reduced movement, coupled with increased stiffness from inactivity could also contribute to the worsening of nerve related pain.Lastly it’s worth noting there is research showing piriformis syndrome can also cause significant emotional and mental distress, leading to frustration, irritability, anxiety, worry, sadness, and even depression due to persistent and unpredictable pain.  In fact the fear of triggering pain can lead to avoidance behaviors thus know piriformis syndrome can take a considerable toll on mental well-being.

Can you run with piriformis syndrome (Buttocks Pain) ?

Running with piriformis syndrome is generally not sensible, particularly at the onset in the early stages as it can worsen inflammation and sciatic nerve irritation and interfere with recovery.  In fact many people develop piriformis syndrome from running due to the repetitive leg movements overusing and fatiguing the piriformis muscle. Since the piriformis muscle is central to hip stabilization and leg rotation while running, it’s vulnerable to become strained, tight, and inflamed.  In fact the risk of developing or worsening piriformis syndrome from running is increased with poor running form, muscle imbalances and insufficient hip flexibility.  Generally speaking once stretches that are part of your recovery protocol are pain-free a gradual return to short, low-impact runs focusing on proper form might be possible, with trained guidance.  However healing and treating the root causes of pain should be the priority before any consideration of returning to running.

Can piriformis syndrome cause hip pain (Buttocks Pain)?

Piriformis syndrome can cause hip pain because the piriformis muscle is located near the hip joint and the sciatic nerve, passing just beneath or through it. Everyday movements like extended sitting or standing, getting in and out of cars, walking long distances, climbing stairs, bending over, putting on socks and shoes, reaching low, or even sleeping positions and crossing legs can all potentially cause hip pain if you have piriformis syndrome. The reason is these actions require movements (hip rotation, flexion, abduction, etc) stressing the piriformis muscle and thereby possibly compressing the sciatic nerve, triggering a cascading of events that can culminate in referred pain to the hip.  Referred pain from piriformis syndrome travels as electrical signals along the nervous system sending these pain signals up the spinal cord to the brain. The location of the pain depends on the specific nerves involved in sending the signals – which actually can originate from anywhere in the region (hip, groin, lower back, leg, etc.)

It’s also important to remember piriformis syndrome can alter hip mechanics, resulting in compensatory movements that ultimately trigger pain in other hip structures (the nerves and numerous muscles and their tendons surrounding the hip). Compensatory movements are the body’s way of finding alternative ways to function when one area is painful or weak.

Does piriformis syndrome cause sciatica (Buttocks Pain) ?

Piriformis syndrome is a frequent cause of sciatica, a radiating pain along the sciatic nerve’s path. The piriformis muscle, situated in the buttock, is essentially adjacent to the sciatic nerve, which often passes underneath or through it. When the piriformis muscle becomes tight or inflamed, it compresses or irritates the sciatic nerve, triggering sciatic pain that extends down the leg.  

This compression results in symptoms like buttock and hip pain, radiating leg pain, numbness, and tingling, often worsened by sitting or any activity calling upon hip movement or rotation. The anatomical relationship between the piriformis muscle and the sciatic nerve means that piriformis syndrome is a common culprit if you’re experiencing sciatica-like symptoms, particularly if the pain is concentrated in the buttock region.

Can piriformis syndrome (Buttocks Pain) make it difficult to ascend stairs?

When the piriformis muscle is tight or inflamed its central role in performing the hip rotation and abduction movements required to go up steps is marginalized and can exacerbate pain. If the sciatic nerve is also involved, beyond the muscle pain, shooting nerve pain can radiate down the leg, making lifting and placing the leg on steps difficult.  Furthermore, pain-induced compensatory movements (the body’s way of finding alternative ways to function when one area is painful or weak) can strain other muscles, and the combination of regional muscle pain coupled with nerve pain can make the physical demands of stair climbing with piriformis syndrome trying and painful.

Can piriformis syndrome (Buttocks Pain) cause pudendal neuralgia (nerve pain in the pelvis)?

Piriformis syndrome and pudendal neuralgia are separate conditions that can coexist due to the close proximity of the piriformis muscle and pudendal nerve in the pelvic region.

While piriformis syndrome primarily affects the sciatic nerve, pudendal neuralgia affects the pudendal nerve causing burning, aching, shooting, or stabbing pain in the perineum, genitals, and rectum, that can worsen with sitting. Piriformis syndrome doesn’t directly cause pudendal neuralgia but the muscle tension it produces in the region might indirectly irritate the pudendal nerve. 

Because some of their symptoms can overlap, a thorough medical examination is crucial to differentiate between these conditions and provide appropriate treatment. In treating you we will differentiate between piriformis syndrome potentially causing pudendal neuralgia and pudendal neuralgia from other sources through a comprehensive assessment. This includes a detailed patient history focusing on pain location, onset, and aggravating factors, particularly the impact of sitting. We may also use palpation to assess tenderness in the piriformis muscle.

Can piriformis syndrome (Buttocks Pain) cause back pain?

Piriformis syndrome can lead to back pain through referred pain, compensatory movements, muscle imbalances, and pelvic instability.  For example, if you have piriformis syndrome and are experiencing pain in your right buttock, to reduce the pain while walking you might start to favor your left leg, putting more weight on it and shortening the stride on your right side. This subtle change in gait (stride) can cause your pelvis to tilt or rotate slightly to the left with each step. To compensate for this pelvic imbalance and maintain an upright posture, your muscles in their lower back on the right side have to work harder to prevent them from leaning too far to the left. Over time, this constant extra work and strain on the right lower back muscles can lead to fatigue, muscle tightness, and eventually, back pain.  

In sum, tightness in your piriformis muscle can trigger a cascading of biomechanical effects resulting in pain in the lower back by; altering your posture and causing strain, creating muscle imbalances affecting your spinal support, all contributing to pelvic instability and possible back pain.