Piriformis syndrome:
Piriformis syndrome otherwise known as wallet syndrome, obviously usually Piriformis syndrome starts with pain, tingling, or numbness in the buttocks. Pain can be severe and extend down the length of the sciatic nerve (called sciatica). The pain is due to the piriformis muscle compressing the sciatic nerve, such as while sitting on a car seat or running. Who is having or maintaining wrong postures they can get this Piriformis syndrome.
Causes
It is usually because of overuse obviously, which causes the pirofirmis muscle to go into spasm resulting in pressure on the sciatic nerve. The piriformis muscle is one of the small deep muscles in the buttocks that rotates the leg outwards. It runs from the sacrum bone at the bottom of the spine and attaches to the thigh bone or femur roughly near the outside crease of the buttocks. The sciatic nerve runs very close to this muscle and in around 10% of the population it actually passes straight through the muscles fibers. If the piriformis muscle becomes tight it can compress the sciatic nerve and cause pain which can radiate down the leg, commonly known as sciatic pain.
It has been suggested that this condition would be better referred to as piriformis impingement due to the impingement of the sciatic nerve. A common cause of piriformis syndrome is tight adductor muscles on the inside of the thigh. This means the abductors on the outside cannot work properly and so put more strain on the piriformis muscle.
Pathophysiology
The piriformis muscle is flat, pyramid-shaped, and oblique. This muscle originates to the anterior of the S2-S4 vertebrae, the sacrotuberous ligament, and the upper margin of the greater sciatic foramen. Passing through the greater sciatic notch, the muscle inserts on the superior surface of the greater trochanter of the femur. With the hip extended, the piriformis muscle is the primary external rotator; however, with the hip flexed, the muscle becomes a hip abductor. The piriformis muscle is innervated by branches from L5, S1, and S2. A lower lumbar radiculopathy may cause secondary irritation of the piriformis muscle, which may complicate diagnosis and hinder patient progress.
Many developmental variations of the relationship between the sciatic nerve in the pelvis and piriformis muscle have been observed. In approximately 20% of the population, the muscle belly is split, with 1 or more parts of the sciatic nerve dividing the muscle belly itself. In 10% of the population, the tibial/peroneal divisions are not enclosed in a common sheath. Usually, the peroneal portion splits the piriformis muscle belly, although in rare cases, the tibial division does so.
Involvement of the superior gluteal nerve usually is not seen in cases of piriformis syndrome. This nerve leaves the sciatic nerve trunk and passes through the canal above the piriformis muscle.
Symptoms of Piriformis Syndrome
Most commonly, patients describe acute tenderness in the buttock and sciatica-like pain down the back of the thigh, calf and foot. Typical piriformis syndrome symptoms may include:
A dull ache in the buttock
Pain down the back of the thigh, calf and foot (sciatica)
Pain when walking up stairs or inclines
Increased pain after prolonged sitting
Reduced range of motion of the hip joint
Symptoms of piriformis syndrome often become worse after prolonged sitting, walking or running, and may feel better after lying down on the back.
What’s the Physiotherapy Treatment for Piriformis Syndrome?
After a thorough assessment of your back, pelvis and hips, your physiotherapist will determine the cause of your pain. Your physiotherapist will tailor exercises and treatment according with your condition
Once your diagnosis is established, treatment could involve any of the following:
Pelvis and spine re-alignment techniques(Postural correction exercises)
Joint mobilisation to restore normal joint mobility, range of motion and function
Electrotherapy to help decrease pain and spasm in your piriformis and increase blood flow plus soft tissue extensibility.
Stretching program for muscle length and flexibility, mainly piriformis, hamstring and addctor muscles
Dry Needling to reduce muscle tightness around the buttock.
Deep core stability and hip strengthening exercises to stabilise your hip, pelvis and spine.
Foot orthotics or exercises, if indicated by your physiotherapist or podiatrist, to help restore foot and lower extremity alignment.
The therapist can also give several tips to avoid an aggravation of the symptoms. This includes:
Avoid sitting for a long period
Stand and walk every 20 minutes
Make frequent stops when driving to stand and stretch
Prevent trauma to the gluteal region
Avoid further offending activities.
Daily stretching is recommended to avoid the recurrence of the piriformis syndrome.
Both stretching and strengthening exercises are important for treating and preventing piriformis syndrome.
Stretching exercises release spasm in the muscle and therefore pressure on the sciatic nerve whilst strengthening ensures the muscle is strong enough to cope with the demands placed on it, preventing the injury recurring. We also demonstrate below how foam roller exercises should be performed to help treat piriformis syndrome.
Stretching exercises
Due to the position of the piriformis muscle in the hip, static stretches are more appropriate. Static stretching is where the stretch is applied then held for a period of time. It is important the stretch is not forced by is applied gently. The piriformis muscle itself should be stretched on a daily basis and in the early stages at least 3 times a day may be required. In addition other stretching exercises for the groin and other buttock muscles will help ensure the joint is balanced.
Outer hip stretch -
To stretch the muscles that rotate the hip outwards. Lie on your back and bend the knee of the leg to be stretched. Use the opposite hand to pull the knee over to the side as shown opposite. You should feel this in the hip and buttocks. Hold stretch for 20 to 30 seconds, repeat 3-5 times and stretch 3 times a day.
Piriformis stretch: -
Lay on your back and bend both knees with the feet flat on the floor. Place the outer foot of the leg you wish to stretch on the lower thigh/knee of the other leg. Grip behind the thigh and pull this knee in towards your chest. You should feel a stretch in the buttock. Hold this position for 30 seconds, repeat 3-5 times and stretch 3 times a day.
Another version of this stretch can be done standing up where the knee is placed under and across the body resting on a table. The patient then leans forward using bodyweight to increase the stretch.
Long adductor stretch :-
It is important to stretch the long adductor muscles which attach at the knee as well as the short adductor muscles which attach above the knee. Long adductor muscles need to be stretched with a straight leg. This can be done either sitting or standing. Short adductor muscles are stretched with the knees bent. 
Short adductor muscle stretch - Sit on the floor and put the soles of your feet together. Use your elbows to apply a gentle downward pressure to your knees to increase the stretch. You should feel a stretch on the inside of the thigh. Hold this position for 30 seconds, repeat 3-5 times and stretch 3 times a day.
Muscle energy technique :-
With a partner lie on your front and get the partner to rotate the bent leg outwards (towards the horizontal) as far as it will comfortably go. Then the athlete applies gentle pressure at about 25% effort to try and return the leg to the vertical. The partner resists this movement.
Hold this pressure for about 10 seconds and then relax. The partner then moves the leg further to stretch the muscle and holds this position for 30 seconds. Repeat this process until you get no further improvements in mobility. This is an excellent stretching method and has produced some exceptional and instantaneous results. This should only be done by trained therapists.
Foam roller exercises for piriformis syndrome
The foam roller is used to apply deep tissue myofascial release massage to the muscle. One leg is placed across the other to put the muscle on stretch. The athlete then moves over the roller in a slow and controlled manor working backwards and forwards along the length of the muscle. This may be mildly uncomfortable but should not be painful. If you are not able to perform the exercise and keep the muscle relaxed then try performing the exercise a little more lightly. The aim is to relax the muscle and if it is tightening up through pain it is not working.
Strengthening exercises
Strengthening the piriformis muscle itself and also the other hip abductor muscles can be helpful in preventing piriformis syndrome recurring.
Resistance band abduction :-
Stand with one end of the band tied around the ankle and the other end attached to a fixed object, close to the floor. Move the leg out to the side, away from the body, keeping the knee straight. Once you get as far as is comfortable, slowly return the leg back to the center. Repeat 15 times and gradually build this up to 2 sets of 20 reps.
Side lying clam exercise :- 
Lay on your side with the hip to be worked on top. Bend your knees and position them forwards so that your feet are in line with your spine. Make sure your top hip is directly on top of the other and your back is straight. Keeping the ankles together, raise the top knee away from the bottom one.
Remember, don't move your back or tilt your pelvis, all the movement should be coming from the hip. Slowly return it to the starting position. Repeat 15 times initially and gradually build this up to 2 sets of 20.
Hip extension exercise :-
Position yourself on all fours. Shift your weight slightly off the leg to be worked. Keeping the knee bent, raise the knee off the floor so that the sole of the foot moves towards the ceiling. Slowly lower the leg, almost back to the starting position and repeat. Repeat 15 times initially and gradually build this up to 2 sets of 20.
