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Running Doc: Piriformis syndrome is a real pain in the butt

SUN;Watts, Susan

Stretching under the watchful eye of a physical therapist is one part of the rehab process for runners dealing with Piriformis syndrome.

Dear Running Doc:

I have a pain in my right butt that goes to my leg. My doctor says I have Piriformis Syndrome and he gave me a script for physical therapy. He did not tell me much else. Please fill me in. Thanks.

— Barbara F. New York City, NY

Barbara, Piriformis syndrome is — figuratively and literally — a pain in the butt, one that does an excellent imitation of the catchall ailment called sciatica. This pain can also show up in the lowermost portion of the back, which is why I’ve included it in back sections of my books. It can also show up as sciatic symptoms. Therapy is possible but tricky. Don’t try to diagnose and treat yourself. Since your Doc diagnosed it, we don’t have to discuss the entire differential diagnosis; we can talk only about Prirformis today.

Not long ago, for example, a 45-year-old patient of mine, came to me with what he described as a dull ache in the middle of one buttock. It hurt him to run, and the pain was especially sharp as he was going up hills or even walking up stairs. A string of doctors had pegged it as everything from a deteriorated spinal disc to that classic medical non sequitur, low back pain. None apparently suspected the piriformis, one of the muscles deep in the rear of the pelvis that helps turn your leg outward and that runs alongside, and occasionally surrounds, the sciatic nerve. Like any muscle, it can be overused and go into spasm, something that can also be triggered by tight hamstrings, prolonged sitting, or anything that twists that area. When that happens — and especially when the sciatic nerve becomes involved — the pain is dull, constant, and, it often seems, permanent.

Diagnosis is not difficult for anyone who has seen the condition before. One or two simple exercises with the patient on a table can pinpoint it, and trained fingers can actually feel down to sense the spasming muscle. But diagnosis is only the start of treatment, and therapy is far from simple, news that is always a big disappointment to experienced athletes who are accustomed to being sent home with a list of simple stretching and strengthening exercises and follow-up appointment.

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My patient, for example, listened to me for 20 minutes while I explained why he had to do exactly as I said. Yes, there would stretches, but they would have to be done with the guidance of a physical therapist. Beyond that, because the muscle is so deep and the spasm so hard to break, we would also need to gang up other available therapies, including PRP shots; a specialized technique called transverse frictional massage in which the massage is applied opposite the alignment of the muscle and tendon fibers; electrogalvanic stimulation of the tissues, where an electric current is applied to break up the pain messages in thenerves; ice; and ultrasound. The patient was supposed to follow up with me every four weeks during this physical therapy.

I heard from him nine months later when he called to tell me how disappointed he had been with my care. Why? Because he still hurt. Of course, it turns out that once he knew what was wrong with him, he’d decided to skip the PRP, skip all that therapy stuff, get some piriformis stretches out of a book, and get to work on his own.

A condition that’s commonly not correctly diagnosed in the first place, that requires otherwise intelligent athletes to follow orders like robots, and that’s all but impervious to anything but the full galaxy of therapies is as close as one can come to a sports medicine physician’s nightmare. But if you do what you’re told, it needn’t be your nightmare, too.

I hope this helps Barbara. Let us know how you are doing.

Enjoy the ride!

Lewis G. Maharam, MD, FACSM is one of the world’s most extensively credentialed and well-known sports health experts. Better known as Running Doc™, Maharam is author of Running Doc’s Guide to Healthy Running and past medical director of the NYC Marathon and Rock ‘n’ Roll Marathon series. He is Medical Director of the Leukemia & Lymphoma Society’s Team in Training program. He is also past president of the New York Chapter of the American College of Sports Medicine. Learn more at runningdoc.com.

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