20 Sep Frustrated? Piriformis Syndrome Treatment That Works When Your Pain Has Lasted Longer Than 6 Months
If you’re not annoyed and frustrated by the pain in your ass, literally and figuratively speaking, feel free to click through to another piriformis syndrome treatment page.
What I write here is for people who have had butt pain more than 6 months, even though they’ve seen 3-5 other doctors or therapists…
… and tried stretching, strengthening, physical therapy, chiropractic adjustments, ice, heat, electronic stimulation, cortisone shots, steroids, and any other magical cure promised to you.
Between 1-4 out of 10 people will have “sciatica” at least once in their lifetimes. (Source)
The longer you’ve had piriformis syndrome, the harder it is going to be to get your problem fixed (and the more you need to understand why you haven’t been fixed yet).
As with any health condition, it becomes really important that you use your mind to think through the “stories” different doctors tell you when it comes to getting rid of your pain.
Check in with your intuition:
Does what this doctor says is my problem make sense?
Does this doctor seem like an honest person?
If you answered “no” to any of the above, find a doctor who you can answer “yes” to. Until then, you risk spending serious amounts of time, money, and energy trying to get fixed when your intuition knew the answer all along.
Here’s the sarcastic, but very real, Piriformis Syndrome Treatment That Worked story.
What causes Piriformis Syndrome?
Once your pain is severe and you’re completely and utterly annoyed, frustrated, and pissed off by the lack of relief you’ve found in self-treatments and doctor or therapist-driven treatments, I’ve found that most people don’t care what the cause of their Piriformis Syndrome is.
These patients just want the pain gone!
Before I start treating a patient at Barefoot Rehab, it’s super important to be on the same page about the cause of Piriformis Syndrome.
If you don’t understand the cause, then your mind will wander off the path of getting fixed to other possible treatments that provide very temporary relief, potentially making the cause of your Piriformis Syndrome bigger.
First thing you need to know is that any diagnosis with the word “syndrome” in it tells us nothing as far as what the tissue-specific (is it a muscle or bone or cartilage or ligament? etc.) cause of the problem is and therefore, what treatment you should be looking for.
So, what is Piriformis Syndrome actually? Or what surgeons are starting to cut open with their scalpel and call Deep Gluteal Syndrome?
Below is an actual surgery for Sciatic Nerve Decompression for Deep Gluteal Syndrome:
It’s glue sticking your piriformis (or one of the other hip external rotators) to the sciatic nerve.
That glue is known as adhesion in the medical world. The illustration shows the “black stuff” in the muscle on the right as glue within your muscles.
This adhesion forms between your sciatic nerve and one of the hip external rotators:
- piriformis (actually, very uncommon to get adhesion here)
- superior gemellus (most common location to get adhesion)
- inferior gemellus
- obturator externus
- quadratus femoris
Here is Dr. Brady of Integrative Diagnosis explaining how nerves get stuck to muscles. Keep reading and I’ll show you an actual treatment for Piriformis Syndrome with BEFORE and AFTER ranges of motion.
In the image below (source), the gluteus maximum has been taken off the image. The sciatic nerve is the thick black line. In your body, it’s as thick as your index finger. It’s quite easy for an expert doctor to feel if the nerve moves or if it’s glued down by what feels like a wad of gum called adhesion.
Orthopedic surgeons have confirmed that adhesion (or what they call “fibrous bands”) on the right side (or lateral side) of the nerve is MOST COMMON.
Anyone who is reading this and who has had “piriformis syndrome” for less than 6 months with mild pain and the pain was helped by the standard advice of:
- physical therapy
- electronic stimulation
- massage therapy
- medication …
… either never had adhesion in this location or had a small amount of it that hasn’t gotten thick enough to cause more intense pain.
Stretching and movement can get rid of tiny bits of adhesion.
There are only two ways to get rid of thicker wads of adhesion.
More on that below.
Now that we understand adhesion, we have to see if you actually have adhesion by determining if Piriformis Syndrome is your correct diagnosis.
How do you know if “Piriformis Syndrome” is the Correct Diagnosis?
Getting the correct diagnosis for your pain, especially when it’s lasted more than 6 months, is a difficult thing to accomplish.
The wrong diagnosis can leave you feeling silly, wondering how you ever got into such a predicament.
The human body is quite the puzzle and it’s not easy for doctors with regular orthopedic, chiropractic, medical, or physical therapy educations to get hard answers right.
Educational institution’s job is to graduate doctors, not create experts.
A discussion of what piriformis syndrome “looks like” is necessary.
If it looks like a duck and quacks like a duck, is it a duck?
It’s a good thing that chimeras (those magical animals that are actually 3 MULTIPLE ANIMALS in ONE) don’t actually exist.
Real-life lion-goat-snakes would scare the bejeesus out of most of us.
Unfortunately, chimeras do exist when it comes to pain, as much as you might not want to believe it.
Your chimera might be the possibility that you have MULTIPLE problems going on, which will confound the case. If it sounds like you do, I highly recommend you find a musculoskeletal specialist to manage your case for you.
With that said, let’s dive in to getting your diagnosis right.
Let’s assume your Piriformis Syndrome is just a normal duck.
Piriformis Syndrome will typically look like this:
Location of pain (can be any combination of the below locations:
- Your butt check (you’d rate it at least a “5” on the 0-10 pain scale, where “0” is no pain and “10” is the worst pain ever)
- Right down the back of the middle of your thigh
- Right down the back of the middle of your calf OR down the outside of your calf (not the inside)
- Along the top or bottom of your boot.
Location of nerve symptoms: Possible numbness or tingling in your butt cheek or down the back of your thigh, usually not past the knee.
What makes the pain worse?
- Walking for a period of time
- Stretching your “hamstring” like touching your toes or doing a hamstring stretch lying on your back.
- Lying in bed at night
- Sitting for a period of time (i.e. caused by direct pressure to the location of adhesion), especially directly on the painful side
Notice in the image below, the individuals are leaning on the opposite hip.
Can you test yourself at home?
- Yes, with the Hamstring Stretch Test
Get your friend, lie on your back, have them straighten your knee and bring your hamstring as high as you can go until you feel not a mild, but at least a “moderate” intensity stretch or pain symptom.
A great confirmation that you have Piriformis Syndrome is when this test reproduces pain precisely in your butt.
“Good” range is higher than 45 degrees (above a 50% grade).
“Bad” range is lower than 45 degrees (below a 50% grade).
At your end range, have your friend push down on the ball of your foot 1-2″ (no more than this).
If the pulling or pain INCREASES, you can be sure that your sciatic nerve is the problem. We don’t yet know if the sciatic nerve is being pulled at your piriformis, hamstring, or low back. Your expert adhesion doctor will confirm that for you.
If the symptoms INCREASED right in your butt, the diagnosis of Piriformis Syndrome becomes more probable.
Are there any other tests you can do?
- Ultrasound of the sciatic nerve can determine if your sciatic nerve is swollen (Kara et al.)
Piriformis Syndrome will NOT look like this:
Any of the below data points that are true either:
- Lessens the probability that you have Piriformis Syndrome … or …
- Introduces the possibility that you have a chimera (MULTIPLE problems instead of just ONE problem)
Location of pain:
- Your low back
- Down the inside, front, or outside of your thigh
- Down the inside of your calf (not the outside)
Location of nerve symptoms: Numbness or tingling in the front of your thigh, shin, or foot.
What makes the pain worse?
- Movements of the spine
Can you test yourself at home?
The Pencil Test is like a blood pressure test for your low back. It tells you how healthy or unhealthy your low back is, just like blood pressure tells you how much risk you have for a heart attack or not.
In Barefoot Rehab, we use a pencil ruler to get an exact measurement.
You can just take a simple pencil and grade 1 observation?
- Is the pencil flat against your low back with a grade of 90% through 65% below (the higher the grade, the healthier your low back is)?
- The better your grade is, the MORE likely you have Piriformis Syndrome.
- Or is there space under the pencil with a grade of 40% (the lower the grade, the more likely you have a disc problem).
- The worse your grade is, the LESS likely you have Piriformis Syndrome.
A very healthy low back – 90% function (fxn) – Notice the pencil is flat for 1.5″:
Or a D-grade low back – 65% function (fxn) – Notice the pencil is flat for 4.5″:
Or do you have a major fail – 40% function (fxn) – Notice the space under the pencil:
Then, if you do the Touch Your Toes Test and the speed of your movedment is Yellow-Lighted, then you can be confident you have a disc problem (and NOT Piriformis Syndrome). You can be CERTAIN you have a disc problem if you have pain or tightness in the MIDDLE of the range of motion that gets better as you get to your end range.
Are there any other tests you can do?
- An MRI can confirm low back disc involvement.
2 Piriformis Syndrome Treatments That Work
Your head may be spinning a bit right now.
Diagnosing pain cases that have lasted more than 6 months and have been failed by multiple doctors requires deeper thinking.
That’s why the very first sentence of this post tried to get you off of this page. If you weren’t ready to use your head, you wouldn’t have spent the mental energy to try to figure out what your problem really is.
Now, you should have confidence whether you have Piriformis Syndrome or not.
If you do have Piriformis Syndrome, there are only 2 treatments that work to remove the adhesion from your sciatic nerve and the hip external rotators.
There is some research stating that a steroid injection works for 50% of patients. If this worked, there was either no or minimal adhesion. If you’re not able to try Piriformis Syndrome Treatment #1 below, I’d do this as the next step before trying Piriformis Syndrome Treatment #2.
Piriformis Syndrome Treatment #1: Get Your Adhesion Removed With Manual Therapy
Healthcare standards universally say to treat conservatively (without getting cut open) before invasively (getting cut open).
This applies here.
A skilled adhesion removal specialist like an Integrative Diagnosis provider can feel where the sciatic nerve is stuck with only his/her hands.
Then, he can remove that adhesion with the help of an assistant.
Below is a live case study with a young professional dancer with a tighter right hamstring than the left. He’s been stretching for years, not seemign to make a dent in his flexibility. The great thing about this treatment is, 3 passes, and 48 hours after the treatment, Ray said:
I’m still tighter in my left hamstring now! Will it stay this way?
I replied, “Of course. There’s less adhesion in your right hip now!”
The results are often immediate, with significant relief happening within 5 treatments.
Piriformis Syndrome Treatment #2: Get Your Adhesion Removed With Surgery
Or, you can go straight towards getting cut open.
Interestingly, a common cause of Piriformis Syndrome is previous piriformis release through a steroid injection.(Source – 18:00)
TAKE ACTION NOW: Find a Specialist
Regardless of which Piriformis Syndrome treatment you want, you’ll need to find a specialist as there aren’t many doctors doing this type of work.
To find a doctor/provider to release the adhesion (treatment #1) with his hands, I recommend finding a provider on Integrative Diagnosis.
If you’ve already tried conservative care with an Integrative Diagnosis provider, I’d contact one of two doctors:
Dr. Hal Martin, lead author of The Endoscopic Treatment of Sciatic Nerve Entrapment/Deep Gluteal Syndrome.
Address: Oklahoma Sports Science & Orthopaedics, 6205 N Santa Fe, Ste 200, Oklahoma City, OK 73118, U.S.A.
Dr. Shane Tipton, lead author of Arthroscopic Decompression of Greater Trochanteric Sciatic Nerve Impingement.
Address: Department of Orthopaedics, Wake Forest School of Medicine, Winston Salem, North Carolina, U.S.A.
If you can’t get to Oklahoma or North Carolina, these doctors would likely know the closest surgeon to you who can help you with your pain.
If you have questions about your butt pain, please answer all of the questions below about your pain and I can help steer you in the right direction. If you don’t give me all of the answers, I’ll reply and ask you to give me ALL of the answers.