• Thigh bone swung too far back (hip joint hyper-extension).
• Knee pointing too far outward (hip joint lateral rotation).
• Thigh bone swung too far out to the side (hip joint abduction).

You can see this in the following cartoon pictures of golfers at the end of their swing:-

Picture to Left: Piriformis Muscle Syndrome in the making: Junior perfectly demonstrates the Piriformis Syndrome Position! - There are many joints taken well beyond their strong middle range. Note especially the positioning of the right hip joint (see text above for precise description). Picture to Right: Healthy movement pattern: Approximates what we expect to see in a professional golfer. No joint is taken outside of its strong middle range. Note that the knee is bent, and this is the key to keeping the hip joint and surrounding muscle within its strong middle range.

1. The Gluteus maximus is slow to activate in this positioning, leaving the Piriformis as the sole muscle of control for the rotational movements of the hip.
2. The Piriformis muscle is being asked to do its solo effort working over its shorter range. (A muscle cannot achieve maximal strength outside of its "strong middle range").

The Posture Type that encourages the Movement Pattern of Piriformis Muscle Syndrome:- Sway back, Note:- The shoulders are behind a line through the back of the buttocks - hence the term "sway back". The knees are fully locked, or "hyper-extended", as are the hip joints. The Gluteal development is poor: This guy is "flat-assed"! Sway back is common in western peoples. It is not to the best of my knowledge seen in "primitive" peoples that walk bare foot and habitually deep squat(ref."Gluteus maximus - Beauty is in the eye of the beholder). The best way to cure the above postural faults is to engage the "Gluteus maximus": and to lean slightly forward: both at heel strike, and when you feel tempted to put your hip joint into the "Piriformis position".

Piriformis Syndrome Symptoms The patient with Piriformis Muscle Syndrome typically complains of tenderness in the buttock, and difficulty with prolonged sitting. A 20 minute brisk walk or run will cause an acute flare up for a number of days. There may be sciatic pain down the side of the leg and foot. There may also be pain and stiffness just above the sacrum and along its entire edge on the affected side. Diagram Right:- Red: regions of Buttock Pain; Arrow: points to top of Greater Trochanter (top of thigh bone); Black dots close to the pain patterns: Location of Piriformis trigger points (More info - Triggerpoint Therapy Workbook...).

Piriformis Syndrome Muscle Diagram The diagrams to the right show the Piriformis in relation to the Sciatic nerve. When the Piriformis muscle becomes inflamed and swollen, it may press on the sciatic nerve. Even if the piriformis does not press on the siatic nerve, the muscle and its trigger points can still be painfully acute (More info...Triggerpoint Therapy Workbook...). 88% of people have the whole nerve passing under the belly of the piriformis, while 11% of people have a branch of the siatic nerve passing through the belly of the piriformis. This anatomical variation finding bears almost no relationship at all as to whether or not you will develop sciatic nerve pain alongside your piriformis muscle inflammation(19).

• It is common in golfers, skaters, skate style cross country skiers (both of whom are pushing off a leg that is close to the faulty hip joint positioning that has already been described), and cross country runners who regularly run hills.
• Piriformis Syndrome may also be due to repetitive strain at your place of work.
• Sitting still for long periods potentiates the trigger points at the heart of your Piriformis Syndrome (more info, refer Triggerpoint Therapy Workbook...).
• Occasionally blunt trauma (a fall on the buttock) will trigger Piriformis syndrome. Obviously, this is not primarily due to poor patterns of posture and movement, but you are still likely to get some benefit from improving your patterns of use. (See comments re: surgery below).
• Sitting on your wallet or other sharp object (fat wallet syndrome).
• Sitting cross legged is also a suggested cause, but this may more likely be associated with the less widely recognised condition "posterior gluteus medius muscle strain". In fact, if you have had a diagnosis of Piriformis Syndrome and cannot identify the movement faults that I describe, you may have "Posterior Gluteus medius strain" instead of or in addition to your Piriformis diagnosis. Posterior Gluteus medius strain is more common than Piriformis syndrome, but usually is not quite so acute, and most people can live with the pain without seeking a cure. Posterior Gluteus medius strain is not the topic of this article, but note that gentle stretches, trigger point massage and Gluteus maximus activation will help (Further info.(Triggerpoint Therapy Workbook....

1. Avoid the "sway back" movement pattern - that is, lean forward a little, and do not let your knees lock. This will feel strange. In fact, it is easy to describe and very hard to do. The following two exercises will help.
2. Engaging Gluteus maximus at heel strike.
3. Performing the Runner's Squat to encourage Gluteus maximus engagement.

Diagram: The Supine True Piriformis stretch as advocated by Clair Davies(22). Standing True Piriformis Stretch: Lean against a wall and apply the same positioning (not illustrated).
Side lying True Piriformis Stretch in the "FAIR" position as advocated by Dr. Loren Fishman and associates (19).

Piriformis Syndrome Cure - Timing

Doctors who treat Piriformis Syndrome may advocate the following:-

• Trigger Point dry needling. I have had this done myself. It brought partial cure, but it neglected the fact that "trigger points breed trigger points". You need to attend to all trigger points in all the surrounding muscles, and not just stick needles in the most obvious one! Simple trigger point "ischemic compression" (pressure with thumb, elbow or tennis ball) followed by frequent gentle stretching and short walks is much more adaptable home remedy.
• Injections of Saline, local anaesthetic or corticosteroid in the trigger point are all workable treatments, but rely upon very precise application, which is not easy. The above comments about neglecting other trigger points apply.
• Botox injection causes flaccid paralysis of the muscle. It is injected into the body of the muscle and works by blocking all transmission between the motor nerve and the muscle. Note that this is not a quick cure.
The Botox paralysis in the hands of an experienced surgeon works for months, but note that this intervention is not fully reversible (the muscle will recover maybe 90% of its strength after 12 months), and should not be used as a "first" or a "stand alone" remedy. It takes 14 days for a difference to be noted, with measurable improvement 2 to 6 months later. (21).
• Piriformis muscle surgery to sever the muscle at its femoral attachment is rarely recommended nowadays, but may be appropriate when there has been a blunt trauma to the buttock with resultant scar tissue build up between the sciatic nerve and the piriformis muscle. Surgery is a last resort cure, and the surgeon should additionally offer "neurolysis" (freeing of the scar tissue around the sciatic nerve). In selected cases, an experienced surgeon achieves good rates of cure. (20).

I was performing some hard 3 to 6 minute intervals and just beginning some 15 to 30 second sprint intervals, both on roller skis and on the bicycle. And then that post exercise muscle ache arrived... and persisted... and worsened... It started during the build-up to a 42 km ski race. There is nothing so devastating for the competitive endurance athlete as unexplained pain. At its worst, 20 minutes of brisk walking would have me in agony for the next three days, and sitting for prolonged periods became an endurance exercise in pain.

• Pain over the buttock toward the greater trochanter.
• Lumbo-sacral pain and right sacro-iliac joint pain which was especially bad in the morning when getting out of bed. At its worst, putting my back into lumbar lordosis (lumbar extension) was excruciating.
• There was no sciatic pain, and the physiotherapist confirmed a negative slump test.

• What would happen if I put a heavy pack on my back and then did some roller skiing?

I hope that this story of Pirirformis Syndrome Cure is of benefit to you!

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Piriformis Syndrome has a Cure!