Exercises and Explanation of Sciatica and Piriformis Syndrome

Ok, so you just got a Sciatica diagnosis or maybe it was a Piriformis Syndrome diagnosis? All I know is you probably don’t care what it is called, but you do want it to go away.

The first problem is that people interchange Sciatica and Piriformis Syndrome like they are the same thing… they aren’t.

Piriformis Syndrome is a TYPE of Sciatica.

Most articles and videos will mistakenly lead you to think that the key to relieving “Piriformis Syndrome” or “Sciatica” requires plenty of stretching, foam rolling or jamming a tennis ball into your butt muscles. It is actually quite the opposite. But when this does work, it is usually another diagnosis we are dealing with. One that I will talk more about later in this article.

What Is Sciatica? (What is a Sciatica Diagnosis?)

Sciatica is a term used to describe pain, numbness or tingling anywhere along the Sciatic Nerve.

It is common for people to report a deep burning pain at the buttock or pain that travels (radiates) down the leg and sometimes into the bottom of the foot.

Irritation at the Sciatic nerve is often because of compression (or pinching) of the nerve combined with inflammation. The inflammation piece is important. Compression by a nerve alone is relatively common and does NOT mean you will have pain.

Now let’s clear up some of the confusion.

When your Doctor gives you a “Sciatica Diagnosis” she is usually implying that the Sciatic nerve is being compressed (pinched) and inflamed at the LOWER BACK.

Pictures below show the Sciatic Nerve, as well as compression of the nerve by a disc at the lower back (more on that to come).

When Your Doctor gives you a “Piriformis Syndrome Diagnosis” she is implying that the Sciatic nerve is being compressed by the Piriformis muscle.

Now here is the real dilemma…Some Doctor’s get really loose with the term Sciatica and Piriformis Syndrome.

Instead of doing a thorough evaluation to try to figure out where and if the Sciatic nerve is being compressed/inflamed they will call ANY radiating pain down the leg or deep buttock pain Sciatica… or Piriformis Syndrome. It depends on which one is their favorite word. This is incorrect and leads to confusion. 

Sciatica (Lower Back) VS. Sciatica (Piriformis Syndrome)

Sciatica (Lower Back)

Sciatica that results from a pinched nerve at the back is likely because of a disc herniation or disc bulge at the lower back (a.k.a lumbar spine, usually at L4, L5, S1 or S2). Sometimes called a “lumbar radiculopathy” (lumbar= lower back, and radiculopathy=radiating pain).

This generally happens to people in the first half of their life. This form of Sciatica is often triggered by repeated rounding and twisting at the lower back with static postures and with bending or lifting (see pictures below).

With Sciatica, many people in an effort to relieve their pain actually worsen it with sit ups, crunches and aggressive stretching of the lower back. It starts to create the Jelly Donut Effect that we describe below.

Jelly Donut Analogy

Pressing on the front of a jelly donut will often cause the jelly to “bulge” or squirt out the back. Similarly, when you round your back with sitting and standing, or bending and lifting you will start to weaken the disc. This allows the gel like material in the disc to bulge or “squirt” out (disc herniation) the back side of the disc, which will press on the nerve.

In some scenarios, especially in flexible individuals with a history of participation in gymnastics you might find a spondylolisthesis which causes compression on the nerve. This is basically when a fracture causes one vertebrae to slide forward or backward (also narrowing the space where the nerve comes through).

Sciatica (Piriformis Syndrome)

Let me start by saying, “Piriformis Syndrome is kind of like a Unicorn or maybe an Alien.” We really don’t know to what extent it actually exists. It is very challenging to diagnose Piriformis Syndrome. Even with the use of fancy medical imaging and tests.

A true Piriformis Syndrome appears more common after trauma or injury to the buttock region, such as a fall. It is hypothesized that inflammation and/or muscle spasms at the Piriformis muscle cause irritation to the Sciatic nerve.

In some instances, the Sciatic nerve may be injured by something else in the vicinity of the Piriformis muscle. It is possible for the Sciatic nerve to be compressed at the Sciatic Notch (see below) by tumors, fibrotic scarring or compression of the Sciatic nerve by local blood vessels that run along the Sciatic nerve (i.e. hematoma or aneurysm).

It is also possible for fractures in the pelvis near the piriformis muscle to trigger an inflammatory response that causes Sciatica. Something to keep in mind if you have had any trauma around the pelvis from a fall.

Why The RIGHT Diagnosis Makes All The Difference

In reality, whether it is Sciatica from the back or Sciatica from the Piriformis the treatment is not much different.

Most articles and videos will mistakenly lead you to think that the key to relieving “Piriformis Syndrome” or “Sciatica” requires plenty of stretching, foam rolling or jamming a tennis ball into your butt muscles. It is actually quite the opposite.

A truly irritated nerve DOES NOT LIKE to be aggressively stretched and or compressed by a ball, hand, knee, or any other inanimate object.

So we all know someone that swears by stretching to relieve Sciatica and Piriformis Syndrome. You are probably asking, “Then why did stretching help them?”

Enter Option 3: “Tight Butt Syndrome”

If you find relief from stretching your butt muscles and some deep soft tissue work, what you likely had was “Tight Ass Syndrome.” I borrowed that phrase from Kelly Starrett, Physical Therapist and Strength Coach.

What is Tight Butt Syndrome?

It’s exactly what it sounds like. Tight butt syndrome is stiffness or tension in your butt muscles.

“Your Butt Is A Non-Weight bearing Surface.” -Kelly Starrett

Sitting on it all day will start to create stiffness and tension in the butt muscles, similar to standing on your feet all day. Let’s compare our hands to our feet for a second. We don’t weight bear through our hands so they tend to be soft and pliable. Our feet on the other hand are more stiff and calloused.

Besides stiffness in the butt muscles, the side effect of a lot of sitting is reduced blood flow in the butt region, reduced ground substance (gel like material around the muscles) and more trigger point development in the butt muscles. These trigger points can actually cause pain at the butt and down the leg that resemble Sciatica.

Picture of trigger points in Gluteus Minimus muscle that commonly create referred pain down the leg. You can actually try pressing on this muscle or muscles near it to see if it re-creates a similar pain. 

Fun Fact: Nerves actually have blood vessels. When we restrict blood flow to the Sciatic nerve it can actually create Sciatic like pain in the butt and leg.

Fun Fact: What is a trigger point, you ask? A trigger point is a hyper-irritable nodule that develops in your muscles that can cause local and referred pain. They can even cause a disruption in how well your muscle works. They are common and we all have them.

Similarities: Sciatica, Piriformis Syndrome and “Tight Butt Syndrome” 

• Buttock Pain
• Pain Aggravated with Sitting
• All feel relatively good with stretching (in the moment, if done gentle)

…. Most people will feel great with stretching despite the diagnosis because of a nice stretch reflex that occurs with stretching.

It can also temporarily “hide” the pain, kind of like rubbing an area that hurts.

However, if your pain keeps returning despite stretching and exercise, it’s more likely that you have some form of Sciatica (triggered by compression of the Sciatica nerve at the lower back or Piriformis).

Treatment For Tight Butt Syndrome

If the exercises below work it is likely that you have Tight Butt Syndrome. These exercises will help counteract the side effects of sitting. These exercises will also help restore blood flow and elasticity to the muscles in the butt region. As well as reduce trigger points in the muscles, in turn reducing pain.

If the following exercises do not work or have not worked in the past you likely have Sciatica. In which case we will go with a different treatment plan (in the next section).

Read below or download the PDF here Home Exercise Plan Tight Weak Butt

You can also see the exercises here. Enter code: SUEV838

Sciatica Treatment (Low Back or Piriformis Muscle)

This one is trickier. It becomes more about avoiding certain postures and movements that trigger your pain.

The goal is to reduce inflammation first and foremost. That is the key to relieving Sciatica pain.

Second, we attempt to remove compression on the nerve. We need to be very cautious and calculated with how much we do though. It is like playing a game of Don’t Wake Daddy. Too much and we could easily aggravate an already angry nerve.

Fun Fact: Many of us have “tight” Piriformis muscles and pinched nerves in our back without any pain. Inflammation combined with compression is usually the problem.

So with that said, if you truly have Sciatica (regardless of the problem site) your primary goal should be reducing inflammation.

Instead of always trying to find the “right exercise” to put the fire out just STOP lighting the the fire. The flame is often started by some of the errors below.

1. Sit with Good Back Alignment and Sit Less (when you do sit use a cushion or pillow under your butt)

2. Sleep In Good Alignment

Notice how a pillow or small towel is being used to help prevent bending at the spine. The towel is being used to support the natural curvatures in the spine. The pillow between the knees helps keep the hips in a more comfortable position and reduces compression on the Sciatic nerve at the buttock region.

3. Bend and Lift with Good Alignment

Regardless of the object you are attempting to pick up you should not be rounding at your back (Picture A). You need to perform a squat (Picture B) or a “golfers pick up” instead. This imposes much less stress on the back and Sciatic Nerve.

4. Exercises For Sciatica

The video below with discuss most of the exercises in this section.

The exercises below allow you to gently restore movement at the low back with minimal stress and strain. Spending time on your stomach and progressing to being propped on your elbows (when you are ready) can help get the “jelly back into the jelly donut.” Being on your stomach also tends to reduce tension in the Piriformis muscle.

Lumbar Decompression Exercise (a.k.a Traction)

Lumbar decompression, sometimes called traction, can be done without equipment. This technique takes a little practice for some people, but can do wonders for relieving a pinched nerve at the lower back. Dr. Stuart McGill is a brilliant Biomechanist. Check out his video below.

Walking

In the video above titled “Best 3 Exercises For Sciatica” we discuss the importance of good posture with walking and a good arm swing from the shoulder joints. You may also find that brisk or fast paced walking is less painful than slow walking.

Do not walk through pain. If you can only tolerate walking for 30 steps, you will walk 29 steps and then rest. Keep performing short frequent bouts of walking until you can walk continuously for 30 minutes pain-free. Try to stay on flat ground until you can tolerate 30 minutes of walking pain-free.

Nerve Floss Exercise

When flossing your teeth, the goal is clearly to remove any gunk between your teeth. With Nerve Flossing we attempt to help the nerve slide better by removing any areas of friction from compression on the nerve. In this case that would be disc material or compression at the piriformis muscle.

This exercise can be helpful for Sciatica, BUT if done incorrectly or too soon it has the ability to worsen Sciatica. I see this exercise being prescribed online without enough guidance. In many cases I will not have patients do this exercise at home until they have demonstrated the ability to do it without recreating pain.

As you do this, picture one long nerve that runs from the back of your head, all the way down to the bottom of your foot. You are NEVER putting tension on the nerve, you are gently flossing the nerve by putting tension on one end as you take tension off the other end. This exercise should not produce pain and in most cases should not even produce a stretch sensation.

Medical Imaging and MRI

First off, X-Ray is not a valuable tool when determining the source of Sciatica pain. However, insurance companies generally will not provide MRI until you have attempted conservative care.

You should attempt conservative care before requesting an MRI for a couple reasons.

1. Many people have all kinds of findings on their MRI report, even if they don’t have pain.
2. Earlier MRI often leads to an increased rate of invasive and often un-necessary medical procedures.
3. If you have good days and bad days MRI is not necessary. You need to learn how to identify postures and movements that trigger your pain and then eliminate them.

Red Flag Symptoms on the other hand often warrant immediate medical attention Red Flags include, but are not limited to trauma, bowel/bladder incontinence, numbness in saddle region, onset of symptoms without cause with history of cancer OR unable to find ANY position that brings relief. Pain in combination with fever or recent infection also warrants immediate medical attention.

Nerve Conduction Study

To more accurately determine whether or not the Sciatic nerve is injured, and at what location, a nerve conduction study and/or an EMG may be useful. However, I recommend a rehabilitation approach first. This test is reserved for failed conservative care.

What Medical Provider Should You See First?

As long as you are not experiencing any of the red flags mentioned above I would recommend you see a skilled physical therapist or chiropractor that is well versed in manual therapy and exercise prescription.

Soft tissue treatment and spine adjustment might serve some benefit, but they will be short lived without an understanding of how to adopt good spine alignment on a daily basis, at rest and with movement. Not knowing how to sit and stand with good posture or squat is going to lead to re-occurring issues.

If you have gone this route without success the next step is to see an Orthopedic Doctor.

 Sciatica Medications and Sciatica Injections

A time and place certainly exists for medications. Like mentioned above, Sciatica is often a combination of compression on the nerve and inflammation. Removing the source of the inflammation should be priority number one. This does NOT mean that medication is a must. Remember, instead of always looking for a way to put the fire out (medication and exercise) STOP lighting the fire.

Too many people pop Advil, Tylenol or Aleve while continuing to adopt poor posture and bending with a rounded back. Pain killers (opioids) or nerve medications (i.e. Gabapentin, Lyrica) may be helpful in the short term, but they are also dulling the pain allowing you to get away with pain provoking postures and movements. They also lower your pain tolerance over time. Getting the nerve drunk and then proceeding to irritate it with bad posture and movement is not the best idea.

Steroid packs (i.e. Prednisone) and steroid injections (i.e. Epidural) have shown to be beneficial for reducing inflammation local to the site of injury. You need to be cautious. Injection at the spine or piriformis has the potential to make symptoms worse if done poorly. It can be helpful in the short term, but it will be short lived if you don’t learn how to avoid postures and movements that trigger pain.

Fun Fact: An injection is not always a reliable diagnostic tool for Sciatica. Regardless of whether your Sciatica is from the lower back, Piriformis or some other inflammatory cause, injection anywhere along the Sciatic nerve has the potential to diminish pain temporarily.

Conclusion

Here is a quick recap.

1. Piriformis Syndrome is a Type of Sciatica

2. Sciatica can be cause by compression anywhere along the Sciatic nerve. With Piriformis Syndrome, the Sciatic nerve is being compressed by the Piriformis muscle. This tends to be more common after trauma to the buttock region.

3. Sciatica also commonly occurs because of a pinched nerve at the lower back.

4. Sciatica pain is often because of inflammation of the Sciatic nerve. Compression of the nerve alone is not enough to trigger pain. So try to resolve the inflammation the best you can. Instead of trying to put the fire out stop lighting the fire!

5. The real culprit with butt and leg pain is often “Tight Butt Syndrome.” This is likely what MOST people are actually suffering from, which is why stretching and foam rolling do the job. True Sciatica will not resolve with stretching alone and it may even make it worse.

Looking for a more in-depth solution to Sciatica? Check out our free online course.

Other Common Questions Answered:

“Can Sciatica Cause Foot Pain?”

Yes, pain or sensory changes might show up at the bottom of your foot. Symptoms can show up anywhere along the Sciatic nerve or in Dermatomes associated with the Sciatic Nerve (L4, L5, S1, S2).

Pain or sensation changes can show up in the regions labeled L4, L5, S1, S2. These are the spinal levels that connect to the Sciatic Nerve. (Picture courtesy of Healthline).

“Can Sciatica Cause Foot Numbness?”

Yes. Pain, numbness, tingling, pins and needles, and prickling are just some of the symptoms that you might feel in regions along the Sciatica nerve.

“How long does Sciatica take to “heal”?”

Healing and pain are two totally different things. Healing can take months to years. Pain reduction might be only days if you apply the right treatment. Which typically entails avoiding postures and movements that trigger pain.

“Is Sciatica or Piriformis Syndrome causing my back pain?” (left sided or right sided back pain)

Back pain is often a result of an injury to the low back (lumbar spine). In the first half of life this pain is often because of an injury to one of your discs (disc bulge or herniation). Depending on where the disc is injured you may feel pain on your left or right side.

Sciatica often occurs because of a disc injury that causes compression of the Sciatic nerve with inflammation. Piriformis Syndrome can trigger Sciatica as well, but it is not responsible for back pain. Back Pain with Sciatica symptoms quickly lead me to believe that your Sciatica is being triggered by a back injury, not Piriformis Syndrome.

“Can Sciatica Cause Calf Pain?”

Yes, the calf is a muscle that the Sciatic nerve has connections to. So pain could show up here.

“Can Sciatica Cause Knee Pain?”

Yes, it can. This is not as common, but it is a possibility do to the proximity of the nerve to the knee. Often times, the pain and weakness that occurs because of Sciatica causes the knee to become irritated because of modifications how you move.

“Can Sciatica Cause Leg or Calf Swelling?”

This is also possible, but uncommon. Nerve irritation may trigger an inflammatory response anywhere along the nerve, which might cause swelling. However, my concern with swelling in only one of your limbs or calf would be deep vein thrombosis, which requires an immediate visit with a physician.

“Can Sciatica Cause Groin Pain?”

This is uncommon. Pain is often from the surrounding muscles or irritation to the hip joint. In some cases injury at the lower back local to L1, L2, L3 or L4 may cause referred pain to the groin region (recall that the Sciatic nerve is innervated by L4, L5, S1 and S2). Obturator nerve entrapment is also a common cause of groin pain.

“Can Sciatica Cause Constipation?”

If you are taking pain killers you may be experiencing constipation. With compression of nerves at the lower back a warning sign is actually bowel incontinence rather than constipation, and this requires immediate medical attention.

Resources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2997212/?hc_location=ufi

Click to access jathtrain00034-0008.pdf

Click to access Piriformis-Syndrome.pdf

https://www.ncbi.nlm.nih.gov/books/NBK507908