Pain in the butt..piriformis syndrome myths, hamstring confusion and other reasons that might not be why you think you are in pain

Pain in the butt..piriformis syndrome myths, hamstring confusion and other reasons that might not be why you think you are in pain

It isn’t until you’ve succumbed to a deep horrible pain in the butt, that you come to realise why the phrase, “pain in the butt,” exists. At times it can be debilitating for some, with painkillers having no real impact, yet daily stresses and difficulties, can increase the pain to the point of not being able to interact with anyone, without filling your yearly swear jar quota in a day.

Runners in particular tend to jump to 2 conclusions for a pain in the butt. Hamstring tendinopathy and piriformis syndrome lead the charge here, and very often, Dr. Google, and poorly armed therapists, commonly misdiagnose these, and even worse, offer up treatments that never really see the patient set free from the patient status.

Here we look at some common reasons for butt pain and a few ideas as to what needs to happen to get past it.

Piriformis syndrome

Piriformis syndrome refers to a possible disorder whereby the sciatic nerve, which runs underneath the piriformis, becomes compressed by the muscle. I say possible, as there is some debate as to whether or not this is a real thing. Certainly, pain in this area can occur as a result of some spinal nerve root compression, but there is some debate as to whether or not “piriformis syndrome,” which may possibly present with similar symptoms, is an evidence based diagnosis.

Without going into the full debate and diagnostic disagreements here, clear indications of what is really going on in this area is difficult. Pain can come from lumbar bulging and the like, but we also know that lumbar bulging does not equal pain. We can see contributions from other spinal conditions such as stenosis, anatomical variations in muscle/nerve relationships, sacroiliac joint, leg length discrepancies and more (real leg length changes, not the thing where your Chiro or therapist puts you on a table and tells you that you have one leg longer than the other-I’ve rarely ever seen this diagnosis to be true).

So whether or not you have “Piriformis syndrome” is super difficult. But lets say there is a case for the Piriformis to become overworked and angry, we need to look at why this may be the case.

Often protective gait patterns can occur as a result of some other instigating issue, ranging from back pain to foot pain. This can cause the hip to hike on one side, or even rotate back, never really leaving this position to allow muscles to eccentrically contract and shorten. In my practice, this is a must check for people who present with persisting “Piriformis syndrome.”

Weakness around other external rotators of the hip (a job the piriformis takes part in), may also transfer a large load to the piriformis, making it a bit grumpy about the whole affair.

Outside of this, often the fear of having nerve pain raises enough alarm, particularly in someone who has had it before, that the stress alone around this heightened sensation can make matters worse, and continue to worsen symptoms with additional changes in gait patterns exacerbating things even more.

Hamstring tendinopathy

Another pain in the butt, usually a little lower than Piriformis stuff, but not necessarily, this one is usually a little more simple. In the majority of cases I have seen, this condition has been the result of increasing training too quickly, or not recovering well between bouts.

Like any tendon injury, genetics, chronic illness, age and other factors can be involved in whether or not you will end up with this condition, which if treated poorly, can see runners stop running for months to years (I have seen some give up before receiving proper treatment), and many athletes of all sorts, stretching out their hammies in vein, in the hope that loosening things up a bit will be the answer to their prayers.

One common point of difference between this and piriformis syndrome, is that, in the early stages, hamstring tendinopathy may actually feel better as you start running or exercising, though becomes very painful once cooled down, and seems to linger longer as it gets worse. Having said this, it is still important to rule out any other contributions to pain in this area.

Hamstring tendinopothy is one of the few conditions where local treatment wins the day. Sure, we need to take into account gait patterns, pre-existing injuries, injury history etc., but once the tendon has begun to hate life, it needs some special focused love. Isometrics and eccentric loading are a usually god friends to the rehab process here, and root causes, if any, can be addressed along side this.

Quadratus femoris injury

I don’t think this little fella gets the attention he deserves. He is the quite kid that sits up the back of the class, throwing small pebbles to the back of the other students heads, inciting violence between everyone else in the room, as he gets on with his job unannounced.

While it is said to be an uncommon injury, I have seen addressing this muscle to be helpful in many presentations of hip pain. Tears can occur in this muscle, which is also an external rotator of the hip like its piriformis cousin. Making this muscle angry may also be implicated in similar potential nerve pain, or anything else that piriformis might take the blame for.

On top of this, the quadratus femoris, may also be implicated in groin pain. If you look to the diagram, you will see how this is the case, (with the muscle attaching on the external border of the ischial tuberosity… to get specific). 

So many athletes, runners in particular, are pretty quick to pop a ball in the piriformis to relive pain, ironically usually right on top of where the sciatic nerve passes under the muscle, which should be clear that this is not the brightest idea around. If you are using a ball to try and chill out the external rotators like the piriformis, I tend to start at the insertion of the femur on the quadratus femoris. It won’t be specific only to this muscle, and a little movement towards the hip (superior) will see piriformis get in on the action without smashing into the nerves.

Should I strengthen, stretch, foam roll, eccentrically load...?

Maybe.

In the case of hamstring tendinopathy, we know that incorporating eccentric loading (resistance training while lengthening the muscle) into a rehab program has some big wins. But depending on how long you have been walking around for with an injury to this area, will dictate how much other work you need to do to make sure stuff is “fixed.”

Injuries cause compensation patterns in gait, that will see this compensations continuing to occur, unless the body is given a reason for them not to. So the strategies mentioned here are good for symptomatic relief, make sure you strengthen those bits that are weak, and make sure the knock on effects to how you move are minimised. The muscles that need strengthening will only stay strong if you give them a job to do through joints being in the position they need to work, so having someone check in on movement patterns is a must.