Individuals dealing with pain in the buttocks and in the back of the thigh, along with numbness and tingling down to the bottom of the foot, may be experiencing hamstring syndrome, a condition caused by pressure on the sciatic nerve. What is the recommended treatment?
Hamstring-Syndrome Relief
The hamstrings are three muscles in the back of the thigh, extending from the pelvis or upper thigh across the back of the knee to the leg. This muscle group is important for bending the knee, straightening the hip, and stabilizing the knee. The sciatic nerve is a large nerve that runs from the lower back down the legs. It usually passes near or through these muscles, and the pelvis then runs under these muscles in the thigh. Hamstring syndrome refers to pain in the buttock and back of the thigh, often radiating down the leg, caused by compression or irritation of the sciatic nerve at the hamstring-insertion point on the ischial tuberosity, typically due to tight or scarred tissue. (Sakari Orava, 1997)
Pain Location
The pain is primarily felt in the buttock and back of the thigh, sometimes extending down the leg. It’s characterized by pressure on the sciatic nerve, which runs through the buttock and into the back of the thigh, where it supplies the hamstring muscles. (Kaiser Permanente, 2024)
In some cases, injections with cortisone and numbing medicine may be used to reduce nerve inflammation and pain. (Lower Limb Surgery, 2024)
Surgery
In severe cases, surgery may be necessary to release the compressing bands and free the sciatic nerve. (Lower Limb Surgery, 2024)
Injury Medical Chiropractic & Functional Medicine Clinic
Talk to a healthcare provider about what interventions would help the most. Injury Medical Chiropractic and Functional Medicine Clinic works with primary healthcare providers and specialists to develop an optimal health and wellness solution. We focus on what works for you to relieve pain, restore function, and prevent injury. Regarding musculoskeletal pain, specialists like chiropractors, acupuncturists, and massage therapists can help mitigate the pain through spinal adjustments that help the body realign itself. They can also work with other medical professionals to integrate a treatment plan to resolve musculoskeletal issues.
Kaiser Permanente. (2024). Hamstring Syndrome: Care Instructions. https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.hamstring-syndrome-care-instructions.abr3618
Puranen, J., & Orava, S. (1988). The hamstring syndrome. A new diagnosis of gluteal sciatic pain. The American Journal of Sports Medicine, 16(5), 517–521. https://doi.org/10.1177/036354658801600515
Zion Physical Therapy. (2023). Hamstring Tendinitis Vs. Hamstring Syndrome. https://www.zionpt.com/post/hamstring-tendinitis-vs-hamstring-syndrome
Can physical therapy treatment protocols aimed at improving range of motion and flexibility around the hip and relieving inflammation around the sciatic nerve help individuals experiencing deep buttock pain or piriformis syndrome?
Deep Buttock Pain
Piriformis syndrome, a.k .a. deep buttock pain, is described as sciatic nerve irritation from the piriformis muscle.
The piriformis is a small muscle behind the hip joint in the buttocks.
It is about one centimeter in diameter and functions in the hip joint’s external rotation or turning outward.
The piriformis muscle and tendon are close to the sciatic nerve, which supplies the lower extremities with motor and sensory functions.
Depending on an individual’s anatomic variation of the muscle and tendon:
The two cross over, under, or through each other behind the hip joint in the deep buttock.
This relationship is thought to irritate the nerve, leading to sciatica symptoms.
Piriformis Syndrome
When diagnosed with piriformis syndrome, it is thought that the muscle and tendon bind to and/or spasm around the nerve, causing irritation and pain symptoms.
The theory supported is that when the piriformis muscle and its tendon tighten, the sciatic nerve becomes compressed or pinched. This decreases blood circulation and irritates the nerve from the pressure. (Shane P. Cass 2015)
Tenderness with pressure on the piriformis muscle.
Discomfort in the back of the thigh.
Deep buttock pain behind the hip.
Electric sensations, shocks, and pains travel down the back of the lower extremity.
Numbness in the lower extremity.
Some individuals develop symptoms abruptly, while others go through a gradual increase.
Diagnosis
Doctors will order X-rays, MRIs, and nerve conduction studies, which is normal.
Because piriformis syndrome can be challenging to diagnose, some individuals with minor hip pain may receive a piriformis syndrome diagnosis even if they don’t have the condition. (Shane P. Cass 2015)
It is sometimes referred to as deep buttock pain. Other causes of this type of pain include back and spinal problems like:
Herniated discs
Spinal stenosis
Radiculopathy – sciatica
Hip bursitis
A piriformis syndrome diagnosis is usually given when these other causes are eliminated.
When the diagnosis is uncertain, an injection is administered in the area of the piriformis muscle. (Danilo Jankovic et al., 2013)
Different medications can be used, but the injection itself is used to help determine the specific location of the discomfort.
When an injection is given into the piriformis muscle or tendon, it is often administered by ultrasound guidance to ensure the needle delivers the medication to the correct location. (Elizabeth A. Bardowski, J. W. Thomas Byrd 2019)
Avoiding activities that cause symptoms for at least a few weeks.
Physical Therapy
Emphasize stretching and strengthening the hip rotator muscles.
Non-Surgical Decompression
Gently pulls the spine to release any compression, allowing optimal rehydration and circulation and taking the pressure off the sciatic nerve.
Therapeutic Massage Techniques
To relax and release muscle tension and increase circulation.
Acupuncture
To help relax the piriformis muscle, sciatic nerve, and surrounding area.
Relieve pain.
Chiropractic Adjustments
Realignment rebalances the spine and musculoskeletal system to alleviate pain.
Anti-Inflammatory Medication
To decrease inflammation around the tendon.
Cortisone Injections
Injections are used to decrease inflammation and swelling.
Botulinum Toxin Injection
Injections of botulinum toxin paralyze the muscle to relieve pain.
Surgery
Surgery can be performed in rare cases to loosen the piriformis tendon, known as a piriformis release. (Shane P. Cass 2015)
Surgery is a last resort when conservative treatments have been tried for at least 6 months with little to no relief.
Recovery can take several months.
Sciatica Causes and Treatment
References
Cass S. P. (2015). Piriformis syndrome: a cause of nondiscogenic sciatica. Current sports medicine reports, 14(1), 41–44. https://doi.org/10.1249/JSR.0000000000000110
Jankovic, D., Peng, P., & van Zundert, A. (2013). Brief review: piriformis syndrome: etiology, diagnosis, and management. Canadian journal of anaesthesia = Journal canadien d’anesthesie, 60(10), 1003–1012. https://doi.org/10.1007/s12630-013-0009-5
Bardowski, E. A., & Byrd, J. W. T. (2019). Piriformis Injection: An Ultrasound-Guided Technique. Arthroscopy techniques, 8(12), e1457–e1461. https://doi.org/10.1016/j.eats.2019.07.033
Hamstring muscle injuries are common, especially in athletes and individuals with physically demanding jobs. Is there a better chance of full recovery with surgical repair and post-op rehabilitation?
Hamstring Muscle Tear
Most often, hamstring muscle injuries are partial tears of the muscle. These types of injuries are muscle strains that occur when the muscle fibers are stretched beyond their normal limits. Complete tears of the hamstring muscle are unusual, but they do occur in both athletes and non-athletes. Determining the optimal treatment plan depends on:
The severity of the tendon tear
The expectations of the injured individual.
Incomplete tears are when the hamstring muscle is stretched too far, but not completely detached.
Complete tears usually occur at the top of the muscle where the tendon tears away from the pelvis.
A complete tear usually occurs when there is a sudden flexion of the hip and extension of the knee joint – when the muscle contracts in this position, it gets stretched beyond its limits.
Basic hamstring strains can be treated with simple steps – rest, ice, anti-inflammatory medications, and conservative therapies.
Symptoms
Symptoms of a hamstring muscle strain can include pain, bruising, swelling, and movement difficulty. (American Academy of Orthopaedic Surgeons. 2021) Individuals who sustain this injury typically experience sudden sharp pain. Signs of a tear can include:
Sharp pain where the buttock and thigh meet.
Difficulty walking.
Sitting can be difficult as the edge of a chair can place pressure directly on the injury.
Spasms and cramping sensations in the back of the thigh.
Weakness in the leg, specifically when bending the knee or lifting the leg behind the body.
Numbness or burning sensations as a result of sciatic nerve irritation.
Swelling and bruising in the back of the thigh – over time it can travel down to the back of the knee and calf and possibly into the foot.
With a complete hamstring tear, there is usually significant swelling and bruising that develops in the back of the thigh.
Diagnosis
The symptoms can be difficult to spot in the early stages which is why X-rays of the hip or thigh are usually obtained.
In some situations, a fragment of bone can get pulled off the pelvis along with the hamstring muscle attachment. MRI testing can be performed to evaluate the attachment and can define critical features of a complete hamstring muscle tear, including: (American Academy of Orthopaedic Surgeons. 2021)
The number of tendons involved.
Complete versus incomplete tearing.
The amount of retraction – the amount the tendons have pulled back.
This will guide the development of treatment.
Treatment
The treatment of a complete tear will depend on different factors. The other variable is the patient and their expectations.
Treatment is more aggressive in younger individuals like high-level athletes.
Treatment is less aggressive in middle-aged individuals.
Often a single tendon tear can be treated non-surgically.
When one tendon is involved, it is typically not pulled very far from its normal attachment and will develop scar tissue in a positive position.
Conversely, when three tendons have been torn, they usually pull more than a few centimeters away from the bone. These cases have better results with surgical repair. (UW Health. 2017)
Surgeons will use patient characteristics – high-level athletes or less physically active individuals – to guide treatment recommendations.
Rehabilitation
Rehabilitation following surgery can take 3-6 months or longer.
The first six weeks limit weight-bearing with the use of crutches.
Patients may be recommended to wear a brace to reduce tension on the repaired hamstring tendons.
Strengthening does not begin until three months post-op, and even light activities are usually delayed. (UW Health. 2017)
Because this injury can have a long recovery time, some individuals may choose nonsurgical treatment.
Sometimes these individuals experience symptoms of discomfort from sitting and may exhibit long-term weakness of the hamstring muscle.
Full recovery from a complete hamstring muscle injury takes time. Studies have shown high-level athletes are able to resume competitive sports after the repair and rehabilitation of an acute hamstring muscle injury. (Samuel K. Chu, Monica E. Rho. 2016)
Delaying surgical treatment may not always lead to optimal results.
When the tendon is torn away from its normal attachment, it begins to scar around the surrounding soft tissues.
When there is a delay of more than a few weeks following the initial injury, regaining the full length of the tendon and muscle can be challenging.
This could delay the rehabilitation process and may limit the potential for full recovery. (Ho Yoon Kwak, et al., 2011)
With severe injuries, there is a better chance of full recovery with surgical repair but could involve a long recovery and commitment to a post-op rehabilitation plan.
Chu, S. K., & Rho, M. E. (2016). Hamstring Injuries in the Athlete: Diagnosis, Treatment, and Return to Play. Current sports medicine reports, 15(3), 184–190. https://doi.org/10.1249/JSR.0000000000000264
Kwak, H. Y., Bae, S. W., Choi, Y. S., & Jang, M. S. (2011). Early surgical repair of acute complete rupture of the proximal hamstring tendons. Clinics in orthopedic surgery, 3(3), 249–253. https://doi.org/10.4055/cios.2011.3.3.249
Can combining chiropractic treatment with the common therapies of medication, exercise, and/or physical therapy help relieve sciatic endometriosis pain symptoms?
Sciatic Endometriosis
Sciatic endometriosis is a condition in which endometrial cells (tissue that resembles the lining of the uterus) grow outside of the uterine lining and compress the sciatic nerve. This places stress and pressure on the nerve causing back, pelvic, hip, and leg pain, especially before and during the menstrual cycle. It can also cause pain, irregular periods, and infertility. (The American College of Obstetricians and Gynecologists. 2021)
These areas of endometrial tissue growth are also known as lesions or implants.
Women with sciatic endometriosis often experience leg pain and weakness around the time of their menstrual cycle. (Lena Marie Seegers, et al., 2023)
Sciatic endometriosis can also cause pain when urinating, during a bowel movement, during sex, and fatigue, and irregular vaginal bleeding.
The abnormal growth may be caused by higher-than-normal levels of estrogen.
Researchers believe that endometriosis is related to retrograde menstruation, which causes menstrual blood to flow back into the pelvis instead of out through the vagina. (World Health Organization. 2023)
Sometimes, the cells grow in the area of the pelvis right above the sciatic nerve. (Adaiah Yahaya, et al., 2021)
The sciatic nerve is the longest nerve in the body and travels down the back of each leg. (Johns Hopkins Medicine. 2023)
When endometrial lesions place pressure on the sciatic nerve, they can cause irritation and inflammation leading to severe pelvic pain, which makes it harder to conceive. (Liang Yanchun, et al., 2019)
Symptoms
Some women with endometriosis experience no symptoms or misinterpret the symptoms as typical premenstrual syndrome/PMS signs. The most common signs and symptoms of sciatic endometriosis include:
Difficulty walking or standing.
Loss of sensation, muscle weakness, and reflex alteration.
Limping.
Balance problems.
Bloating and nausea.
Constipation or diarrhea before or after a period.
Painful, heavy, and/or irregular periods.
Bleeding between periods.
Pain during sex, urination, and bowel movements.
Pain in the stomach, pelvis, lower back, hips, and buttocks. (MedlinePlus. 2022)
Weakness, numbness, tingling, burning, or dull aching sensations in the back of one or both legs.
Endometriosis, including sciatic endometriosis, typically cannot be diagnosed with a pelvic examination or ultrasound by themselves. A healthcare provider may need to perform a biopsy using laparoscopy and discuss menstrual cycles, symptoms, and medical history.
The laparoscopy procedure involves making tiny incisions and taking a tissue sample with tools attached to a thin tube with a camera. (MedlinePlus. 2022)
Imaging tests, like magnetic resonance imaging/MRI, and computed tomography/CT scans, can help provide essential information about the location and size of any endometrial lesions. (The American College of Obstetricians and Gynecologists. 2021)
Treatment
Symptoms can sometimes be temporarily relieved with over-the-counter/OTC pain relievers. Depending on the condition and severity a healthcare provider may prescribe hormonal treatment to prevent new endometrial implants from growing. These can include:
Hormonal birth control.
Progestin – a synthetic form of progesterone.
Gonadotropin-releasing hormone – GnRH agonists.
If pain persists or worsens, individuals may need to undergo surgery to remove the tissue.
The American College of Obstetricians and Gynecologists. Endometriosis.
Seegers, L. M., DeFaria Yeh, D., Yonetsu, T., Sugiyama, T., Minami, Y., Soeda, T., Araki, M., Nakajima, A., Yuki, H., Kinoshita, D., Suzuki, K., Niida, T., Lee, H., McNulty, I., Nakamura, S., Kakuta, T., Fuster, V., & Jang, I. K. (2023). Sex Differences in Coronary Atherosclerotic Phenotype and Healing Pattern on Optical Coherence Tomography Imaging. Circulation. Cardiovascular imaging, 16(8), e015227. https://doi.org/10.1161/CIRCIMAGING.123.015227
World Health Organization. Endometriosis.
Yahaya, A., Chauhan, G., Idowu, A., Sumathi, V., Botchu, R., & Evans, S. (2021). Carcinoma arising within sciatic nerve endometriosis: a case report. Journal of surgical case reports, 2021(12), rjab512. https://doi.org/10.1093/jscr/rjab512
Johns Hopkins Medicine. Sciatica.
Yanchun, L., Yunhe, Z., Meng, X., Shuqin, C., Qingtang, Z., & Shuzhong, Y. (2019). Removal of an endometrioma passing through the left greater sciatic foramen using a concomitant laparoscopic and transgluteal approach: case report. BMC women’s health, 19(1), 95. https://doi.org/10.1186/s12905-019-0796-0
MedlinePlus. Endometriosis.
Center for Endometriosis Care. Sciatic endometriosis.
Chen, S., Xie, W., Strong, J. A., Jiang, J., & Zhang, J. M. (2016). Sciatic endometriosis induces mechanical hypersensitivity, segmental nerve damage, and robust local inflammation in rats. European journal of pain (London, England), 20(7), 1044–1057. https://doi.org/10.1002/ejp.827
Siquara de Sousa, A. C., Capek, S., Howe, B. M., Jentoft, M. E., Amrami, K. K., & Spinner, R. J. (2015). Magnetic resonance imaging evidence for perineural spread of endometriosis to the lumbosacral plexus: report of 2 cases. Neurosurgical focus, 39(3), E15. https://doi.org/10.3171/2015.6.FOCUS15208
A nerve becomes pinched/compressed when added pressure is placed on it by surrounding structures that can include muscles, bones, ligaments, tendons, or a combination. This injures and damages the nerve causing function problems and symptoms and sensations in that area or other parts of the body that are supplied by that nerve. Medical practitioners refer to this as nerve compression or entrapment. Although compressed nerves are more commonly associated with the neck, arms, hands, elbows, and lower back, any nerve in the body can experience irritation, spasms, inflammation, and compression. The causes and treatment of a compressed nerve in the knee.
Compressed Nerve In The Knee
There’s only one nerve that goes through the knee that has an increased risk of getting compressed. It’s a branch of the sciatic nerve called the peroneal nerve. The nerve goes around the outside of the knee before traveling down the outside of the lower leg. At the bottom of the knee, it lies between the bone and skin, making it vulnerable to irritation or compression by anything that can put pressure on the outside of the knee.
Causes
Traumatic injuries over time can lead to pressure on the nerve from inside the knee. Common causes of a compressed nerve in the knee include:
Frequently Crossing Legs
Compression by the opposite knee, while the legs are crossed is the most common cause.
Knee Brace
A too-tight or strong brace can compress the leg and nerve.
Thigh-High Compression Stockings
Designed to maintain pressure on the legs, if too tight these stockings can compress the nerve.
Squatting Posture For Long Periods
This position places pressure on the side of the knee.
Fractures
A fracture of the large lower leg bone/tibia or sometimes the small bone/fibula near the knee can entrap the nerve.
Lower Leg Cast
The portion of the cast around the knee can be tight and compress the nerve.
Tell the doctor if a cast or brace feels tight or is causing numbness or pain in the leg.
Knee-High Boots
The top of a boot can land right below the knee and be too tight pinching the nerve.
Knee Ligament Injury
The nerve can become compressed due to bleeding or inflammation from an injured ligament.
Knee Surgery Complications
This is rare, but the nerve can inadvertently get pinched during knee replacement surgery or an arthroscopic procedure.
Prolonged Bed Rest
When lying down the legs tend to rotate outward and the knees flex.
In this position, the mattress can place pressure on the nerve.
Tumors or Cysts
Tumors or cysts can develop right on top or next to a nerve irritating and compressing the area.
Abdominal or Gynecologic Surgery
The equipment used to keep the legs rotated outward and the knees flexed for gynecologic and abdominal surgeries can compress the nerve.
Symptoms
The peroneal nerve supplies sensation and movement to the outside of the lower leg and the top of the foot. When compressed, it becomes inflamed, which causes the symptoms of a compressed nerve. Usually, only the lining/myelin sheath around the nerve is what gets injured. However, when the nerve gets damaged, the symptoms are similar but more severe. Common symptoms include:
Weakness that limits the ability to lift the foot toward the leg aka dorsiflexion.
This causes dragging the foot when walking.
The ability to turn the foot outward and extend the big toe is also affected.
Symptoms can be felt on the outside of the lower leg and on the top of the foot and include:
Tingling or pins and needles sensations.
Numbness.
Loss of sensation.
Pain.
Burning.
For individuals that have had a pinched nerve for two or more weeks, the muscles supplied by the nerve can begin to waste away or atrophy.
Symptoms can be intermittent or continuous depending on the cause.
The other common cause is a pinched nerve in the lumbar/lower spine.
When this is the cause, sensations, and pain will present in the lower back or the back and outside of the thigh.
Diagnosis
A doctor will look at medical history and perform an examination to make a diagnosis, determine the cause, and lay out a personalized treatment plan. The nerve in the knee can be felt as it travels around the top of the tibia, so a doctor may tap on it. If there is shooting pain down the leg, a pinched nerve may be present. Tests a doctor may order can include:
Knee X-ray
Shows any bone fractures or abnormal masses.
Knee MRI
Can confirm the diagnosis
Shows masses within the nerve.
Shows details of fractures or other problems in the bones.
Electromyogram – EMG
Tests electrical activity in the muscles.
Nerve Conduction Test
Tests the signal speed of the nerve.
Treatment
Treatment is aimed at reducing pain and improving mobility.
Over-the-Counter Pain Medication
OTC medication can reduce inflammation and improve symptoms short term.
Ice and Heat
Applying either heat or ice for 15 to 20 minutes at a time can provide relief from the symptoms.
An ice pack can make symptoms worse if it adds more pressure on the nerve.
Chiropractic and Physical Therapy
Chiropractic and physical therapy can release the compressed nerve, realign the structures, strengthen the muscles, and provide gait training.
Orthotic Boot
If walking gait is affected because the foot cannot bend, an orthotic boot can help.
This is a support that maintains the foot in a neutral position to walk normally.
Corticosteroid Injection
A corticosteroid injection can reduce inflammation and relieve pressure on the nerve.
Surgery
The nerve can suffer permanent damage if it has been pinched for a long time.
If that happens, surgery cannot repair the damage.
A doctor can perform surgery to correct a fracture, tumor, or other invasive problem causing a compressed nerve.
If conservative treatment doesn’t work, a peroneal nerve decompression procedure can be done to remove the pressure.
If surgery is needed, symptoms can disappear immediately, but it takes around four months to recover and rehabilitate.
Injury Rehabilitation
References
Krych, Aaron J et al. “Is peroneal nerve injury associated with worse function after knee dislocation?.” Clinical orthopedics and related research vol. 472,9 (2014): 2630-6. doi:10.1007/s11999-014-3542-9
Lezak B, Massel DH, Varacallo M. Peroneal Nerve Injury. [Updated 2022 Nov 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549859/
Soltani Mohammadi, Sussan, et al. “Comparing the squatting position and traditional sitting position for ease of spinal needle placement: a randomized clinical trial.” Anesthesiology and pain medicine vol. 4,2 e13969. 5 Apr. 2014, doi:10.5812/aapm.13969
Stanitski, C L. “Rehabilitation following knee injury.” Clinics in sports medicine vol. 4,3 (1985): 495-511.
Xu, Lin, et al. Zhongguo gu Shang = China Journal of Orthopedics and Traumatology vol. 33,11 (2020): 1071-5. doi:10.12200/j.issn.1003-0034.2020.11.017
Yacub, Jennifer N et al. “Nerve injury in patients after hip and knee arthroplasties and knee arthroscopy.” American Journal of physical medicine & Rehabilitation vol. 88,8 (2009): 635-41; quiz 642-4, 691. doi:10.1097/PHM.0b013e3181ae0c9d
The piriformis is a large and powerful muscle beneath the gluteal/buttocks muscles. It runs from the bottom of the sacrum, where the base of the spine and pelvis converge to the top of the femur. This muscle plays a critical role in running motion; it helps externally rotate the hips and upper leg outward, provides hip flexibility and stability, and stabilizes the pelvis. The sciatic nerve passes next to, over, under, or through the piriformis muscle. When the piriformis contracts or spasms, it can irritate, become entangled and compress the nerve, resulting in painful symptoms. This can lead to various problems and is how piriformis syndrome occurs.
Running Piriformis Syndrome
The proper function of the piriformis muscle is essential for athletes who participate in running sports. Repetitive activities, like running, can fatigue the muscle and irritate and inflame the nerve.
Symptoms
Piriformis syndrome can be challenging to diagnose because it can be confused for a herniated disc, sciatica, a proximal hamstring strain/high hamstring tendinitis, or lower back problems. A few symptoms that can help determine whether the piriformis is the cause include:
Sitting, Stairs, Squatting Discomfort or Pain
Individuals don’t always experience discomfort while running.
Instead, it’s sitting, climbing stairs, and squatting where pain symptoms present.
Pain while running, specifically an overstretched sensation when going up a hill or increasing speed, is more associated with a proximal hamstring strain.
Tenderness
The area around the piriformis is tender.
Applying pressure can cause discomfort or pain around the area and radiate down the leg.
Centered Pain
Piriformis syndrome is usually felt in the middle of the glutes.
A proximal hamstring strain typically causes non-radiating pain at the bottom of the glutes, where the hamstrings connect to the pelvis.
Causes
Pelvic misalignment.
Pelvic misalignments created by other conditions, like a tilted pelvis, functional leg-length discrepancy, or practicing unhealthy posture, make the piriformis work harder to compensate, which leads to tightness and/or spasms.
Sudden increases in distance or workout intensity can worsen any weakness in the piriformis and other gluteal muscles.
Continuing to run, which is possible, can worsen and prolong the condition.
When running, the muscle’s signal transmissions are interrupted by inflammation and/or compression and cannot synchronize with each other.
The result is the inability to withstand the repetitive strain of running.
Resting may not be enough to alleviate piriformis syndrome. This is especially true if the problem involves spine and pelvic misalignment. Chiropractic can provide significant relief from running piriformis syndrome. A combination of spinal, pelvic, and extremity adjustments, therapeutic massage, MET, decompression, stretches, and anti-inflammatory nutrition will take the pressure off overly tight areas, realign the body, and maintain nervous system function.
Running form could be evaluated and checked for leg-length discrepancies and muscle-strength imbalances.
Running can continue if the individual can do so without pain or symptoms.
But it is recommended to avoid slanted surfaces, which increase the risk of pelvic misalignment.
Avoid long runs, which increase the chance of overload and fatigue.
The goal is to relax and release the piriformis.
If it’s impinging on the sciatic nerve, loosening and releasing the muscle will significantly lessen radiating pain.
Orthotics may be recommended for excessive overpronation or inward movement of the foot when landing.
Other treatments to stop piriformis spasms.
Ice and take over-the-counter anti-inflammatory medications can be used during acute phases when the area is tender.
Work out tight spots using a foam roller or percussive massager.
Stretching and loosening the muscle before and after runs can help it relax and increase blood flow.
Ahmad Siraj, Sidra, and Ragini Dadgal. “Physiotherapy for Piriformis Syndrome Using Sciatic Nerve Mobilization and Piriformis Release.” Cureus vol. 14,12 e32952. 26 Dec. 2022, doi:10.7759/cureus.32952
Chang A, Ly N, Varacallo M. Piriformis Injection. [Updated 2022 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
Heiderscheit, Bryan, and Shane McClinton. “Evaluation and Management of Hip and Pelvis Injuries.” Physical Medicine and rehabilitation clinics of North America vol. 27,1 (2016): 1-29. doi:10.1016/j.pmr.2015.08.003
Julsrud, M E. “Piriformis syndrome.” Journal of the American Podiatric Medical Association vol. 79,3 (1989): 128-31. doi:10.7547/87507315-79-3-128
Kraus, Emily, et al. “Piriformis Syndrome With Variant Sciatic Nerve Anatomy: A Case Report.” PM & R: the Journal of Injury, Function, and Rehabilitation vol. 8,2 (2016): 176-9. doi:10.1016/j.pmrj.2015.09.005
Lenhart, Rachel, et al. “Hip muscle loads during running at various step rates.” The Journal of Orthopedic and sports physical therapy vol. 44,10 (2014): 766-74, A1-4. doi:10.2519/jospt.2014.5575
Sulowska-Daszyk, Iwona, and Agnieszka Skiba. “The Influence of Self-Myofascial Release on Muscle Flexibility in Long-Distance Runners.” International Journal of environmental research and public health vol. 19,1 457. Jan 1, 2022, doi:10.3390/ijerph19010457
A peroneal nerve injury/peroneal neuropathy can be caused by direct trauma to the outer knee with symptoms and sensations of numbness, tingling, pins-and-needles sensations, pain, or weakness in the foot that can cause a condition known as foot drop. Chiropractic can perform spinal manipulation, realignment, and decompression to restore the nerve’s function. They can also help with walking and mobility by providing muscle strengthening and stretching exercises to correct abnormal gait caused by foot drop and increase the range of motion in the ankle.
Peroneal Nerve Injury
The peroneal nerve begins near the sciatic nerve at the glutes/hip and buttocks. It travels down the back of the thigh to the knee, which wraps around the front of the leg and extends into the feet to the toes. It provides sensory input from the lateral aspect of the lower leg and the top of the foot. It also provides motor input to the muscles responsible for lifting the foot off the ground lifting the toes and ankles and turning the foot outwards.
Causes
Structural problems in the spine or misalignment can affect the functionality of the nervous system and lead to peroneal neuropathy. Traumatic nerve injury causes include musculoskeletal injury, peroneal nerve paralysis, compression, or laceration. Injuries by trauma and nerve compression include:
Compression of the nerve in the leg.
Knee dislocation.
Knee or hip replacement surgery.
Knee or leg fracture. Fractures of the tibia or fibula, especially in the areas closer to the knee, can injure the nerve.
Ankle fracture.
Blood clot.
Compression by a nerve sheath tumor or cyst.
Certain underlying medical conditions can cause symptoms of peroneal nerve injury. It is recommended to be evaluated by a medical professional who can diagnose and offer appropriate treatment options. Neurologic disorders that can cause similar symptoms:
Herniated lumbar disc
Multiple sclerosis
Parkinson’s disease
Amyotrophic lateral sclerosis – ALS or Lou Gehrig’s disease.
Metabolic syndromes – diabetes, alcohol abuse, exposure to toxins.
Symptoms
Nerve injury symptoms include:
Numbness, tingling, or loss of sensation in the top of the foot or outer part of the lower leg.
Inability to flex toes or ankles upward/dorsiflexion.
Inability to flex the ankle to take a step forward.
Inability to move the foot.
Weakness in foot eversion/rotating outward.
Flopping or slapping sounds when walking.
Gait changes – dragging the toes or lifting the knee higher than the other to raise the foot off the ground.
Tripping often.
Pain in the foot or lower leg.
Diagnosis
In diagnosing a peroneal nerve injury, a healthcare provider examines the leg and analyzes symptoms. Tests can include:
Imaging tests – CT scan, ultrasound, or MRI.
Magnetic resonance – MR – neurography is a specialized high-resolution MRI of the nerves.
An electromyogram measures how muscles react to nerve stimulation.
Treatment for a peroneal nerve injury depends on the severity and can be surgical or non-surgical. Non-surgical options include orthotic footwear, chiropractic care, and physical therapy. A physical therapy program could consist of the following:
Icing
Massage
Manual manipulation
Stretching
Strengthening exercises
Mobilization exercises
Balancing exercises
Ankle bracing
Ankle taping
Shoe inserts – splints, braces, or orthotics can improve gait.
Longo, Diego, et al. “The Muscle Shortening Maneuver: a noninvasive approach to treating peroneal nerve injury. A case report.” Physiotherapy theory and practice, 1-8. 31 Jul. 2022, doi:10.1080/09593985.2022.2106915
Milenković, S S, and M M Mitković. “Common peroneal nerve schwannoma.” Hippokratia vol. 22,2 (2018): 91.
Radić, Borislav et al. “PERIPHERAL NERVE INJURY IN SPORTS.” Acta clinica Croatica vol. 57,3 (2018): 561-569. doi:10.20471/acc.2018.57.03.20
Thatte H et al. (2022). Electrodiagnostic evaluation of peroneal neuropathy. ncbi.nlm.nih.gov/books/NBK563251/
T Francio, Vinicius. “Chiropractic care for foot drop due to peroneal nerve neuropathy.” Journal of bodywork and movement therapies vol. 18,2 (2014): 200-3. doi:10.1016/j.jbmt.2013.08.004
IFM's Find A Practitioner tool is the largest referral network in Functional Medicine, created to help patients locate Functional Medicine practitioners anywhere in the world. IFM Certified Practitioners are listed first in the search results, given their extensive education in Functional Medicine
