How to Stretch and Strengthen a Painful Piriformis Muscle.

Do you have a throbbing pain deep in the . . . butt? Do you suspect it’s coming from your piriformis muscle? If the sensation feels like an ache or tightness that is deep in the glute muscle then you might be right.

You’ve tried some stretching or foam rolling but the troublesome ache keeps coming back. No matter what you do, you seem to only get temporary (if any) relief. This is because most recommendations don't address the root cause of piriformis discomfort.

The piriformis muscle has certain functions, like any other muscle in the human body. We need to respect these functions when we select stretches and exercises that target the piriformis. 

In this article, I'll explain why you might be feeling discomfort in the piriformis and what you can do to start feeling better. I'll share some effective exercises that target the main functions of the piriformis muscle.  Because the path to healing is chasing movement function, not pain.  

Function and Action of Piriformis 

Where is the Piriformis Muscle? 

The Piriformis muscle is located in the buttocks region. It attaches to the sacrum on one end of the muscle and the top of the femur (aka the greater trochanter) on the other side. [Source - Gray's Anatomy]. 

What is the Action of the Piriformis Muscle?

The Piriformis externally rotates and abducts the hip.  [Source - Yoganatomy.com]. 

An example of hip external rotation is when you bring your leg into a pigeon position. 

 An example of abduction is when you bring the leg out to the side.

Do you have a tight piriformis muscle? 

The Piriformis muscle is one of six deep glute muscles that are known as the deep 6.  Although the piriformis is the muscle that gets the most attention, all 6 of these muscles are equally important to proper function.

It’s possible your piriformis is tight but it’s also possible that the obturator externus is tight. I don’t think many people out there have the body awareness to feel one of the deep 6 muscles over another. I know I don’t.

Another issue is that a sensation of “tightness” is different for everyone. I work with many clients in chronic hip pain. After years of working behind a desk, many of them have muscles that atrophy. They will often describe a muscle as “tight” but when we do some tests, we discover the muscle is actually weak.

My recommendation is to remain curious about the sensations you’re experiencing. Many of us judge sensations as tight and then spend months or years stretching or foam rolling. Often times, it is strength and stabilization that is needed instead.

Piriformis Syndrome 

Piriformis syndrome is a controversial diagnosis that causes sciatica, leg or buttock pain.  The theory is that the piriformis muscle compresses the sciatic nerve which causes pain and discomfort in the surrounding region.  [Source - Parziale et al. 1996].

I am a corrective exercise specialist, not a doctor.  If you have any medical questions or concerns, please consult with your doctor.  The below advice is not intended as a substitution for medical advice or treatment. 

It’s  difficult to write an article on a painful piriformis without discussing piriformis syndrome.  So I will. Piriformis syndrome is not much different than hip impingement, hip labral tears or other controversial diagnoses for chronic hip pain.  It gives you a reason for your chronic hip pain which can be reassuring.  But sometimes, getting a diagnosis can push people further from the path to healing. 

The main assessment for diagnosing piriformis syndrome is the FAIR test.   If pain occurs in this position then a diagnosis of piriformis syndrome is given.  The FAIR test assesses the hip in flexion, adduction and internal rotation (FAIR).  If pain occurs in this position then a diagnosis of piriformis syndrome is given. [Source - Fishman et al. 2002].

But this position is difficult for many individuals. Not just for those with a painful piriformis muscle.  Thinking of myself 10 years ago when I was in debilitating chronic hip pain, this position would make me cry.  But that doesn’t mean I had piriformis syndrome.  It meant that I did not have enough hip function to enter this position pain-free. 

I would never perform this test with my clients that are in chronic hip pain.  The position is too advanced for most beginners.  The FAIR position combines 3 major hip movements (flexion, adduction and internal rotation).  

Instead, I would test each of these movement patterns separately.  By testing each movement individually, we’d have a better understanding of where the weaknesses are and focus on them in training. 

The risks of receiving a piriformis syndrome diagnosis are not as severe as some other chronic hip pain diagnoses.  Those diagnosed with FAI for example are often pushed into receiving unnecessary surgeries. 

Getting diagnosed with piriformis syndrome will more likely result in frustrating and ineffective conservative treatments. This includes steroid injections, ineffective physical therapy, acupuncture, chiropractic care, etc.  

But a quick search on Google Scholar shows many recent studies praising the success of surgery for piriformis syndrome. See Vij et al., 2021 and Han et al. 2017.  It is possible that surgery for piriformis syndrome might become more common in the next few years.

My advice is to focus on the things you can control - your movement function.  Not only the piriformis but the deep 6 gluteus muscles. Not only the deep 6 but how the rest of the hips function also. How the pelvis functions.  And how the rest of the body functions.  This is the path to moving and feeling better. 

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Piriformis Tests 

We now know that the piriformis and deep 6 assist in hip abduction and hip external rotation. Now we’ll test our function in these movements to see if we are limited there.

In each movement of the human body, there is a length (stretch) component and a strength component. In addition, I find that many people in piriformis discomfort are imbalanced from side to side. In other words, one side of the body is stronger or more flexible than the other.

We will test all three of these elements here - strength, length and balance. These tests are considered beginner level. We are looking for your low hanging fruit here. So if you have trouble with these basic exercises then you know you need work on that movement.

Exercises for Piriformis Muscle 

The below exercises target hip abduction and hip external rotation. There are exercises for lengthening, strengthening and balancing this area of the body. You can focus on exercises that target your weakness or you can just try all of the exercises.

Every exercise can be an assessment and every assessment can be an exercise. So experiment and see what works best for you.

CLOSING THOUGHTS 

The conventional approach to treating a painful piriformis is to get laser focused on the muscle itself.   Stretch the piriformis.  Foam roll the piriformis.  But this can lead us to lose sight of the big picture. 

Our bodies are smart and we can use pain signals to help us identify what movements might be restricted or dysfunctional.   But that does not mean we need to go poke and prod an already sensitive and aggravated area. 

Instead, I recommend zooming out and taking a more universal approach.  What are the piriformis and surrounding muscles supposed to be able to do? And can you do them?  What are the hips supposed to be able to do?  And can you do them?

In my experience working on my own body and now with many others, the more we focus on the painful area, the less progress we see.  When we start investigating how the hips and pelvis function more holistically, that's when we start seeing results.  My advice is to chase movement function, not symptoms.  

Good luck!