Integrative therapies for piriformis syndrome

Photo Cred: Polina Tankilevitch/Pexels

By Bill Reddy, LAc, DiplAc

Piriformis syndrome and sciatica are common among patients, though conventional treatments offer limited solutions. Patients diagnosed with piriformis syndrome may benefit from an integrative approach, using a combination of stretches, exercises, manual therapies, and nutritional considerations. 

Sciatic nerve irritation stems from mechanical compression, such as a lumbar disc herniation, spinal stenosis, spondylolisthesis, foraminal stenosis, degenerative disc disease, or piriformis syndrome. In rare occasions, subdural hematomas or pelvic tumors will displace tissue and press on the nerve, causing pain and paresthesia. Typically, patients will have confirmation through diagnostic imagery, however, roughly 50 percent of people who have disc herniations are asymptomatic, and many practitioners will immediately blame the disc for the current discomfort, which is not unreasonable since 90 percent of sciatica is caused by disc herniations.

Piriformis syndrome is not considered true sciatica, but rather mimics the symptoms, with pain in the buttock region that may radiate into the thigh, calf, or foot sometimes accompanied with paresthesia, numbness, or weakness. The sciatic nerve commonly passes under the piriformis muscle, and in a small percentage of the population, will pass through the muscle. When the muscle is tight or in spasm, it will press the nerve against a bony prominence or squeeze the nerve.

To test for piriformis syndrome, practitioners should have the patient place their affected leg’s ankle on the opposite knee when sitting in a chair. If the knee elevation is higher than the unaffected side, then the piriformis muscle may be involved. Another physical examination technique is to palpate the belly of the piriformis muscle for tenderness by placing the patient with their unaffected side on the table. Have them raise their knee past their waistline and ask them to externally rotate their leg while the practitioner resists that motion. If there is discomfort at the piriformis, that’s another positive sign. A LaSegue or Straight Leg Raise test will indicate an irritated sciatic nerve but won’t identify where the compression is located. Asking the typical pain-related questions regarding pain quality, frequency, and intensity may offer additional clues toward etiology.

Ruling out a disc herniation can be done a number of ways, the most common of which is to have the patient, while supine on the examination table, lock their knees and raise their heels about six inches off the table. If that reproduces their symptom, it’s a positive sign for disc herniation. Another quick method is to use a reflex hammer to tap your finger pressed firmly at the nerve roots at L3, L4, and L5 vertebral levels, again looking for exacerbation of symptoms.

One of the first approaches to easing piriformis syndrome is to gently stretch the muscle. There are several ways to stretch the piriformis muscle, the simplest being a supine figure four stretch. Recommend the patient hold the stretch for 15 seconds breathing normally and repeat three to four times. It can also be performed in a sitting position, but care must be taken to keep the spine as straight as possible when rocking forward toward the calf of the bent knee. Another approach is pigeon pose, frequently taught in yoga

Strengthening the piriformis can be performed by having your patient lie flat on their back and placing a resistance band just above their bent knees and “clam shelling” their legs slowly open and closed with their sacrum tucked. From there, they can begin lying on their side with their knees bent and opening and closing in a controlled way.

Gently compressing the region of the piriformis with a foam roller can also be helpful. The practitioner would have the patient roll that for a minute, breathing naturally. Eventually they can graduate to a massage ball directly under the belly of the piriformis.

Practitioners can also apply a shear to the tissue that may be gripping the sciatic nerve by having the patient lie prone and bending the affected leg at the knee 90 degrees, so the lower leg is vertical. Press one thumb gently on the belly of their piriformis while rocking their lower leg medially and laterally. Adjust the location of your thumb to find the “sweet spot” or area of tenderness.

Sciatic “flossing” or nerve gliding is also an excellent way to provide relief in both piriformis syndrome and sciatica. Have the patient sit on the examination table with their legs able to swing freely. Ask them to extend their neck—tilt their head back and look up at the ceiling, slacking the nerves in the spinal canal—and then slowly kick out their affected leg to lock the knee and dorsiflex their foot—pull their toes toward their nose.  Then do the opposite—drop their foot, bending their knee and pointing their toes, and then gently flex their neck, bringing their chin to their chest. These actions will gently “floss” the sciatic nerve through or between the muscle and bone, or disc and foramen.

Acupuncture can be used to ease piriformis syndrome by needling the neuromuscular junction or belly of the muscle to release the spasm, feeling for a fasciculation or twitch, or grabbing of the needle that the Chinese refer to as the “fish biting the bait.” Needling the nerve itself has been found to be effective as well. It’s common to clear the affected channel, usually the Urinary Bladder or Gallbladder with local points such as GB 30 and BL36, and distal points such as GB 34, and GB 35 and BL 60 and BL 62. Adding the uricular sciatic point coupled with shenmen and sympathetic on the ipsilateral auricle with an ear tack, seed, or half inch 38 gauge needle can also be very effective. Stationary or moving cupping can be applied to the local area of pain.

Finally, a subset of patients suffering from sciatica and piriformis are vitamin B12 deficient.  Sublingual methylcobalamin is preferred over cyanocobalamin as a non-synthetic form of B12 to support myelin sheath integrity—the liver has to remove the cyanide molecule and attach a methyl group to produce methylcobalamin, the biologically active, tissue-ready form of B12. Having patients tested for B12 would be appropriate.

Supplementing with omega-3 fatty acids and curcumin with meals can be helpful to ease inflammation. Systemic enzymes on an empty stomach can ease the pain, but practitioners should be aware that both omega-3s and systemic enzymes are contraindicated for those who have bleeding disorders.

Cannabidiol (CBD) is known to ease neuropathic pain, starting with a dosage of 15 milligrams before bed and, if there’s no improvement after a few days, to increase the dosage by 10 milligrams and repeat. Since the dose-response curve of CBD is bell-shaped, taking too much will result in an outcome like not taking enough. If the patient notices diminishing returns on greater dosages, recommend easing back.

Combining stretching, strengthening, manual therapies, and supplementation can work synergistically to combat piriformis syndrome.