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VeloNews Training Center: Piriformis Syndrome and cycling

  • By Jason Glowney, MD, CAQSM. Boulder Center for Sports Medicine
  • Published May. 12, 2011
  • Updated Dec. 5, 2012 at 3:52 PM EDT
BCSM FAIR Stretch – Jason Glowney demonstrating (Flexion/Adduction/Internal Rotation)

Periformis Syndrome

Dear BCSM,
I have been riding for about 20 years and have recently developed sciatic pain that radiates down the back of my left leg. My MD thinks it’s something called Periformis Syndrome.

I’m wondering whether cycling over the years, perhaps on a bike that wasn’t perfectly fit for me, might have contributed to this condition. Is there any evidence that cycling might be an underlying cause of Periformis Syndrome? And lastly, what treatments would you recommend for it? Thank you!
— Rich

Dear Rich,
Piriformis Syndrome was first described by Robinson in 1947 and involves a constellation of symptoms including low back/buttock pain that may radiate down the back of the thigh, pain that is worse with prolonged sitting and tends to be exacerbated by activities involving forward lean at the hips (cycling/running). Recent data suggest that it may account for up to 6-8 percent of lowback/buttock pain in the United States. There still exists debate as to if Piriformis Syndrome is a really a distinct clinical entity and if it is secondary to actual compression/irritation of the sciatic nerve as it passes in the vicinity and or through the piriformis muscle or if it’s related simply to myofascial pain that originates from the muscle body itself.

From an anatomic standpoint the piriformis muscle originates from the second through fourth segments of the sacrum and travels inferior-laterally to insert on the superior aspect of the greater trochanter of the femur. When the leg is extended the piriformis acts more as an external rotator of the hip; with the leg flexed it contributes more to hip abduction.

Many clinicians voice concern that piriformis syndrome is being over diagnosed and a patient’s symptoms may relate to other issues such as lumbar disk disease, facet arthropathy, sacro-iliitis, ischial bursitis, and or proximal hamstring syndrome among other things. Assuming your doctor has done a thorough assessment and is correct with his/her diagnosis, cycling has been known to manifest piriformis syndrome symptoms. Some cyclists may present with symptoms after falls from pelvic muscle/joint imbalance and dysfunction. Others present with symptoms more related to an overuse phenomenon.

Bike fit is an important evaluation step in the plan to pinpoint causes of Piriformis Syndrome and to help elicit relief. Two common issues with fit that may relate are the saddle itself and the hip angle the rider carries. A saddle that is ill-fitting and does not support the sit bones properly can irritate the piriformis/sciatic nerve as can a saddle that initially worked well but has become worn. The acute hip angles seen with a rider in the drops or an aggressive aerodynamic position on a time trial bike can also work to aggravate the piriformis, especially with higher intensities.

From a functional standpoint, tightness in the hip flexors may occur from excessive volumes of forward lean from sitting/riding and can contribute to muscular imbalance, in particular weakened gluteal muscles. Many clinicians believe that with weakened gluteals the piriformis may tend to be overworked as it tries to compensate and may over time become aggravated.

Your road to recovery should include a bike fit evaluation by a professional who is adept in musculoskeletal issues, NSAIDs and/or medications suited to decrease nerve pain (e.g. gabapentin) for acute/severe pain and the guidance of a well-qualified physical therapist.

With physical therapy stretching of the piriformis, working out core muscle weakness/imbalance issues and myofascial release will be some of the main things you will get started with. In recalcitrant cases dry needling, corticosteroid injection and more recently even botox injections are being used to help relieve symptoms.

For do-it-yourself at home suggestions, I would sit on a tennis ball and find the tender point of the piriformis body and press deeply into it and move up and down slightly by one inch or so for 30-45 seconds. Doing this too aggressively or for too long can cause lasting soreness, so be careful.

From a stretching standpoint you will want to mimic flexion, adduction and internal rotation at the hip to elongate the piriformis. The way I show my patients to do this is to sit on the floor, flex the affected hip to 45 degrees, flex affected knee to about 100 degrees, abduct the non-affected leg about 20 degrees from midline, internally rotate the affected leg so the foot flairs out and inner aspect rests on the floor, shift the weight of your torso over to the affected side and apply slight pressure to the outside of the knee in a medial direction. Totally relax the muscles of the buttock and you will start to feel the piriformis stretch deeply when done properly. (See photo!) Go lightly as this will put some slight strain on the medial ligaments of the knee if done too aggressively.

This is a very different stretch from the piriformis stretch that many do, where patients are on their backs with legs in a figure-four position. This one will actually abduct the hip and externally rotate it, causing the muscle to likely shorten instead of elongate as the piriformis is really more of an external rotator/abductor of the hip.

Hope this helps and we wish you a speedy recovery!

—Jason Glowney, MD, CAQSM
Boulder Center for Sports Medicine

Have a question for VeloNews Training Center? Send it to TrainingCenter@competitorgroup.com

Dr. Glowney is at Boulder Center for Sports Medicine and is Board Certified in both Sports Medicine and Internal Medicine. He is also a former USA Triathlon All American and an avid competitive cyclist.

Boulder Center for Sports Medicine was founded by Andrew Pruitt, EdD, PA-C, in 1998. For the past 12 years BCSM has been providing athletes from around the world with the highest possible level of care. BCSM offers a wide range of services, including Orthopedic Clinics, Physical Therapy, Expert 3D Bike Fitting, Running Gait Analysis, Coaching & Training, Nutrition Services, Performance Testing, and more. For more information, visit www.bch.org/sportsmedicine, or call (303) 544-5700.

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