Debilitating Piriformis Syndrome and Cycling

thereandback

I'm glad you kept this thread going. I don't know how I missed it when I joined. I joined specifically looking for help with this.
I've been through much the same. I rode 3-4 days/wk. for 16 years, with the exception of one year when I joined two tennis leagues. I was getting out of shape with tennis, so went back to riding.
I started seeing docs in late '97 and had an MRI. LIke you said....nothing showed up. The doc (an ortho in Marietta, Ga.) was unprofessional and insulting, too. He just suggested anti-inflamm's, telling me he had "blue ones or pink ones", when I asked what they were like. I didn't accept them. I saw another ortho and numerous chiro's, incl. one who is famed to be the "chiro to cyclists". He was one of the most clueless, and seemed to be just trying to pull more and more tricks out of his bag in one visit. I also saw two neurologists.
Part of the problem for me now is that I rode through the pain for nine (yes, you read it right) years. Sounds crazy, I know, but I thought running was the cause, not cycling. The reason was that, on the bike, I didn't feel my butt. I rode for years without realizing that, during a ride, the nerves were going numb in the area around my pudendal nerve and sit bones. Then, at about mile 18-20, I'd get an intense ache in my r. lower back, around L5,6. I'd get off and stretch, but could only ride another 5 miles before it started to become unbearable. Sometimes I'd feel it shooting right through to the front of me, making it harder to tell where the problem was originating.

At the same time, I'd been having pain in my leg on that side while jogging. At about mile 3 in a run, I'd start to feel a pain in the crease where the butt ends and the hamstring begins. Afterwards, my leg would be stiff, and I'd have trouble moving it properly for two days. Sometimes, it would be so bad, at night in bed, it felt like some woman with those really long fake nails had put her claws together on one hand and was digging into and pinching my butt. I could never palpate it, though, and neither could the docs. It was too deep.
I went back and forth giving up running for two weeks, then cycling for two weeks, then each one for 3 weeks, then longer and longer. It wasn't until I had a really bad mtn. bike crash in 2001, that forced me to give up all road AND off-road cycling and for six months, and jogging for a year, that i figured it out.

I went back to riding, and the pain started back up. So, I quit it again for six more months. Then did each one of jogging and cycling, a few days apart and alone so I could pay close attention. The jog was first. I felt it slightly, but not much. Then I rode. I noticed some discomfort in my crotch first, then it became numb, which came as a surprise, as I'd never even noticed it before. Well, I suppose the absence of pain wouldn't make one think there's a problem. Then, at about mile 10, the pain in my back started, earlier in the ride than ever. I continued jogging, but not riding. I felt it, but not badly, while jogging.

About three years ago, someone on another forum suggested piriformis syndrome, and I started piri stretches. I definitely felt those, but it didn't help much. I've just done too much damage for too long, I'm afraid.

I can't believe it took me nine friggin' years to figure it out. And I share your frustration with medicine and doctors.


I haven't been on the road bike in three years this summer. THe last mtn. bike ride was last summer, but I had not been on it in months before that. Both hurt now, and I don't know if I'll ever ride again. The most uncomfortable thing for me now is driving. It always was very uncomfortable, but I'm surprised it continues. I can't stand it for more than about 10 minutes. On longer highway drives, I'll put the car in cruise and press both feet hard against the floorboard to hoist myself up off the seat, so I'm basically hovering about six inches over it. When my quads or toes get tired of that, I'll sit back down on one foot to keep myself slightly elevated and get the pressure off those nerves.
Now, it actually feels like my hamstring muscles, near the hip attachment, have gotten too thin. It feels like they're both going to just split one day.

As for the Piriformis syndrome, I read that it's the muscle in front that abducts your leg, but only when the leg is rotated outward. So, there's a stretch I used to do that causes my leg to do just that: rotate outward while it's abducted. Trying to put weight on that leg to lift myself back up out of the position feels like a tremendous strain on the "bad" side, whereas it's easy on the other side. It seems to be secondary to the other issue(s), or a result of the other issues, so maybe that's the problem docs have with it?? That it's not really the primary issue? who knows.

andoli

just found this thread and I can't believe the problems you guys have had !

I'm a physio in the UK and have treated cyclists with Piriformis syndrome on several occasions.
As someone says, there is no gold standard diagnostic test for this, and to the best of my knowledge, MRI is inconclusive due to the nature of the tissues involved.

Something like 15-20% of the population have the sciatic nerve passing through the piriformis muscle, as opposed to around it, I suspect that this is the case in folk suffering from a chronic condition.

Stretching (for example here-
http://www.drbackman.com/piriformis-muscle-stretch.htm )
is a beneficial means of relieving the muscle spasm which contributes to the problem, also specific soft tissue massage, preferably by a strong masseur ! who can dig deep enough to affect the piriformis, or alternatively positioning the most tender spot over a golf ball as a self help measure, is useful.

I have found that acupuncture can have a marked effect and combined with manual therapy/heat therapy generally produces a good response.

Davidson2506

I just stumbled across this forum while searching for info on the piriformis. There has been alot of good advice in this thread so I thought you guys might be able to help.

For the last few years I've had pain in my piriformis. Mostly on the left side, but also on the right. Lately this has been accompanied by some lower back pain. I used to shrug it off because the pain wasn't that bad and only came around every 2 months or so. But about two months ago it got so bad that it lasted for days and I ended up in the er because I couldn't walk or move without massive pain. The pain was 10x worse lying down for some reason. I was told I don't have piriformis syndrome because the pain doesn't migrate down my leg or give me a tingling sensation. I've been stretching daily, including the stretches that were suggest here, but now the pain is back and just as strong as ever and it doesn't seem as though the stretching has done any good.

Has anyone ever encountered this or albe to offer any advice? Any help would be greatly appreciated.

Davidson

andoli

Davidson, don't mess about, get an accurate diagnosis of what's going on.

If you're experiencing pain as you describe, then it's really dangerous to try to self diagnose by reading forum replies !

I don't mean to be patronising in any way by saying that, but it does sound as though there may be something more than piriformis syndrome going on and it needs a professional opinion.
The key pointer to this is the way you describe how the pain is worse ++ on lying down.

Please get it checked out properly.

And let us know how you get on..
Kind regards.

Davidson2506

Andoli, thanks for the response. I did get a professional opinion. In fact I went to one of the top sports medicine practices in North America. They do olympic athletes, professional sports teams etc. It is there that I was told that I do not have piriformis syndrome. However an accurate diagnosis was difficult for them to provide because by the time I got an appointment my symptoms had abbated. No matter how hard they tried - and it was very - they could not reproduce the pain. They seemed to think I had a strain of the piriformis. I found this to be dubious as the pain was present on both sides. They said that I must have strained both!

They could not provide an explanation as to why it is worse lying down or why it occurs randomly, seemingly with out any precursors such as exercise vs rest etc. The reason I posted here is the possibility that someone else might have had a similar experience and might be able to offer some advice or point to a possible answer. Further, such appointments can be expensive and, since I have no new information to offer, it would be doubtful that they would either given the same facts. Since the stretches I was given seem to have had little to no effect, I was hoping that a change in focus might be offered here. Perhaps I could have been clearer in my earlier post.

Thanks again,
Davidson

andoli

The fact that your symptoms have abated is reassuring, and if attempts to provoke the symptoms have been unsuccesful, that would indeed indicate soft tissue injury (muscle, ligament or tendon).

What concerned me was the way things became worse on laying down, my thoughts on that were that maybe you had a stenosis or spondylolysthesis, in which case MRI/Xray would be necessary.

But... the good thing is that if it is resolving, then this is a very remote possibility.

Still if you're not sure I would recommend a referral for scans, as much as anything else to reassure you.

kind regards
Andoli

bulaboy

As a massage therapist (CMT) I have treated many people w/ piriformis syndrome. I also teach continuing ed classes for MTs. Piriformis syndrome is one of the conditions that we cover. There are accurate ways to differentiate pain that comes from nerve root impingement ie spinal disc protrusions etc (radiculopathies) and pain from piriformis syndrome (peripheral neuropathy). Conservative treatment with massage and stretching can be very effective in most cases. The trick is to find a MT who knosw what he or she is doing. Good luck.

CapeRoadster

Any doctor who does not recognize the piriformis syndrome is living in the dark.

It is an easy differential diagnosis from herniated disc and other "space-occupying" lesions of the lumbar spianl cord and nerve roots.

Surgery should be a last resort for anyone (exception, cauda equina syndrome).

I had an L5-S1 herniated disc last year. Two surgeons said operate, one said wait and see, and of course the first two were dead wrong.

Dead wrong.

Pilates is great! But functional training is better. My sports chiropractor (not the one listed above) is fantastic.

Remember, most low back pain is muscular, and Type I muscle fiber has to be trained to restore a healthy back. So many PT's I went to never understood that. Stability is key, and endurance exercises are where it's at. Any seated exercise that loads the lumbar spine is IDIOTIC, and will lead to a low back injury. Yet most health clubs have seated machines that load the back.

Dumb, dumb, dumb, dumb, dumb, dumb, dumb (like most personal trainers I have met).

More power to you, Latdog. The active figure 4 stretch and active isolated stretching (ART technique is passive and way over-hyped; it's also expensive for the chiropractor to learn--that is, the people selling it are interested in MONEY) are a good start.

__________________
I love France. I just hate Toulouse. I'd really hate to lose le Trek.

CapeRoadster

There are 4 anatomical variations of sciatic nerve passage under/over/through the piriformis (Travell & Simons), and I agree with you that passage through it may be the cause of chronic cases. But you know as a PT that passage under a tight, scarred piriformis can also lead to chronicity.

MRI will detect which anatomical variation is there. resolution of MRI on a good day is about a quarter inch. The problem is that radiologists and doctors do not yet utilize MRI for this problem mostly, so patients will likely not get an answer from MRI.

Massage, heat and ice (and knowing when to use which), electric muscle stimulation (I like microcurrent therapy among others), ultrasonic therapy, active stretching, spray and stretch, acupuncture, myofascial release, trigger point myotherapy can all work. Spinal manipulation often works well in these patients also, albeit indirectly. Clearly, endurance training of adjacent muscles is key. A strong gluteus medius and strong lateral hip rotators are essential, among other things. For my patients, active exercise, in the correct order with the correct progressions is the most important thing.

For my painful right piriformis, I use a foam roller and it works MAGIC! Way better than the golf ball, although that definitely works for some as well.

Diagnostically, piriformis syndrome is often accompanied by:
-toe-out on the affected side
-decreased medial hip rotation on the affected side with pain upon testing
-tenderness to palpation at the posterior-medial trochanteric region adjacent and posterior to the trochanteric bursa (i.e., piriformis insertion)
-tenderness to palpation at the origin and belly of the piriformis
-possible sciatic radicular symptoms without positive orthopedic tests for herniated disc or other space-occupying lesions (negative orthopedic tests include, SLR, seated or supine; Valsalva's; Dejerine's triad signs of coughing, painful bowel movements, etc.; Bragard's sign (dorsiflexion of the foot and/or great toe); Soto-Hall test (seated knee extension with cervical spine flexion); pain upon sitting relieved by standing or extension; etc.

My experience with herniated discs has been that the patient experiences the pain in the spinal region and NOT JUST the gluteal region. With disc patients, there is often tenderness at the spinous processes or interspinous spaces at the level of the disc herniation. Not so in the piriformis patient. Disc patients usually do not like to sit, and the pain is often relieved by walking if antalgia isn't too bad. Walking often aggravates the piriformis patient. Disc patients often respond to McKenzie protocol whereas piriformis patients do not.

Piriformis patients are often confused with gluteus medius patients and other patients with short lateral hip rotator problems. Again, easy differential for glut. med. pts. But more difficult for the other short lateral hip rotator patients. I have found that piriformis definitely behaves differently than, say, a patient with obturator or gemelli problems, and that diagnosis can be made by rotation with varying degrees of hip flexion on the affected side. But that's another story for elsewhere.

I'm a chiropractic physician on Cape Cod Massachusetts, working with athletes regularly, and practicing much like physical therapists, for whom I have great respect.

__________________
I love France. I just hate Toulouse. I'd really hate to lose le Trek.