Friday Q&A: Recovering from Piriformis Syndrome

Q: I have a student who is recovering from piriformis syndrome. What poses are beneficial and which should be avoided as they will trigger it? 

A: Let’s start with defining piriformis syndrome and then we will get to the specific questions our reader has for me. The piriformis muscle is one of the six deep buttock muscles on each side of the back of the pelvis, all of which contribute to rolling the thigh bones roll out (external rotation). It has a close anatomical relationship to the sciatic nerve, with the nerve either passing through or just under the muscle. So if the piriformis muscle is too tight and squeezes or presses on the nerve, it can produce both local buttock pain and send pain down the leg along the course of the sciatic nerve. These symptoms sometimes arise following trauma to the area, from sitting for long periods of time, or as a result of repetitive vigorous activities, such as long-distance running. Piriformis syndrome (PS) is a condition related to the piriformis muscle, one of the six deep buttock muscles on each side of the back of the pelvis, all of which contribute to rolling the thigh bones roll out (external rotation). In this syndrome, there is either excessive tightness or spasm of the piriformis muscle (or both), often from overuse. There can also be swelling of the muscle from spasm or injury, which results in one-sided buttock pain, numbness, or tingling, and sometimes sciatica (pain that shoots down the leg as far as the foot). This syndrome is one of many possible causes of one-sided buttock pain, one of which can be quite serious, bulging or ruptured lumbar discs. There is no diagnostic test to prove piriformis syndrome, so you have to rule out more serious possible causes of this kind of pain, such as a herniated lumbar disc, before settling on the diagnosis. So, you have one-sided buttock pain with or without radiating pain down your leg, you should get it evaluated to make sure you have a correct diagnosis before starting to treat it. Be smart! Western treatments and recommendations for prevention for piriformis syndrome include:

1. Avoiding the possible triggering factors, such as prolonged sitting or prolonged running, running on hill, or running uneven surfaces 
2. Applying ice or heat locally 
3. Pain medication 
4. Medication for spasms 
5. Steroids for swelling and inflammation of the muscle 
6. Botox for spasms of the muscle 
7. Physical therapy to stretch the muscle and reduce the compression of the sciatic nerve (prevention and treatment)
8. Warming up for physical activities (prevention) 
9. Paying attention to maintaining good form in physical activities (prevention) 
10. Resting if pain returns and until it subsides (prevention) 

The physical therapy stretches usually target the piriformis muscle, the hamstring muscles, and other hip extensors (muscles that lift the leg up and back, such as in the lifted leg in Hunting Dog pose). It is important to continue with these stretches even after the symptoms have resolved to keep those muscles flexible.

Yoga is an excellent way to keep those muscles both flexible and strong. Today we will look at poses to help keep them flexible, and will look at poses for hip strength in a future post. And because in some people, piriformis syndrome results in a decrease in the range of motion in the hip joint, a yoga practice that includes exploring the range of motion of the hip in all directions can also be helpful during and after recovery. For this post, I’m assuming that our reader’s student has returned to a pain-free status and has been given the green light by their healthcare team to return to activity. Let’s now look at the questions our reader had. I’m going to start with which poses should be avoided. Since repetitive, vigorous activity can trigger piriformis syndrome, I suggest that our reader’s student should not immediately return to the same practice they were doing before the problem arose. A better way to go would be to gradually return to just about any activity by starting out with shorter gentle practices, and slowly increase the intensity of activity. And yoga poses that the student found aggravating when the pain was present should be reintroduced carefully and mindfully. Perhaps ask your student to make a list of those poses so you both know what they should be avoiding. Finally because prolonged sitting can trigger the pain, make sure that sitting asana practice or sitting meditation practice are initially shorter. Gradually increasing time in those positions could allow your student to get back to pre-injury activity levels. Finally, if the student feels that their yoga practice contributed to the development of piriformis syndrome, check whether they were doing repetitive vinyasa style practices or doing the same poses every day. If so, I’d recommend avoiding these types of repetitive yoga practices. Unfortunately, it is impossible for me to guess which specific poses might trigger the student’s symptoms. However, any poses that strongly externally rotate the thigh, such as the lifted leg in Half Moon pose or Reclined Leg Stretch pose, version 2 (leg out to the side) and seated poses with one or both legs out to the sides, such as Cobbler's pose, Lotus/Half Lotus, etc., could conceivably over-tighten or even trigger spasm in the piriformis. So for poses that include this movement I recommend approaching such poses mindfully, starting with shorter holds of 10-15 seconds and if tolerated gradually increasing holds. As for beneficial poses, the following poses, which are often used for initial treatment, would also be good to practice when you are healthy again. (By the way, some of these poses could also be beneficial for people with other buttock issues and/or other issues, such as back pain so feel free to give them a try.) 

Reclined Knee to Chest: This pose stretches the deep buttocks muscles, including the piriformis. Lying on your back with your legs stretched out, bend your right knee into your chest and hold on with both hands and stretch your buttock muscles for up to 30 seconds of more. Then, draw your knee toward the opposite shoulder and hold again for the same amount of time. Repeat on your left side. Thread the Needle/Figure 4 Pose: This pose also stretches the piriformis muscle and the deep gluteal muscles. From Constructive Rest position, cross your right ankle over your left knee. Then draw your legs in this position towards your chest while holding on to the back of your left thigh. Hold the pose for 30 seconds or more. Then repeat on the second side. You can also cross your legs tightly to stretch other parts of your buttock muscles (not shown on videos). These videos demonstrate the pose:

Reclined Hip Stretch Pose, both classic version and version 4: The classic version of this pose stretches the back of your leg and can release hamstring tension and improve sciatica, and version 4 with the full twist version stretches the piriformis muscle. See Featured Pose: Reclined Leg Stretch Pose  for instructions on how to do this pose. 

Marichi's Pose 3: This is a good pose for stretching the deep gluteal muscles, including the piriformis muscle. See Featured Pose: Marichi's Pose 3 ) for instructions on how to do this pose.Other poses that could also help include Pigeon pose and Half Lord of the Fishes Twist (Arda Matseyendrasana), which I will not describe here. However, if you wish to practice them, I recommend you work with an experienced teacher to learn these intermediate poses. 

Next week I will provide information about strengthening your hips, which will benefit a wide range of people (not just those recovering from piriformis syndrome). —Baxter

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