A Pain in the Butt
Prevention and Treatment of Piriformis Syndrome
By Cathy Fieseler
As featured in the June 2005 issue of Running Times Magazine 

     You're 12 weeks into your marathon training program; while out on a long run, you develop a sharp pain in your buttocks. As you continue to run, the pain persists. Your hamstrings feel tight and even a little sore, though by slowing the pace the symptoms subside a little, and you finish the run. While sitting at your favorite post-run hangout, there is a tingling sensation in the back of your thigh and calf.

      You’ve just been introduced to your piriformis muscle. This muscle arises from the sacrum, passes through the sciatic notch (an opening in the pelvic bone) and attaches to the bony prominence on the side of the thigh (greater trochanter). The piriformis plays a role in the outward rotation of the hip. The sciatic nerve is formed by five nerves exiting from the spinal cord; it typically passes through the notch in front of the piriformis. In approximately 15 percent of the population, the nerve passes through the muscle. 
 

  

     Problems occur when the piriformis becomes inflamed. This may be due to direct trauma (falling on your butt), overuse, or a sudden, forced rotation of the hip, which may occur when running on an uneven surface. The inflamed muscle may cause pain in the center of the buttock or may compress the sciatic nerve causing pain, aching or tingling in the leg. Pain may be increased by sitting, climbing stairs, or squatting. Deep palpation of the center of the buttocks will cause pain, as will sudden stretches of these muscles. Initially you can run through the pain, but in many cases, symptoms become severe enough to restrict activity. The muscle tightens and may even spasm during activities, which can cause an alteration in gait. The affected side of the pelvis is pulled upward, creating a functional leg length difference; stride on the affected side is shortened. These alterations in gait can cause a number of overuse injuries due to poor biomechanics.

Why Me? 

     Why did you develop this problem? A common finding is tight hip adductor muscles (these are the muscles along the inner aspect of the thigh that pull the leg inward),  which override the hip abductors (muscles along the outside of the thigh that pull the leg outward); the piriformis acts as a hip abductor. If your foot excessively pronates when pushing off, your leg rotates inward; the piriformis acts as an external rotator of the hip (turns outward) and contracts in reaction to each push-off. 

     Not all pain in the buttocks and legs is due to piriformis syndrome; diseases of the lumbar spine, such as a ruptured disc, and dysfunction of the sacroiliac joints are just a couple of the common causes of pain in this region. Stress fractures of the sacrum or pelvis can cause recalcitrant pain in this region. 

     If you are avoiding the doctor, you will need to work on stretching your piriformis muscle. One method of doing so is to lie on your back, bend the affected knee and hip. Grasp your knee with the right hand and push toward your left shoulder. Grasp your right ankle with your left hand and rotate the leg inward.  To stretch the hip adductor muscles, sit on the floor and put the soles of your feet together, holding your feet with your hands. Very gently pull yourself forward until you feel a stretch, not pain, in the groin muscles. Make sure to lean from the hips and lower back, not the upper back and neck. Hold this stretch for 20 to 30 seconds. Work on stretching all of the muscles of the hip, as they will have been affected by the alteration in gait.

      Strengthening the hip abductors is very important. Lie on your side and lift the upper leg 25 to 30 inches, making sure that your pelvis remains perpendicular to the floor. Hold this position for 10 seconds. Perform 10 repetitions at the start and gradually increase the number over time. As you become stronger, you may wear an ankle weight while performing this exercise. You can work other major hip muscles in a similar manner, lying on your back for the flexors, on your abdomen for the extensors (upper hamstrings) and on your side with the upper (non-exercise) leg moved back for the adductors. Depending on the severity of your symptoms, you may be able to continue running, but will need to decrease your mileage by at least 50 percent. Avoid speedwork; you should not run hills or on uneven terrain. 

Getting Help

If you are working on stretching and strengthening, but running has become progressively more difficult, you should see a local sports medicine specialist. The evaluation should reveal a tender area in one buttock. Provocative stretches will cause pain, possibly even symptoms radiating into your leg. Evaluation of your lower back  and hip will be normal; X-rays will be unremarkable. If nerve studies are performed (not usually ordered), they are typically normal; if your hip is manipulated during this test, abnormal results may be seen. Other tests, such as an MRI, may be used to help rule  out other sources of your pain, but results usually are normal with piriformis syndrome.

     Once the diagnosis is made, what next? Treatment may include a combination of physical therapy (exercises and modalities, such as ultrasound), anti-inflammatory medications, deep tissue massage, and possibly a cortisone injection. You may need to stop running and perform cross training that does not cause pain. Once symptoms subside, continue the exercises as you gradually increase your training. Once you have re-established your base, you can slowly add hills or speed work. 

     If symptoms are not improving despite all of these measures, surgical release of the piriformis may be necessary; other muscles will take over the function of the piriformis. The majority of patients have pain relief following this surgery, but this treatment is a last resort.

      Be smart with your training; maintain good strength and flexibility of your trunk and hip muscles to decrease the chances of an introduction to your piriformis.

    EVANSVILLE, IN - The Greater Evansville Affiliate of Susan G. Komen for the Cure will be holding its 11th annual Komen Evansville Race for the Cure event on Sunday, Sept. 21st at Eastland Mall. 
 

 

     Pick up your t-shirts and bibs, or register for the Race on Friday, Sept. 19 from 10:00 a.m. to 7:00 p.m. and Saturday, Sept. 20 from 10:00 a.m. to 5:00 p.m. at Eastland North, 4301 Vogel Road, or come early on race morning to the Late Registration Tent starting at 6:30 a.m.  You can still register at these same times and places!  Limited parking will be available at the Mall. Additional free parking is available at Roberts

Stadium, on the armory side, with free round-trip shuttle service from 6:30 am to noon.

             The event will be held rain or shine with the following schedule:

            6:00 a.m.        Pre-Worship Service Music
            6:30 a.m.        Late Registration/T-shirt Pickup
            7:00 a.m.        Service of Hope
            8:00 a.m.        Survivor Recognition Program
            8:30 a.m.        Aerobic Warm-Up
            9:00 a.m.        5K Run/Walk
            9:15 a.m.        1-Mile Family Fun Run/Walk
            10:30 a.m.      Awards Ceremony

      Seventy-five percent of the funds raised at this annual event will benefit our local community by providing mammograms, treatment and educational programs. Twenty-five percent is forwarded to our national office in Dallas, Texas to fund innovate breast cancer research programs worldwide.

      Susan G. Komen for the Cure began as a promise between Nancy Goodman Brinker and her sister Susan Goodman Komen, who died from breast cancer at age 36.  Susan G. Komen for the Cure has played a critical role in every major advance in the fight against breast cancer over the past 25 years - transforming how the world talks about and treats this disease and helping to turn millions of breast cancer patients into breast cancer survivors. The five-year survival rate for breast cancer, when caught early before it spreads beyond the breast, is now 98 percent (compared to 74 percent in 1982).

     For more information contact the Komen Greater Evansville Affiliate office at 812.962.2202 or email info@komenevansville.org or visit our website at www.komenevansville.org.

Sheila Seiler, Executive Director Susan G. Komen for the Cure Greater Evansville Affiliate 4424 Vogel Road, Suite 205 Evansville, IN 47715 www.komenevansville.org Telephone:  812.962.2203 Fax:  812.962.2204 Our vision:  a world without breast cancer

Go to any pre-race party or post-run potluck and you'll see legions of runners twirling forks in huge plates of spaghetti. And why not? Carbs are king, right? Except you may be missing out on another essential running nutrient, especially if you've been following the government's dietary guidelines. The International Society of Sports Nutrition (ISSN) released a position paper by nine researchers in the field of protein and exercise and found that people who engage in regular exercise, don't just need more calories than desk jockeys--they need more protein.

"With every footstrike, a runner carries two to seven times his or her body weight," says Douglas Kalman, Ph.D., R.D., who has done extensive research on the effects of protein in athletes. "Protein is what keeps your body healthy under all that strain." Adequate protein intake accelerates muscle growth and speeds recovery by helping rebuild muscle fibers stressed during a run. Since protein helps muscles heal faster, runners who consume the right amount are less likely to get injured. The reverse is also true, according to the authors of the ISSN paper: Athletes who get insufficient amounts of protein are at a higher risk of injury.

What's more, high-protein intake has been shown to help maintain a strong immune system. "After an intense bout of exercise, your immune system is weakened for about four to five hours," says Richard Kreider, Ph.D., one of the ISSN study's authors and head of the Exercise and Nutrition Laboratory at Baylor University. "Protein stimulates white blood cells, which helps shield against upper-respiratory problems." Military research studies show that Marines who ingested high amounts of protein had fewer medical visits than those with lower protein intake.

Just How Much? The USDA's Recommended Dietary Allowance (RDA) for protein is .8 grams per kilogram (or .36 grams per pound) of body weight. But that's not enough for athletes, according to the ISSN, which says endurance athletes like runners need 1.0 to 1.6 grams per kilogram a day (or .45 to .72 grams per pound). That translates into 75 to 120 grams of protein daily for a 165-pound runner. Don't worry about "overdosing" on protein. While some reports claim that high-protein intake is linked with kidney problems and calcium loss, the ISSN says it's not a concern for healthy athletes.
 

Lean meats and other animal products, like eggs, milk, and whey (a by-product of milk), pack a lot of protein. Four ounces of chicken breast, for example, contain about 32 grams of protein. The fat in food interferes with the rate of protein absorption, so limit your intake of high-fat foods, such as rib eye or prime rib. Vegetable-based sources, such as beans, lentils, nuts, seeds, and soy, aren't as protein-dense--a half cup of black beans, for example, has about 8 grams-- and they fall short on all nine essential amino acids, the chemical building blocks of protein (the exception is soy). Runners who avoid animal products can make up for this deficit by eating a variety of the most protein-rich vegetables and grains, such as soybeans, oats, and quinoa. "Not all the protein in a food is easily absorbed by your body," says Kalman. "But you'll probably get enough as long as you eat a lot of different kinds of food."