Article by Dr Raghuram Y.S. MD (Ay)
Famous American actor Anthony Anderson is said quoting ‘I’ve gotten my butt kicked by the best. Jet Li beat me up the best, but Steven Seagal can still kick a good butt. It’s a different kind of kicking though’ in a lighter sense.
But there is a different form of ‘kick in the butt’ condition which is really painful when it eclipses your butt. It makes you difficult to sit, walk around and have all the fun in life. You may feel ‘Wish I would not have this butt, at least not me!!’
It is called Piriformis Syndrome – A painful condition which hurts the buttock and legs.
Piriformis syndrome is a painful neuromuscular disorder. It occurs when the Sciatic nerve is either compressed or irritated by the Piriformis muscle, one of the muscles forming the butt. Sciatic nerve is a nerve which travels from lower back to the foot passing through the back of thigh and leg.
The disease mainly presents with pain, numbness (loss of feel) and tingling (feeling of pins and needles) in the buttocks. These symptoms are also experienced along the course of the Sciatic nerve, descending from the buttock into the thigh and leg. This picture gives an impression of another painful condition called Sciatica which has a similar clinical presentation.
Piriformis syndrome may occur due to –
Anatomical variations in the muscle-nerve relationship
Overuse of the muscle or irritation of nerve on a constant basis.
Table of Contents
Other names –
Wallet Sciatica – Piriformis syndrome often occurs in people who have a habit of keeping a filled fat wallet in the rear pocket. Constantly sitting with the wallet in the rear pocket will put pressure on the muscle and irritate the Sciatic nerve. In those already having Piriformis syndrome, keeping the wallet in the rear pocket can further aggravate pain and other symptoms by further increasing pressure on the piriformis muscle and sciatic nerve.
Fat Wallet Syndrome – Piriformis syndrome is called Fat Wallet Syndrome for the same reasons as explained in Wallet sciatica above
Since we will be discussing about Piriformis muscle and Sciatic nerve throughout the article, I shall give a brief introduction to these 2 terms –
Piriformis muscle – It is a flat, band-like muscle located in the buttocks near the top of the hip joint. This muscle plays an important role in the lower body movement. It stabilizes the hip joint and lifts and rotates the thigh away from the body. This helps us to walk, shift our weight from one foot to another, and maintain balance. The muscle is also used in sports that involve lifting and rotating the thighs.
Sciatic Nerve – It is a thick and long nerve in the body, supplies lower limb. It passes beneath, alongside or within the piriformis muscle. It travels on the back of thigh, down the back of the leg and branches off into smaller nerves that end in the feet. There are many causes which compress the sciatic nerve. Among them, spasm of piriformis is one of the main causes.
Prevention, lifestyle tips and remedies
Preventing secondary causes –
Piriformis syndrome resulting from previous injury due to trauma (secondary piriformis syndrome) is the most common form of the disease. Larger injuries include trauma to the buttocks. Micro traumas result from small repeated bouts of stress on the muscle.Secondary causes occurring during daily activities are preventable.
Avoiding sitting for prolonged periods of time, especially on hard surfaces – Minor stress is produced on the muscle and nerve due to periods of prolonged sitting, especially on hard surfaces. This can be relieved with bouts of standing.
Precautions at work place and sporting activities –
To avoid injury proper safety and padded equipment should be worn for protection during any type of contact, especially during high impact sports and when working in physically demanding conditions.
In the workplace, one must be aware of one’s surroundings and recognize anything in one’s routine that might produce micro and or macro traumas’s and keep away from them.
Other preventive strategies –
Warm-ups – Warming up before physical activity decrease one’s risk of injury during flexion, or rotation of the hip.
Practicing correct exercise form
Stretching – increases range of motion
Strengthening – Strength training is an important strategy. Strengthening hip adductors and abductors allows the piriformis to tolerate trauma more readily. All activities should be stopped when experiencing pain. By doing this, further damage can be prevented.
Hip adduction is a strengthening exercise for the piriformis muscle. A cable attached at the ankle can be used to adduct the hip, bringing the leg in toward the opposite side of the body. The same equipment can also be used for hip abduction, where the leg starts beside the opposing leg and moves out to the side, away from the body.
Avoid running or exercising on hills or uneven surfaces
Use good posture while running, walking and / or exercising
Staying active has better results than bed rest. Rest is equally important, but only when the pain needs to be pampered.
Staying in only one position or sitting in one position for long durations makes the pain of Piriformis syndrome worse. Regular breaks should be taken. Keep moving around and stay fit.
Walking gently with good posture is the key for relief. Don’t overdo by indulging in strenuous brisk-walks or jogging.
Correct postures and ergonomics –
Keep maintaining good and balanced postures in all the activities you do. Maintain good posture when you sit, stand, sleep or stretch.
Walking / Standing – While walking or standing make use of smooth, gentle and relaxed movements. Don’t keep the muscles tight and tensed. Tight and tensed muscles worsen pain. Stand straight and tall making sure that your lower back is not curved.
Carrying – Never carry a heavy bag on one shoulder or all shopping bags in one hand. Distribute weight evenly on both shoulders and in both hands. Use backpacks and not shoulder bags.
Lifting / Bending / Twisting / Reaching – Avoid lifting heavy weights as far as possible, If you need to lift something, do not bend over or twist the back suddenly. Use your knees to lift. Bend on your knees and slowly lift things, keeping your body in balance. Likewise use your feet to turn. Avoid twisting when you are trying to reach for something above your head or below your waist. Don’t pick or lift children. Kneel down if you need to reach something low. Be gentle on yourself.
Sitting – Use a chair which supports your lower back. Position your knees at the same level as your hips, with your feet flat on the ground. A lower back pillow or rolled towel will support your lower back. Use the arms of the chair to help you sit or stand. Don’t sit or rise suddenly, take time and be gentle. Don’t sit for longer duration, take breaks, get up and stretch at regular intervals.
Driving – Avoid driving when the pain is severe. Use a pillow or lumbar roll to support your lower back and maintain a correct sitting posture while driving.
Sleeping – Sleeping on flat ground is useful. A firm mattress with one supportive pillow under the head will help. Pillow can be skipped. Another pillow kept between the knees will add to the relief. Be careful not to twist or place strain on your back when getting into the bed or out of bed. Suddenly getting up or springing up the bed might worsen the pain.
Some more preventive strategies:
Avoid cigarette smoking as it promotes disc degeneration
Reduce your weight, in case you are obese or overweight. This exerts less pressure on your back and legs while walking or seating
Replace soft mattress with a firm mattress
Evenly distribute the weight of the luggage or shopping bags you have been carrying, on either side of the body
Do not push and lift heavy objects
Avoid leaning sideways or twisting your back
All the preventive measures can be considered as Home Remedies for Piriformis syndrome. Some of the home remedies for PS are as enlisted below –
Cold Therapy –
This can be done at the beginning of the pain in PS, especially if it is accompanied by inflammation. Ice cubes can be wrapped in a sterile cloth and kept in position on the most painful part for a few minutes and taken off. This should be repeated for 15-20 minutes. By reducing the blood flow towards the painful area, ice application provides relief. Ice can be rubbed alternatively.
Hot therapy –
If the pain of PS or sciatica is caused due to muscle compression or nerve compression, especially if the symptoms are more in winter season, hot therapy can be done. A sterile cloth or towel soaked in hot water or hot salted water or a hot water bag or hot water bottle can be used for heat application. The temperature should be checked before doing the therapy. Excessive heat application or prolonged contact of hot material can cause burns.
For any kind of painful condition, rest is the best remedy. The best way to get rest is by lying down on a flat surface (floor) by putting a soft pillow underneath the knees. One should sleep in this position for at least 1 ½ – 2 hours. After that they can change their position. By keeping the pillow beneath and between your legs, the spine (back) will come to a straight position and hence will relax.
Massage therapy –
Application of pain relieving cream or ointment made from menthol, capsaicin etc should be done on the painful area and a light massage given. Vigorous massage should be avoided. Vibrating machines can also be used for massaging purposes. Alternatively any herbal oil can be used for massage.
Spinal Decompression Exercise –
You need to stand with your feet at a shoulder length apart. Raise your hands above your head so that your biceps are in line with your ears. This will stretch the upper back. Next, tilt your pelvis forwards slightly to straighten out your lower back. Now bend slowly. Move in the upward direction in the same way. Repeat this 9-10 times.
Inversion table –
Regularly using inversion table will reduce the pain of Piriformis Syndrome and Sciatica.
Balanced diet –
Wholesome and balanced diet, predominantly comprising of organic and seasonal fruits and vegetables is the key for good health. It is also a wholesome practice for those whose immunity is down and out and those who are suffering from chronic and stubborn ailments.
Balanced diet helps your body to experience healing faster and it complements medicines and treatment. Juices of citrus fruits like lemon, orange etc will improve the immune system and help in reducing the inflammation. Constipation is one condition which can worsen the pain in PS and Sciatica. Fibre rich food will help in relieving constipation and help in healing these conditions.
Stretching exercises –
Sitting for a long time will add on to the pressure on the piriformis muscle and sciatic nerve and aggravate pains. Therefore we need to get up and perform some stretching exercises once in 3-4 hours.
There are many asana’s explained in the context of Yoga which help in healing pain of piriformis syndrome and sciatica. I have enlisted some Yoga’s in this article. You can choose any asana / asana’s convenient to you and perform it or them so as to get maximum benefits. But I would suggest you take an opinion from an expert Yoga tutor or trainer before commencing any asana. It is even better to do in their supervision.
Take a lot of water to keep self hydrated. The bones and muscles too need hydration. Water reduces inflammation, keeps you and your tissues hydrated, replenishes you and relieves constipation.
Infrared Light –
Infrared mats will help you to get relieved from pain related to PS, sciatica and low back pain. Plug in your mat to an electric source. Lie down flat on the mat. The infrared light will act on your nerves, soothe them and make you feel relaxed and pain-free.
Good and wholesome stuffs in PS –
Haridra, as it is called in Ayurveda, Turmeric is an essential kitchen spice of Indian homes and has been used as a home remedy for wide array of diseases since ancient times. Among many medicinal properties of Turmeric, its anti-inflammatory property has been well established and proved by many research works world-wide. It has a compound called curcumin which helps reduce nerve pain and inflammation.
Turmeric can be used regularly as a part of food preparations and also as a medicine. It relieves lower back pain, catches, swelling, inflammation and muscle spasms and thus is a handy remedy in Piriformis syndrome and sciatica. Its powder form is used abundantly. It is also available in the form of tablets and capsules. For good results 300mg of turmeric shall be used thrice daily. 1 spoon turmeric powder dispersed in a glass of milk can be taken alternatively as the first thing in the morning and also at bedtime.
Alternately you can add 1 tsp turmeric powder to a cup of milk. You can also add a small cinnamon stick or powder. Boil the solution. Later when it gets warm, add 1 spoon honey and drink it once or twice daily.
Turmeric may not be suitable for those taking blood thinners or diabetes medications. Those suffering from gallstones should also avoid it.
Grapes and Raisins –
Grapes and raisins have unparalleled anti-inflammatory property. They are known to expel excessive Pitta (heat element) from the body by Ayurveda medical science. Regularly consuming them will help you get rid of your inflammation and pains.
They can be chewed and eaten.
Alternatively, 10-15 raisins should be crushed and soaked overnight in a glass of warm water. The raisins should be squeezed and the water with its extract should be consumed the first thing in the morning.
Soak a teaspoon full of fenugreek seeds or crushed fenugreek powder in a glass of water overnight. Strain this water in the morning through a sieve or sterile cloth. Drink this as the first thing, early in the morning on empty stomach.
Garlic is a golden remedy for pains. Ayurveda has extensively used Garlic as a remedy for many joint related disorders, Vata disorders and nerve disorders. It is also best in tackling Sciatica and PS. Garlic is an essential part of Indian kitchen. It can be used as a part of food and medicine. It can be taken raw or processed form.
Lashuna Kshira Paka is a traditional Ayurvedic preparation for effective cure of Piriformis syndrome and Sciatic pain. To prepare this – 6-8 smashed cloves of Garlic (medium size) is boiled with 50ml milk and 200 ml water on moderate flame until the whole water has been evaporated and only milk (50ml) remains. The resultant preparation is strained through a sieve or sterile cloth and consumed hot and fresh.
Nutmeg Powder –
Take 1-2 spoons of nutmeg powder, roast it in 1-2 spoon of ginger oil (alternatively gingely oil also can be used). Allow the mixture to cool or come to warm temperature. Apply it on the affected area.
Parijat – An alcoholic based extract prepared from the leaves of Parijat, also called Harshiangar (Nyctanthes arbour tristis), has also been found useful in treating sciatica and piriformis syndrome.
Mustard oil –
Take 3-4 teaspoons of mustard oil, Add 3-4 crushed cloves of garlic and ½ spoon of carom seed powder to it. When the oil gets warm, it should be used to massage the affected part.
Other things which have been successfully tried out in PS –
The fruits, leaves and flowers of this plant have medicinal use. They relax the muscles, soothe the nerves and relieve pain. 1 glass of Elderberry juice shall be consumed twice daily.
Black Snakeroot –
Take 1 cup of water. Heat it. Add ½ tablespoon full of dried black snakeroot powder to the hot water. Keep it aside by closing the lid. It can be used after 15 minutes. 2-3 tablespoons of the extract should be taken orally for 2-3 times a day.
Burdock Root –
It is said to be one of the best remedies for Sciatica and PS. The powder of the root shall be taken in a dose of 1-2 tsp mixed in water, 2-3 times per day.
Celery Tea –
It consists of a compound known as coumarin. This compound has antioxidant and anti-inflammatory properties. Boil 1 glass of water. Add leaves and stems of celery to it. Boil the water until it gets a green colour. Filter it. Drink 3 cups of this tea daily.
Dong Quai –
A mixture of water and Dong Quai is highly effective in PS and sciatic pain when taken orally
Capsaicin Cream –
Cayenne pepper contains an active ingredient called capsaicin that works as a natural pain reliever. It helps deplete the levels of a neurotransmitter called substance P, which transports pain signals. Cream or ointment containing 0.025% to 0.075% capsaicin is readily available.
It can be liberally applied on the painful area up to 4 times per day for a week or 10 days. It may initially cause burning sensation. Talk to your doctor in such case. Do not use without prescription. Don’t apply the ointment or cream over broken skin or wounds.
Valerian roots work as relaxant. They relieve chronic nerve pain. It is extensively used in sciatica caused by muscle spasms especially Piriformis syndrome. The herb contains volatile oils that help relax your muscles and ease tension. It is popularly used as a sleeping aid.
150mg of the root supplement should be taken 2-3 times a day for a few weeks until relief is obtained. Valerian tea is another alternative. It can be prepared by steeping 1 teaspoon of dried valerian root in 1 cup of hot water for 10 minutes. This tea should be consumed 3-4 times a day for few weeks.
White Willow bark –
This herb can also be used for long-standing pain relief in PS and sciatica. it contains phenolic glycosides with salicin, providing anti-inflammatory and analgesic benefits. White willow bark supplement of 120 or 240 mg salicin should be consumed daily for several weeks. It should be done in consultation with a doctor.
Potato juice –
Take a raw potato of medium size, grate it and extract its juice. To this juice, mix equal quantity of carrot juice. This juice shall be consumed 2-3 times daily. This will relieve you from the inflammation, reduces sciatic nerve irritation and aid in free movement of foot and leg.
Epsom salt tub-bath –
Add 2 cups of Epsom salt to hot water filled in your bath-tub. Sit in the tub and soak yourself for ½ an hour in the Epsom salt added hot water. You will appreciate that your muscles would have relaxed and the pain has soothed out.
Massaging the affected area with chamomile oil three times a day will provide considerable relief from pain and inflammation. This should be constantly practised on a daily basis.
Devil’s Claw –
This herb is known to relieve and ease numbness, radiating pain and low back pain associated with sciatica and butt pain in piriformis syndrome. It can be consumed in the form of tea, tincture, tablet or capsule.
St. John’s Wort –
This imparts its highly effective anti-inflammatory and sedative properties on the irritated nerves, soothe them and provide relief.
Wintergreen Oil –
This oil is highly effective in pain and inflammation. It is readily available in the market or in pharmacies or herbal shops in bottled form. This oil shall be used for massaging the affected part.
Take a few (4-5) fresh horse-radishes, make paste by mincing them. Warm the paste and massage the painful part with it. Apply the paste on the affected area and wrap the area with a clean sterile cloth and let the paste be in place for 2 hours. Remove and wipe the paste after the scheduled time. Alternatively, squeeze the juice from the grated horse-radish. Make it warm and add 1-2 spoon honey to it, mix thoroughly. Drink 2 teaspoons of this juice, 2-3 times a day.
Jamaican Dogwood – This herb can be applied in the form of a tincture over the affected part. It can also be taken in the form of a capsule to alleviate sciatic nerve pain. This is not recommended for lactating and pregnant women.
Exercises and stretches for Piriformis syndrome and sciatic pain –
Exercise is a key for recovery from PS complaints. Exercises should be oriented towards strengthening abdominal and back muscles. Strengthening the core muscles helps facilitate fast recovery.
You can do knee to chest stretch to help reduce the irritation of the sciatic nerve and improve the flexibility of your lower back.
Lie on your back on a mat. Keep your feet straight and hip-width apart.
Keep your upper body relaxed. Bend your right knee upwards with an inhale.
Clasp your hands behind the thigh. Gently pull it towards your chest as far as is comfortable.
Keep the other leg flat on the surface
Hold on to this position for 20 seconds with controlled deep breaths and then lower your leg gently.
Repeat this 3-5 times for 20 seconds with controlled deep breaths and then lower your leg gently.
Repeat 3-5 times more and then switch legs and repeat
Finally do this exercise with both legs 3-5 times
Other exercises – Spinal rolling, Knees-rocking, Floor twists, Back-lock, Back extensions, Sciatic mobilizing stretches and certain Yoga postures. Spinal decompression exercises are also handy.
Alexander technique –
They are some exercises and corrections of postures taught for those suffering from back, lower limb pain and butt pain.
McKenzie exercises –
These exercises were designed by physiotherapist Robin McKenzie in 1950’s to treat a variety of lower back problems including herniated discs and sciatica. They will help you in getting relieved from lower back, leg and butt pain.
Exercises and stretches for Piriformis syndrome and sciatic pain –
Single knee to chest –
Lie down on your back. Keep pillow under your knees. Pull one knee into your chest. Hold for 30 seconds. Repeat on the other side. Repeat this many times. Don’t overstrain. If pain gets more, stop it.
Back massaging –
Lie down on your back. Pull your legs gently towards the chest. Circle your knees so that the lower back is gently massaged. You can keep balance ball under your lower calves while massaging.
Core muscle contractions –
Lie down on your back. Keep your legs straight. Keep a pillow under your knees. Contract only the deep muscles that stabilize the spine. Breathe normally and in a relaxed way. Hold for 30 seconds and then release. Repeat this many times.
Lying Twist –
Lie down on your back. Bend your knees such that the feet are placed flat on the floor. Stretch your arms at shoulder height from your body. Drop your knees on one side. Turn your head to the other. Be gentle. Hold for 30 seconds. Repeat on the other side.
Balance-ball Bridge –
Lie down on your back. Keep a balance ball under your calves. Keep your neck and shoulders on the ground. Raise your pelvis so that your back and upper legs are in a straight line. Drop your pelvis slowly to the ground. Repeat this 10-15 times. Alternatively you can use a chair under your calves.
Balance-ball diagonal arm / leg rise –
Lie down with your stomach on the balance ball, legs and arms on the ground, shoulder width apart. Raise your right arm and left leg horizontal with the floor. Hold for 5 seconds. Release and repeat on the other side. Repeat these 10-15 times. You can do this exercise on your hand and knees if you don’t have a balance ball.
Yoga’s for Piriformis Syndrome –
Just as Yoga helps to provide relief in many psycho-somatic illnesses, it also provides good relief to those suffering from Piriformis syndrome.
The below mentioned are some of the Yoga’s which are really helpful in Piriformis syndrome –
Ardha Matsyendrasana (Half Lord of the Fishes pose)
Garudasana (Eagle pose)
Gomukhasana (Cow-Face pose)
Virasana (Hero pose)
Rajakapotasana (King Pigeon pose)
Supta Padangushtasana (Reclining hand-to-big-toe pose)
Parivrtta Trikonasana (Revolved triangle pose)
Parsva Bakasana (Side crow or Side crane pose)
Marichyasana III or C (Sage Marichi’s pose)
Piriformis syndrome, Disease review – Modern concepts –
Causes of Piriformis syndrome –
The exact causes of PS are not known. The commonly suspected causes are as mentioned below –
Muscle spasm in the piriformis muscle causes PS. It may be due to irritation in the muscle or irritation of a nearby structure such as the sacroiliac joint or hip
Tightening of the muscle, in response to injury or spasm
Swelling of the piriformis muscle (due to injury or spasm)
Bleeding in the region of piriformis muscle
Any one or combination of the above said factors can affect the piriformis muscle causing butt pain. They may also affect the adjacent sciatic nerve causing pain, tingling or numbness in the back of the thigh, calf and or foot.
How does Piriformis syndrome occur? Causes and mode of manifestation (pathology) –
Piriformis syndrome is a type of Sciatica. Its signs and symptoms also resemble Sciatica. Actually Piriformis syndrome refers to Sciatica symptoms not originating from spinal roots and or spinal disc compression but involving the overlying piriformis muscle.
Piriformis is a small muscle in the buttock region (gluteal region). The Sciatic nerve which supplies the whole of the lower limb passes beneath this muscle at this point. In about 17% of population, the nerve passes through the Piriformis muscle and not beneath it.
When the piriformis muscle shortens or spasms due to trauma or overuse, it compresses or strangles the Sciatic nerve passing beneath it. Below mentioned are the frequent causes of Pain is exacerbated with activity, prolonged sitting or walking –
Inactive Gluteal muscles –
Piriformis syndrome can also occur due to inactive gluteal muscles. Gluteal muscles help in hip extension. They also help the piriformis muscle in external rotation of the Femur (thigh bone). This happens in conditions when someone sits with hips flexed as in sitting all day at work which makes the gluteal muscles inactive.
In this condition, the synergists to the gluteal muscles (Hamstrings, adductor magnus and piriformis muscles) have to perform extra roles which are not defined for them. This leads to hypertrophy of Piriformis muscle which later produces painful symptoms of Piriformis syndrome
Overuse injury –
Overuse injury also can result in Piriformis syndrome. This includes activities performed in sitting position that involves strenuous use of the legs, Ex, Rowing, Bicycling and Sculling
Forward moving activities –
Running, cycling and athletics are those activities which involve forward moving activities. People indulged in these forward moving activities on a regular basis are susceptible to Piriformis syndrome. The susceptibility is more if these people do not engage in lateral stretching and strengthening exercises.
Repeated forward movements when not balanced by lateral leg movements can lead to disproportionately weak hip abductors and tight adductors. Disproportionately weak hip abductors / gluteal medius muscles, combined with very tight adductor muscles can cause the piriformis muscle to shorten and severely contract.
Sciatic nerve impingement inevitably occurs following a 40% increase in the size of piriformis muscle.
Pudendal nerve impingement –
Just like Sciatic nerve, the impingement of pudendal nerve also can cause Piriformis syndrome. Pudendal is a nerve which controls the muscles of the bowels and bladder. Its entrapment produces tingling and numbness in the groin, faecal and urinary incontinence.
Stiffness or hypo-mobility of Sacroiliac joints –
This also can cause Piriformis syndrome. Stiffness of SI joints causes compensatory changes in gait. This will result in shearing of one of the origins of piriformis muscle. Shearing of gluteal muscles too can take place at the same time. These changes will result in piriformis malfunctions. They will also lead to the manifestation of other low back pain syndromes.
Over-pronation of the foot –
Piriformis syndrome can be caused by over-pronation of the foot. When a foot over-pronates, it causes the knee to turn medially. This activates piriformis to prevent over-rotating the knee. Due to this, piriformis muscle gets over used and consequently tight. Eventually this leads to manifestation of Piriformis syndrome.
Falling injury –
Injuries caused due to falls are one more cause leading to piriformis syndrome.
Short video to understand Piriformis syndrome in a nut-shell
Signs and Symptoms
Gluteal pain (pain in the buttock of the affected side) which radiates down buttocks (dull ache in the buttock) and the leg
Pain down the back of the thigh, calf and foot (sciatica like pain)
Pain while walking upstairs or inclines
Pain is exacerbated with activity, prolonged sitting or walking
Pain which is relieved by walking with the foot on the involved side pointing outward
Reduced range of motion of the hip joint
Symptoms of PS often become worse after prolonged sitting, walking or running. Patients may feel better after lying down on the back.
Diagnosis of Piriformis syndrome –
Diagnosis is mainly based on clinical symptoms – pain, numbness and tingling sensation in the buttock on the affected side, symptoms radiating along the course of the Sciatic nerve along the back of the thigh and leg, reaching to the foot.
There are only a few standardized diagnostic tests to confirm the diagnosis of Piriformis syndrome
2 validated tests for Pyriformis syndrome are –
FAIR test – This measures delay in Sciatic nerve conductions when the piriformis muscle is stretched against it.
Magnetic Resonance Neurography – It is a type of MRI, this test highlights nerves and the inflammation occurring in them
Sciatica resulting from compression or irritation of spinal nerve roots (ex, herniated disc) will have a similar picture as of Piriformis syndrome. Sciatica nerve irritation is also present in Piriformis syndrome and the pain along the course of the nerve makes the differential diagnosis different. When sciatica is caused due to Piriformis syndrome, the compression may be present as is present in Sciatica but the compression is not causal of the disease.
Physical examination –
Attempts are made to stretch the irritated piriformis and provoke Sciatic nerve compression, such as Freiberg, the PACE, the FABER (flexion, abduction, external rotation) and the FAIR (flexion, adduction, internal rotation) manoeuvres.
By doing these manoeuvres, the below said conditions would be ruled out:
Herniated nucleus pulposus (HNP)
Lumbar muscle strain
For ruling out the other conditions, diagnostic modalities such as CT, MRI, Ultrasound and EMG are useful.
Magnetic resonance neurography – It is an imaging technique which demonstrates Sciatic nerve irritation at the level of sciatic notch (where the nerve passes beneath the piriformis muscle). It also determines if the patient has split sciatic nerve or a split piriformis muscle or not.
Note – When Sciatica occurs without a clear spinal cause, we can think of possibly diagnosing the conditions as Piriformis syndrome
Piriformis Syndrome, Disease review – Ayurveda perspective
Ayurveda provides excellent remedies to combat Piriformis Syndrome. Before discussing the treatment options for Piriformis Syndrome, let us try to understand the disease in an Ayurvedic view.
We cannot find any disease explained in Ayurveda which resembles with the signs and symptoms of Piriformis syndrome. Thus we cannot correlate any particular disease to PS. But still, PS can be compared to and treated on the lines of the below mentioned conditions –
Gridhrasi (Sciatic pain) –
Gridhrasi is a condition explained in Ayurveda which is often compared to Sciatica due to the close resemblance of their signs and symptoms.
Sphik poorvaa kati prushta uru jaanu jangaa paadam kramaat
Grudhrasee stambha ruk todaihi gruhnaati spandate muhuhu
Vaataat vaata kaphaat tandraa gaurava arochakaanvitaa (Ref – Charaka Chikitsa Stanam, 28/55,56)
Explaining the nature of the disease Gridhrasi, Charaka tells that – ‘The disease in which the pain starts from the buttocks and travels along the back of pelvic and hip areas, thigh, knee, legs and ends at the foot is called Gridhrasi’.
This Gridhrasi is of 2 types.
Vataja Gridhrasi – This type of Gridhrasi is manifested due to the vitiation of only Vata. Along with the pain in the above said regions of the lower limb, Vataja Gridhrasi also presents with gripping and pricking pain and intermittent (regular) twitching.
Vata-Kaphaja Gridhrasi – This type of Gridhrasi is caused due to joint vitiation of Vata and Kapha. The pain is present in a lesser intensity along the regions of the lower limb explained in Vataja Gridhrasi. Along with this the patient will also suffer from Tandra (sleepiness), Gourava (heaviness in the limbs) and Arochaka (tastelessness).
Vaatajaayaam bhavet todo dehasya api pravakrataa
Jaanu kati uru sandheenaam sphuranam stabdhataa bhrusham
Vaata shleshma udbhavaanaam tu nimittam vahni maardavam
Tandraa mukha prasekaha cha bhakta dvesham tathaa eva cha (Ref – Madhava Nidanam 22/55, 56)
Symptoms of Gridhrasi or Sciatica manifested due to vitiation of Vata include –
Toda (pricking pain in the limbs),
Deha pravakrata (deformity of the limbs and body, disturbed gait),
Sphurana (twitching, pulsations) and Stabdhata (stiffness, catch) in the Janu (knee joints),
Sphurana and Stabdhata in Kati (pelvis, hips) and
Sphurana and Stabdhata in Uru (thigh)
Symptoms of Gridhrasi or Sciatica manifested due to vitiation of Vata-Kapha include –
Vahni maardavam – Low metabolism
Tandra – Slepiness
Mukha praseka – Watering in mouth, water brash
Bhakta dwesham – Aversion to food, Anorexia
Paarshneem prati anguleenaam tu kandaraa yaa anila arditaa
Sakthnaha kshepam nigruhneeyaat grudhrasee iti saa smrutaa (Ref – Sushruta Nidana 1)
Sushruta tells that when the kandara or nadi (nerve) located near the heels and toes (sciatic nerve?) gets afflicted by vitiated Vata, it leads to the manifestation of a painful disease in the lower limbs and is called by the name Gridhrasi (Sciatica or Sciatic pain). It causes severe gripping pain in the legs and thighs along with twitching.
The explanation available in the above said passages regarding Gridhrasi clearly points out towards Sciatica.
Since Piriformis Syndrome is also a form of Sciatica (sciatic nerve being involved) we can club this condition in Gridhrasi. Thus the treatment options suggested for curing or controlling Gridhrasi, including the medicines, diet changes etc could be administered in Piriformis syndrome without hesitation.
Vata Vyadhi –
Gridhrasi is explained in the context of Vata Vyadhi, i.e. the chapter which covers various diseases caused by morbid Vata. Thus Gridhrasi is a Vata Vyadhi (though Kapha is involved in some conditions). Whatever treatment or medicines are explained for combating Gridhrasi, include those which necessarily have to control the vitiated Vata.
Pain is directly proportional to the quantity of disturbance of Vata in the body. Pain cannot be produced without the involvement of Vata. Thus Vata alleviating medicines and treatments are mandatory for combating Gridhrasi vis-à-vis Sciatica or Piriformis syndrome.
Thus effective treatments and medications mentioned for combating vitiated Vata can also be incorporated for treating Piriformis syndrome.
Mamsagata Vata –
Gatavata is a condition wherein the vitiated Vata gets lodged in some tissue and disturbs the qualitative and quantitative integrity of that particular dhatu (tissue) or organ leading to either depletion or destruction (partial or whole) of the target tissue / organ.
Here Vata getting lodged in Mamsa (muscle / flesh) tissue causes painful symptoms. When this vitiated Vata afflicts the muscles of the butt and legs (thigh, legs) it produces symptoms which almost resemble sciatica. A
charya Sushruta has explained the same context that Gridhrasi is caused due to the affliction of the Kandara (nerve) supplying the foot, toes, leg and thigh by vitiated Vata which further causes pain in the lower limb along with twitching, catches and inability to walk (loss of movements). We have already discussed this aspect in the earlier passages. Therefore Piriformis Syndrome shall be treated on the lines of Mamsagata Vata
In these conditions treatments and medicines so as to pacify vata (Vatashamana) or remove vata (Vatanulomana) should be considered. Apart from this Balya (strengthening) and Brimhana (bulk promoting) medicines along with Rasayana’s (tissue rejuvenators, anti-ageing agents) should be given to increase the cellular immunity and aid their recovery (in terms of quality and quantity)
The below said are said to be the best in tackling Mamsagata Vata – Virechana – Therapeutic purgation
Niruha vasti – Medicated decoction enemas
Shamana chikitsa – Palliative treatments and medicines
Sphik Shula –
Sphik means buttock or butt, Shula means pain
Sphik shula or buttock pain is one of the indications where Asthapana Vasti (herbal decoction enemas) and Anuvasana Vasti (herbal oil or ghee enemas) can be given. Vasti’s (enemas) are the treatment of choices for Vata related disorders. Since Sphik shula is a symptom of Piriformis syndrome and or sciatica, Asthapana and Anuvasana Vasti can also be given in Piriformis syndrome.
Piriformis syndrome – Prevention, Ayurvedic concept:
We have learnt that Piriformis syndrome is a painful disease and pain is essentially associated with Vata vitiation. PS and sciatica can be prevented by keeping away all the causative and triggering factors which tend to vitiate Vata in the body.
Avoiding food and life style activities which aggravate Vata include keeping away the causative factors responsible for Vata vitiation (Vata Prakopaka Karanani). They are as below mentioned –
Vyayama – Excessive exercises
Vyavaya – Excessive indulgence in sexual activities
Apatarpana – Fasting in excess
Prapatana – Fall, injury
Bhanga – Fractures
Kshaya – Depletion of tissues
Jaagarat – Excessive vigil (awakening all night)
Veganam cha vidharanat – Suppression of natural body urges (reflexes)
Ati shuchi – Excessive administration of cleansing procedures (Panchakarma)
Shaityadi – Excessive consumption of cold foods and activities
Traasaat – Fear
Ruksha – Excessive consumption of dry foods
Kshobha – Irritation
Kashaya – Excessive consumption of astringent foods
Tikta – Excessive consumption of bitter foods
Katu – Excessive consumption of pungent foods
Vari-ghanagame – cloudy and rainy season
Parinate anne – After the digestion of food
Aparahne – Evening
Piriformis Syndrome Treatment approach – Ayurvedic aspect –
With the help of the compilation of above said aspects of PS, the treatment line-up of PS can be inferred as enlisted below –
Treatment and medicines on the lines of Gridhrasi chikitsa (treatment of sciatica)
Treatment and medicines on the lines of Vata Vyadhi (treatment of Vata diseases)
Treatment and medicines on the lines of Mamsagata Vata (treatment of Neuro-muscular diseases)
Treatment and medicines on the lines of Spik Shula (treatment of butt pain)
Gridhrasi Treatment –
The below mentioned treatments are highly beneficial in Gridhrasi vis-à-vis sciatica. By soothing the sciatic nerve pain, they will also relieve the symptoms of Piriformis syndrome. Already we have used the term Gridhrasi interchangeably with PS.
Abhyanga – Massage of the afflicted part (butt and lower limb) using medicated oils –
Abhyanga means performing a massage. Massage of the back, afflicted part of the buttock and lower limb / limbs is done using herbal (medicated) oils. Medicated oil and mixture of medicated ghee is also preferred in some cases. Pain is generally caused due to aggravated Vayu / Vata. Taila (oil) is said to be the best remedy for vitiated Vayu.
Massage not only alleviates the morbid Vayu but also provides significant relief from pain and catches. It nourishes and strengthens the bones, joints and soft tissues of the back and also rejuvenates them. Abhyanga when performed as a daily practice keeps up the health of low back while avoiding painful conditions even in the process of inevitable ageing. Ayurveda advocates whole body massage with herbal oils to be practiced on a daily basis.
Best oils used for massage for buttock pain:
Tila Taila (Sesame oil)
Prabhanjana Vimardhana Tailam
Guggulutiktakam Ghritam etc.
Padabhyangam (Foot massage) –
Foot massage is an essential part of Ayurvedic massage. It should be mandatorily done as a part of Sarva Abhyanga (whole body massage with herbal oils). It is not only a soothing treatment, it also is said to be preventive and healing treatment for Sciatica.
According to Ayurveda, one who takes Padabhyanga on a daily basis can avoid being a victim of Gridhrasi (sciatica, PS). Padabhyanga can be done using the same oils and medicines which are used for Abhyanga. Dipping the foot in hot water added with salt or in herbal decoctions or processed milk will add to the healing effect.
Kati Vasti –
Local oil pooling around the lumbar and sacroiliac joints is highly beneficial in Gridhrasi.
The term has 2 terms –
Kati – means low back
Vasti – means to hold (compartment which holds)
Thus Kati Vasti means a treatment in which medicated oils are poured and pooled for a fixed duration of time in a compartment or a cabin constructed over the low back area using wet flour of black gram, covering the Lumbo-sacral and Sacro-iliac joints.
In simple words, Kati Vasti is pain relieving oil-pooling treatment conducted for low back pain caused due to many causes
Vasti or Basti is a term used to describe the urinary bladder in Ayurveda. Urinary bladder is a bag which holds urine for a certain amount of period till it is voided. Similarly in Kati Vasti a compartment is constructed over the low back area by using flour of black gram and the pain relieving medicated (herbal) oils are pooled in this compartment for a fixed duration of time. Therefore the procedure is called Kati Vasti.
Hot fomentation or sweat inducing treatments (sudation, steaming) is highly beneficial in combating Vata disorders and Gridhrasi. Swedana is generally administered after giving Abhyanga to the patient. The below mentioned types of Swedana are generally preferred in Gridhrasi.
Nadi Sweda –
Tube or pipe fomentation, in which the herbs are boiled with water in a big vessel, drum or pressure cooker. In either case, the apparatus should have a lid to which a nozzle is fit. To this nozzle a heat resistant tube is fit. To the end of the tube a filter is applied which absorbs the hot vapors coming out and releases only steam without the water drops falling on the body of the patient. Alternatively a cloth is tied to the end of the tube. The steam coming from the tube is used for fomenting the painful part.
Avagaha Sweda –
Tub fomentation is also beneficial in Gridhrasi, should be done after Abhyanga. In this, the water processed with medicinal roots and herbs is filled in a bath tub or an Avagaha tub (tubs prepared with wood of medicinal plants for treatment purposes) and the patient subjected to Abhyanga (herbal oil massage) is made to sit in the tub for 30-45 minutes.
This will help the muscles and nerves to relax. Alternatively, if Avagaha is done at home, one can apply Vata alleviating oils over the painful parts (Ex, Ksheerabala taila, Mahamasha tailam, Mahanarayana Tailam etc) and sit in a tub filled with hot water added with salt.
Pinda Sweda’s – Bolus fomentations:
Churna Pinda Sweda (Powder bolus fomentation) –
Churna means powder (herbal), Pinda means bolus, Sweda is sweat, Swedana is sweat inducing treatment.
Churna Pinda Sweda is a treatment in which herbal powders having analgesic, anti-degenerative and anti-inflammatory properties are used for fomentation (sweat inducing) of painful parts
In this treatment, the herbal powders prepared by pounding the medicinal drugs which can relieve pain and associated conditions (having analgesic, anti-degenerative and anti-inflammatory properties) are heated or fried in herbal oils to tolerable temperature and are tied in a bolus.
The bolus is heated in a pan or dipped in herbal oils being heated at a less constant temperature in pans. The heated bolus is continuously rubbed over the pain afflicted areas. Different churna’s are selected for different stages of the disease.
Churna Pinda Sweda is an unparalleled treatment in Vata-Kapha morbidity or any disease or painful conditions caused by morbid Vayu and or Kapha, usually degenerative and oedematous diseases of joints and soft tissues associated with mild to moderate inflammation and effusion.
Powders which can pacify morbid Pitta are used in the bolus for tackling inflammatory diseases of joints and soft tissues. Morbid Kapha and its symptoms like catches, heaviness, coldness etc can be got rid of by using Kapha destroying herbal powders in the bolus.
Herbal powders used for Churna Pinda Sweda are:
Kolakulattadi Churna etc
Patra Pinda Sweda (Leaf bolus fomentation) –
Patra means leaves, Pinda means bolus, Sweda is sweat, Swedana is sweat inducing treatment.
Patra Pinda Sweda is a treatment in which leaves of medicinal plants having analgesic, anti-degenerative and anti-inflammatory properties are used for fomentation (sweat inducing) of painful parts
In this treatment, the leaves of medicinal plants having analgesic and anti-inflammatory properties are heated or fried in herbal oils to tolerable temperature and tied in a bolus. The bolus is heated in a pan or dipped in herbal oils being heated at a los constant temperature in pans. The heated bolus is continuously rubbed over the pain afflicted areas.
Patra Pinda Sweda is an unparalleled treatment in Vata morbidity or any disease or painful conditions caused by morbid Vayu, usually degenerative diseases. Leaves which can pacify morbid Pitta are used in the bolus for tackling inflammatory diseases of joints and soft tissues. Morbid Kapha and its symptoms like catches, heaviness, coldness etc can be got rid of by using Kapha destroying leaves in the bolus.
Ex. Leaves of Eranda (Ricinus communis – castor plant), Nirgundi (Vitex nigundo), Arka (Calotropis gigantean), etc are used in Patrapinda sweda
Read related: Patra Pinda Sweda: Ela Kizhi massage Preparation, Procedure, Benefits
Shashtika Shali Pinda Sweda (Medicated rice bolus fomentation) –
The term Shashtika Shali Pinda Sweda is made up of 4 words – Shashtika means sixty, Shali means rice, Pinda means bolus, Sweda is sweat, Swedana is sweat inducing treatment.
Shashtika Shali Pinda Sweda is a treatment in which a special type of rice called Shashtika Shali (which is harvested in 60 days and is exclusively used for treatment purposes in Ayurveda) prepared in milk processed with herbal decoction is tied in boluses and used for rubbing on the body parts which are intended to receive nutrition and strength.
Shashtika Shali Pinda Sweda is basically a strengthening and nutritious treatment. It also has an extraordinary relaxing and analgesic effect. In this form of treatment, initially decoction of Bala mula (roots of Sida cordifolia) is prepared. Two portions of this Bala decoction are boiled with equal quantity of milk separately. In one portion of processed milk, the Shashtika rice is cooked until properly formed. This processed rice is tied in 8 boluses. The boluses are dipped in the other portion of processed milk and continuously rubbed over the body. The process is carried out until proper sweating occurs.
Read related: Navarakizhi: Shashtika Shali Pinda Sweda Procedure, Benefits
Other beneficial treatments in Piriformis syndrome –
Pichu (Kati-Pichu) –
A larger piece of cotton swab (pichu) is dipped in medicated oil and ghee, kept in the affected area of the back and or buttock and bandaged. It is left in place for a prescribed duration before it is removed. This is carried on day to day basis.
This will continuously keep nourishing the bones, joints and tissues of the back, prevents degeneration, lessens inflammation, and heals pain and catches. Moreover it will soothe the sciatic nerve and piriformis muscle and relieves pain and catches. The same oils used for Abhyanga can be skilfully used in this format of treatment also.
Lepa (Kati Lepa) –
Lepa means application. Powders of drugs which alleviate pain are made into paste. The paste is applied over the low back area and or afflicted buttock area. It is allowed to stay in place for a prescribed period or till the paste starts to dry. Depending on dosha involved, the Lepa is applied either hot / warm (vata, kapha vitiation) or cold (pitta, rakta vitiation).
The common medicines which are used for Lepa are –
Dashanga Lepam etc
Upanaha (Kati Upanaha) –
Upanaha means poultices. The same powders mentioned in lepa are used as medicaments in Upanaha. After mixing them with suitable medicated oils, salt etc. the medicines are applied and tied around the back such that the medicines lie in contact of the painful part for a prescribed duration until they are removed.
Sira Vedha –
Blood-letting is another treatment mentioned as an effective cure for Gridhrasi vis-à-vis sciatica or piriformis syndrome. The Sira (vein) located 4 angula’s away from the location of mutrendriya (penis) or mutrashaya (urinary bladder) should be cut open and the blood let out to provide relief in Piriformis syndrome and or sciatica.
Agni Karma –
Fire cauterization is one of the effective treatments in Gridhrasi. Metallic rods or needles or Panchaloha rods (rods made up of 5 metals) are burnt in fire and is used to cauterize or burn the point in the Kanishtika anguli (lesser or small toe of the afflicted foot)
Sira Vedha and Agni Karma should be considered as last resorts if all the other treatments and medicines fail to provide relief.
Abhyantara Chikitsa (Internal treatments):
Consumption of oils / ghee processed with medicinal drugs is used orally in metered doses on a daily basis. Snehana will help in lubricating, soothing and strengthening the muscles and nerves. Sneha (medicated oil and or ghee) is the best in the business of combating Vata, thus helps in soothing pain associated with Piriformis syndrome.
The below mentioned medicaments are used for Snehapana –
Gandharvahastadi Eranda Tailam (for purgation)
Nimbamritadi Eranda Tailam (for purgation)
Vamana – Therapeutic Emesis / vomiting –
Gridhrasi is a Vata Vyadhi i.e. predominantly a Vata disorder. Vamana is a therapy generally preferred in high Kapha conditions. Thus Vamana should not be logically given in the diseases of Vata origin. But Acharya Chakrapani suggests administering Urdhwa Shuddhi (cleansing of upper parts of the body) by giving Vamana therapy before giving Vasti (treatment of choice in Gridhrasi, vis-à-vis sciatica, piriformis syndrome).
He further emphasizes that administering Vasti which is a treatment of choice in Vata diseases without having given Vamana will be a waste exercise and that the effect of the treatment will not be fruitful. Thus it becomes clear that Vasti gives best results when administered after having administered Vamana.
Read related: Vamana Therapy – Right Method, Side Effects, Management
Therapeutic purgation is very beneficial in combating Vata and Pitta related disorders, it expels morbid Kapha also. Virechana is given after having administered Snehapana (metered doses of medicated oils and or ghee given orally in increased doses until signs of saturation have occurred) and Abhyanga-Swedana (herbal oil massage and sweat inducing treatments).
Snehayukta Virechana (herbal purgatives or laxative herbs processed in oil base) is highly effective in combating Vata morbidity. This should be carefully administered in sciatica or PS having association of Kapha symptoms like stiffness, heaviness etc. in such conditions (Vata-kaphaja Gridhrasi), Ruksha Virechana (dry purgative formulations which do not have oil base) in the form of choorna (herbal powder laxatives / purgatives) and Kashayas (decoction purgatives) etc can be given. Ex, Trivrit churna, Haritaki churna, Gandharvahastadi churna etc
Virechana is also given on a daily basis while the above said treatment procedures are carried out. This helps in regular detoxification of the cells, soothes the irritated nerves and muscle and relieves pain and other associated symptoms of Sciatica and PS. This procedure is called Nitya Virechana. Below mentioned are some of the medicines used for nitya virechana –
Gandharvahastadi Eranda Tailam (for purgation)
Nimbamritadi Eranda Tailam (for purgation)
Triphala Ghrita/ Triphala churnam
Drakshadi Ghritam etc
Read related: Virechana Therapy – Right Method, Side Effects, Management
Vasti means medicated Enemas. Vasti is said to be the best treatment for combating vitiated Vata. It regulates and normalizes all the body mechanics, restores health in each and every cell, strengthens the body and provides long standing immunity. Vasti is also the best in the business of combating Gridhrasi vis-à-vis sciatica and or piriformis syndrome.
It is given in various forms as said below –
Kashaya Vasti – (Decoction enemas) – The best Kashaya Vasti’s (Asthapana Vasti) which can be administered in PS are:
Erandamooladi Kashaya Vasti
Mustadi Yapana Vasti
Raja Yapana Vasti
Dashamula Vasti etc
Sneha Vasti – Enemas with medicated oils / ghee is called Sneha or Anuvasana Vasti.
Below mentioned are a few best choices in PS and sciatica –
Brihat Chagalyadi Ghritam
Ksheerabala Tailam etc
Ksheera Vasti – Enemas using milk processed with medicinal herbs is called Ksheera Vasti. Since milk is used as a base for preparation of this Vasti, it acts as a nutrient apart from being a good analgesic. Ksheera Vasti’s are handy and highly effective remedies for Vata diseases. Its efficacy is unparalleled in combating painful conditions like Sciatica and Piriformis syndrome.
Vata Vyadhi Chikitsa (Treating on the lines of Vata disorders) –
Vata disorders can be prevented by avoiding the causative factors which aggravate Vata. The causative factors for Vata disorders have been discussed in the section of ‘Prevention of PS – Ayurvedic perspective’.
Sneha – Administration of medicated oils / ghee, Massage, oil pouring etc
Sweda – Steaming / sudation / sweating therapy
Mridu shodanam – Evacuation treatment (mild cleansing treatments like Virechana etc)
Svadu bhojana – Consuming sweet foods
Amla bhojana – consuming sour foods
Lavana bhojana – consuming salt foods
Ushna bhojana – Hot and fresh foods
Abhyangam – Massage with herbal oils
Mardana – Tapping the body with closed fists after application of vata alleviating oils
Seka – Pouring of medicated oils over the body in streams
Paishtika Madhya – Alcohol or fermented products prepared with flours
Goudika Madhya – Alcohol or fermented products prepared with jaggery
Snigdhoshna Vasti – Medicated enemas with oils and ghee, given luke warm
Deepana pachana sneha – Oils and ghee processed with deepana (appetizer) and pachana (digestant) drugs
Useful Vataghna drugs (Drugs alleviating Vata) –
Devadaru – Cedrus deodara
Kushta – Saussurea lappa
Bala – Sida cordifolia
Atibala – Abutilon indicum
Shallaki – Boswellia settata
Agnimantha – Clerodendrum phlomidis
Guduchi – Tinospora cordifolia
Eranda –Castor: Ricinus communis
Shatavari – Asparagus racemosus
Punarnava – Boerhavia diffusa
Dashamula – Roots of 10 drugs
Mamsagata Vata treatment –
Piriformis syndrome can be treated on the lines of Mamsagata Vata. In these conditions treatments and medicines so as to pacify vata (Vatashamana) or remove vata (Vatanulomana) should be considered.
Apart from this Balya (strengthening) and Brimhana (bulk promoting) medicines along with Rasayana’s (tissue rejuvenators, anti-ageing agents) should be given to increase the cellular immunity and aid their recovery (in terms of quality and quantity)
The below said are said to be the best in tackling Mamsagata Vata–
Virechana – Therapeutic purgation
Niruha vasti – Medicated decoction enemas
Shamana chikitsa – Palliative treatments and medicines
Spik Shula treatment –
Piriformis syndrome can also be treated on lines of Spik Shula (butt pain). Treatments and medicines mentioned in Gridhrasi are handy in dealing this condition. Mainly Asthapana and or Anuvasana Vasti’s are preferred as best choices of treatments. Abhyanga, Pinda Sweda, Lepa, Upanaha can also be used for effective results.
Useful medicines in Piriformis Syndrome –
Kashaya’s (Herbal decoctions):
Maharasnadi Kashayam etc
Ghritam and Tailam (medicated ghee and oils):
Ksheerabala tailam 101
Dhanwantaram tailam 101
Asava / Arishtam:
Vati and Gulika (Tablets):
Panchatikta Ghrita Guggulu
Mahavata vidhwamsini ras
Ksheerabala Tailam 101 caps
Dhanwantaram Tailam 101 caps etc
Best Rasayana’s / Lehyas (Rejuvenators and confections):
Drakshadi Rasayanam / Drakshadi Leham
The same herbal oils mentioned in Abhyanga etc. can be used for external application.
Treatment – Modern Approach
Medicines – Non-steroidal anti-inflammatory drugs and / or muscle relaxants – provide symptomatic relief of muscle and nerve pain
Conservative treatment – stretching exercises, myo-fascial release, massage, avoidance of contributory activities like running, cycling, rowing etc
Physical therapy – include soft tissue mobilization, hip joint mobilization, stretching techniques, strengthening of gluteal muscles to reduce strain on the piriformis muscle, pelvic-trochanter isometric stretching, hip abductor, external rotator and extensor strengthening exercises, Transcutaneous electrical nerve stimulation (TENS) and Massage physiotherapy of piriformis muscle region
Rehabilitation programmes – include physical therapy, low doses of muscle relaxants and pain relief medication
Stretching – It is recommended to be done once in every 2-3 hours during hours of being awake. In this, the hip joint capsule is moved anteriorly and posteriorly. The muscle is manually stretched by applying pressure. The pressure is applied perpendicular to the long axis of the muscle and parallel to the surface of the buttocks. It is done until the muscle has been relaxed.
Other useful Treatments –
Application of Ice –
This works wonder in some patients suffering from Piriformis syndrome. Application of ice can be helpful when the pain starts or immediately after an activity that causes pain. This can be carried out in the form of an ice pack or ice massage.
Muscle strengthening is an important strategy in dealing the pain due to Piriformis syndrome. This includes working on increasing the strength of abductors, external rotators and extensor muscles of the hip joint. It includes implementation of various exercise programmes so as to strengthen single muscle and also group of muscles.
This not only strengthens the muscles, but also helps in getting over the pain and improvises the movements. This treatment involves 3 phases – non-weight bearing exercises (focussing on isolated muscle recruitment), weight-bearing exercises and Ballistic exercises. Ballistic exercises consist of plyometrics.
Ballistic (Greek word ballein) means ‘to throw’. In this type of training, the person accelerates and releases the weight into ‘free space’. Common ballistic exercises or bench throws, jump squats, cleans, snatches and push presses
Plyometrics (jump training) –
They are exercises in which muscles exert maximum force in short intervals of time, with the goal of increasing power (speed-strength).
Therapeutic injections –
Therapeutic injections such as local anaesthetics (ex, lidocaine), anti-inflammatory drugs and / or corticosteroids, botulinum toxin (BTX, BOTOX) etc can be considered when the conservative treatments have failed to give results
It is rarely recommended. But the prognosis of surgery is generally good.
Iontophoresis is using mild electric current to relieve pain and related symptoms in PS
Physical therapy –
Range of motion exercises – A customized programme can be developed by a physical therapist, physiatrist, chiropractor or other qualified health practitioner. The programme can include stretching and range of motion exercises to help stretch the muscle and decrease spasm
Deep massage – Deep massage or manual release is usually done by a physical therapist or qualified specialist. It is said to enhance healing by increasing blood flow to the area and decrease the muscle spasm in PS.
Heat therapy –
Heat therapy or application of heat sometimes helps. Alternate cold and hot therapies can be done. A heat pad can be placed on the affected muscle for 15-20 minutes.
Application of electrical stimulation to the buttock with a Transcutaneous Electrical Nerve Stimulation (TENS) unit or Interferential Current Stimulator (IFC) can help to block pain and reduce muscle spasm related to Piriformis Syndrome. In persistent cases, the piriformis muscle can be cut to relieve symptoms, but this is rarely performed.
Few other strategies tried towards healing PS –
It is an alternative form of medicine where the practitioner will insert needles in your skin. Warm acupuncture can alleviate symptoms of PS and sciatica. This treatment shall be taken under the supervision and guidance of a licensed practitioner.
A 2009 study published in the Journal of Traditional Chinese Medicine found that warmed acupuncture with heated needles helped improve sciatica pain. In fact, 17 of the 30 participants got complete relief after acupuncture therapy.
Spinal Manipulation –
Chiropractic care is a popular treatment for neck and back pain. Chiropractic spinal manipulation includes different techniques involving rapid, short thrusts to alleviate nerve irritability responsible for inflammation and other symptoms associated with sciatica.
A 2010 study published in the Journal of Manipulative and Physiological Therapeutics found that spinal manipulation benefited 60% of the study participants suffering from sciatica to the same degree as a surgical intervention could have provided.
It is an alternative medicine technique to relieve pain associated with sciatica and piriformis syndrome. Acupressure uses physical pressure over the body points for clearing the blockages that might be causing pain and other discomforts in your body. Pressure can be applied by hands, elbow, & other devices.
Lie straight on your back. Make fists with your palms; place both your fists below your lower back with knuckles pressing against your lower back muscles. Hold the position for a minute. Now role over on to your side (the side which has maximum pain)
Place your fist or tennis ball underneath the side of your buttock. This is the acupressure point GB30. It is one of the major points for sciatic nerve relief.
When you keep your fist or tennis ball at this point, it hurts. Hold on to this position. Close your eyes and breathe deeply for few minutes.
Slowly you will feel the pain and soreness reducing at this point. Re-adjust your fist or the ball to place pressure on the other tight points of the area.
Do this for 1-2 minutes at each point. Move to put pressure on other points of your leg to get relief from sciatic pain.
Use your fingers and hands to put pressure on a point outside your lower leg, just below and in front of the head of the fibula (calf bone). Its head is situated below the level of the knee joint. It is the GB 34 acupressure point, a muscle relaxant point. Put pressure on this point for few minutes.
Next put the pressure on another point, the GB40 point. It is located in the large hollow directly in front of the outer ankle bone. Press this point hard for a few minutes.
Then shift to GB 41 point. It is situated between 4th and 5th metatarsal bones (foot bones). Maintain pressure for 1-2 minutes.
Piriformis Syndrome – Differential Diagnosis –
Ischio-gluteal Bursitis or Weaver’s bottom –
Ischio-gluteal bursa is a sac filled with fluid, situated at the base of the pelvis, at the level of the bony prominence called ischial tuberosity (a bony bulge in the butt region which comes into contact with the surface as we sit down). Inflammation of this bursa is called IGB. It presents with pain and tenderness in the butt. Pain worsens on sitting, running, walking, jumping, kicking, climbing stairs, and sitting excessively on hard surfaces.
Sciatica caused by compression secondary to a fibrotic band, hematoma or aneurysm of the inferior gluteal artery causes sciatic pain (pain down the lower limb along the course of sciatic nerve) and buttock pain.
Spinal stenosis –
It is a condition in which the spinal column (backbone or spine) narrows and starts compressing the spinal cord. It is a gradual process. If the narrowing is minimal, no symptoms will occur. Too much narrowing can compress the nerves and cause problems. The symptoms include leg or arm weakness, lower back pain while standing or walking, numbness in legs or buttocks and balance problems.
Hamstring muscle injury –
When the muscles making the back of our thigh (Hamstrings) get injured, we will experience butt pain along with other symptoms like difficulty to walk, sudden pain during exercise, tenderness, bruising etc.
Lumbosacral disc injuries –
When the disc (soft cushions which are present in between 2 adjacent bones making our back, helping in movements of the back) or discs of the lumbo-sacral (low back) region gets injured it generally leads to low back pain. But in many conditions of LS disc injuries we can also find butt pain as a symptom.
Lumbosacral discogenic pain syndrome –
It is a serious medical and social problem and accounts for 26-42% of the patients with chronic low back pain. It is the most common type of chronic low back pain. It happens due to the degeneration of the disc. Butt pain is one of the symptoms accompanying this condition.
Lumbosacral facet syndrome –
The facet joints are a pair of joints in the posterior aspect of our spine (back bone). These joints are potential sources of pain and one of the most common sources of LBP (Low Back Pain). Butt pain is associated with LFS.
Lumbosacral radiculopathy –
It refers to a disease involving the lumbar spinal nerve root. This can manifest as pain, numbness or weakness of the buttock and leg. It is also considered and called as Sciatica by some. It is typically caused by a compression on the spinal root.
Lumbosacral spine sprain / strain injuries –
Sprain is the stretching or tearing of a ligament. Strain is an injury to either a muscle or tendon. Strain and Sprain at Lumbosacral spine worsens with movement, with sudden uncontrollable muscle contractions and decreased movement of joints.
Lumbosacral Spondylolisthesis –
Spondylolisthesis is a forward displacement of a vertebra, especially a 5th lumbar vertebra. This condition also presents lower back pain, sciatic like pain and butt pain.
Lumbosacral Spondylolysis –
It is also called as osteoarthritis of Lumbosacral joints. This occurs due to the degenerative changes occurring in the spine and vertebral joints (joints making the back bone) and degenerative intervertebral discs (degenerative disc disease) in the low back.
Sacroiliac joint injury –
Injuries occurring at Sacroiliac joint also presents with low back pain and buttock pain mimicking Piriformis syndrome.
Gouty arthritis –
It is usually an extremely painful attack with a rapid onset of joint inflammation. The inflammation is precipitated by the deposition of uric acids in the lining of the joint (synovial lining) and the fluid within the joint. This can affect the joints around the hip and low back giving raise to severe pain in the low back, butt and lower limb.
Pelvic mass or tumor –
Pelvic mass is a general term for any growth or tumour on the ovary or in the pelvis. A pelvic mass can be cystic (cystadenoma), solid (fibroma) or both (dermoid). A pelvic mass can be benign or malignant. When a pelvic mass or tumour puts pressure on the bones, muscles and soft tissues around the low back, it can cause severe painful condition mimicking sciatica and piriformis syndrome.
Endometriosis in women –
It is a condition resulting from the appearance of endometrial tissue outside the womb and causing pelvic pain, especially associated with menstruation. Low back pain, pain in the lower limbs and nerve irritation is common in Endometriosis.
Epidemiology, Research and Statistics
Piriformis syndrome (PS) data is often confused with other conditions due to differences in definitions, survey methods and whether or not occupational groups or general population are surveyed. This makes it difficult to figure out the exact numbers related to epidemiology of PS.
Some studies showed the following results –
In some studies, 6-8% of lower back pain occurrences were attributed to PS. Other reports concluded 5-36%.
In a survey conducted on general population, 12.2 – 27% included a lifetime occurrence of PS, while 2.3 – 19.5% showed an annual occurrence.
Other studies – Proportion of sciatica, in terms of PS, is about 0.1% in orthopaedic practice. This is more common in women with a ratio of 3 is to 1 and most likely due to wider quadriceps femoris muscle angle in the os coxae.
Between 1991-1994: PS was found to be 75% prevalent in New York, Connecticut, New Jersey, Pennsylvania; 20% in other American urban centres and 5% in North and South America, Europe, Asia, Africa and Australia. Common ages were between 30 and 40, cases were scarcely found in patients less than 20 years of age. It affects people of all lifestyles.
In 2012, 17.2% of lower back pain patients developed Piriformis syndrome.
PS doesn’t occur in children and is mostly seen in women of age between 30 and 40. This is due to hormone changes throughout their life, especially during pregnancy, where muscles around the pelvis including Piriformis muscles, tense up to stabilize the area for birth.
In 2011, out of out of 263 patients between the ages of 45 to 84 years of age, treated for PS, 53.3% were female. They are 2 times more likely to develop PS than males.
The average cost of treatment was $29,070 for hospitalizing over 4 days.
Yeoman first described PS in 1928 as periarthritis of the anterior sacroiliac joint. The history of this condition stems from one of many causes of low back pain and leg pain. Many patients who underwent unsuccessful surgery in the lumbo-sacral region were later found to have piriformis syndrome.
Just before finish –
It is really like being in a hell when you cannot sit on your painful butt. The pain of Piriformis syndrome is not only limited to the buttocks or sciatic involvement leading to sciatica like condition, but also gets on to your nerves and starts staying in your mind. The fear of pain constantly keeps reminding you about many activities you need to avoid.
Ayurveda provides many medicines and treatment options which help to heal the pain and associated symptoms of Piriformis syndrome apart from soothing the nerves and muscles. PS might be a rare disorder but the fractions of people who are suffering from this condition know exactly what it means to live with it. If you have anyone in your good circle who is suffering from PS, it is right time to forward them this article and suggest them to get rid of their pain in a comprehensive and holistic way, naturally through Ayurveda.
Consult Dr Raghuram by Skype