Is running becoming a pain in the butt?
By Michael Gordon, MD, Milwaukee Orthopaedic Group, Ltd. Orthopedic Surgery, Sports Medicine Fellowship
Piriformis Syndrome, an uncommon cause of pain in the gluteal (i.e., "butt") region, has sparked numerous discussions on the Badgerland Striders' Website. Located in the back of the hip, the piriformis muscle runs between the pelvis and the posterior aspect of the thigh bone (i.e., "femur"). This muscle functions as an external rotator of the hip helping to turn the foot outward.
Running directly underneath the piriformis is the sciatic nerve. This nerve serves the muscles of the back of the thigh, as well as the entire lower leg. It's also the source of the term "sciatica," a reference to the pain that radiates down the back of the leg and is frequently associated with low back problems. Oftentimes, when the piriformis muscle gets inflamed, it can irritate the neighboring sciatic nerve and mimic the symptoms of sciatica.
Piriformis Syndrome is classically described as a direct trauma to the back of the hips through an injury to this muscle. It can also occur in active individuals when a muscle imbalance across the hips leads to inflammation of the muscle. In particular, the repetitive impact of running can easily convert a slightly inflamed muscle into a severely symptomatic Piriformis Syndrome.
The symptoms of Piriformis Syndrome include pain in the back of the hip/upper thigh, as well as a sense of pain or aching that radiates down the back of the leg. In addition, patients may note that sitting on a hard surface can exacerbate their symptoms. Upon examination, the classic finding of this condition is decreased hip internal rotation with the ability to recreate the pain with this maneuver.
It's important to distinguish Piriformis Syndrome from a low back problem or a herniated disc that can lead to sciatica. These conditions are also characterized by low back pain with the possibility of pain radiating down the back of a leg. Specifically, any changes in strength or regions of numbness could be signs of a more serious lumbar spine problem.
The treatment for Piriformis Syndrome focuses on decreasing the inflammation, stretching out the muscle, and correcting any muscle imbalances. A short course of anti-inflammatory medications is recommended as a 1st step provided there are no medical contra-indications for the particular patient. Next, a stretching regimen, which works the muscles about the hip, and in particular the "short external rotators", is emphasized. Finally, a good biomechanical and gait evaluation should be completed to locate and ultimately correct any muscle imbalances that may exist.
If a patient has symptoms that are resistant to these treatments, then further investigation may be needed to confirm that the diagnosis is correct. Additional testing can include nerve conduction studies (checking for a pinched nerve), MRIs, and a diagnostic injection of a local anesthetic into the region around the piriformis muscle. If the diagnosis is confirmed, then the next level of treatment includes a cortisone injection along the piriformis muscle or possible surgery to partially release the muscle. Since there are several other muscles that serve a similar purpose, the piriformis can be partially cut without much consequence.
A fairly rare condition, Piriformis Syndrome can be a difficult diagnosis to make. Fortunately, it generally responds very well to conservative treatment and doesn't keep runners off the road for too long. If you're experiencing similar "pain in the butt" symptoms, have it checked out by a sports medicine physician or with a free injury evaluation at the Aurora Sports Medicine Institute.
An orthopedic surgeon with a fellowship in sports medicine, Dr. Michael Gordon is a partner with Milwaukee Orthopaedic Group, Ltd. Office phone number: (414) 276-6000.