Great Muscles to Know: the piriformis

Steward Noack, House of Indulgence Photography

While I probably shouldn’t have favorites, I do confess to having a special fondness for the piriformis.  It’s got a super cool name that just kind of rolls off the tongue (click here to hear it pronounced), it feels great to stretch it, and when it’s flexible it’ll add much more sukha to your Sukhasana (Comfortable pose) and make postures like Eka Pada Galavasana (Flying Crow) more accessible.  However, if it’s tight it will limit the ability of the femur to laterally rotate within the hip joint, which has a lot of potentially not-so-great consequences (both on and off the yoga mat).  By taking the time to learn more about this little muscle you’ll be able to more skillfully stretch it in your own practice and help your students find ways to safely stretch it in theirs.

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WHERE IT IS
The piriformis is one of six muscles located deep to gluteus maximus on the posterior aspect of the pelvis.  It attaches from the anterolateral aspect of the sacrum to the greater trochanter of the femur.

Piriformis (posterior view)

Piriformis (anterior view)

Images courtesy of Visible Body (www.visiblebody.com)

WHAT IT DOES WHEN IT CONTRACTS

• Lateral rotation of the thigh at the hip joint
  
• Medial rotation of the thigh at the hip joint*
• Horizontal abduction of the thigh at the hip joint*
  

*Most anatomy sources only list the standard actions of the piriformis from anatomical position, which is that it can laterally rotate the thigh at the hip joint.  However, when the thigh is sufficiently flexed the line of pull of the piriformis changes and it becomes capable of medially rotating and horizontally abducting the thigh at the hip joint!  How is this possible?  Well, when the thigh is flexed beyond 60° the distal attachment of the piriformis starts to move anterior to the axis of the hip joint, which changes its line of pull (see image, right).  As a result, when the piriformis contracts and shortens it pulls the lateral aspect of the femur anteriorly, which medially rotates it!

When the thigh is flexed beyond 60 degrees, the line of pull of the piriformis is anterior to the hip joint, making it a medial rotator!

HOW A TIGHT PIRIFORMIS MANIFESTS IN ASANA
Sukhasana (the "comfortable posture")
It’s pretty easy to tell if someone has tight piriformis muscles — just observe them sitting in a cross-legged position like Sukhasana (below, left).  Because the thighs are flexed significantly in this posture the piriformis muscles have become medial rotators, which means that if they're  tight then lateral rotation will be limited and the knees will be higher than the hips.  Elevating the pelvis on a bolster or two would be very helpful, as it will decrease the amount of lateral rotation necessary to sit comfortably.  When elevating the pelvis, finesse the height of the props so that the pelvis is the same height as the knees.  You could further support the posture by placing a rolled blanket underneath the crossed legs (below, right).

If the piriformis muscles are are tight, they'll cause the thighs to medially rotate in Sukhasana

You could address this issue by elevating the pelvis on a tall prop and using a rolled blanket under the legs

Left image Shutterstock.  Right image Steward Noack, House of Indulgence Photography.

Virabhadrasana 2 (Warrior 2)
In Virabhadrasana 2 (Warrior 2), the lateral rotators of the front hip need to contract to help align the front knee with the 2nd toe of the front foot.  If the lateral rotators are weak, or if the piriformis is tight, this will be difficult to do and will likely result in the knee drifting medially.  If this happens, you could have the student turn the pelvis slightly toward the front of the mat in order to more easily align the knee with the 2nd toe.

Image from Yoga International, Yoga Therapy for Your Knees

Knee Pain in Pigeon and Related Postures
As we’ve been discussing, if the piriformis is tight it will limit lateral rotation of the femur when the thigh is flexed.  Think of all the postures in yoga that this would effect!  Bada Konasana (Bound Angle pose), Janusirshasana (Head-to-Knee pose), Ardha Matsyendrasana (Seated Spinal Twist), Gomukasana (Cow-Faced pose), Padmasana (Lotus) and all related postures, Eka Pada Raja Kapotasana (Pigeon pose), and the list goes on. 

And here’s the thing: in all of these postures, if lateral rotation is limited it is very likely that the medial meniscus will get compressed and that the lateral collateral ligament (LCL) will be overstretched (see image, right for illustration of these soft tissues).  To get a little more insight into how this might occur, be sure to check out the video Keeping the Front Knee Safe in Pigeon.

Image courtesy of Visible Body (www.visiblebody.com)

HOW TO STRETCH THE PIRIFORMIS
The easiest way to stretch the piriformis is to first flex the thigh beyond 60° to turn it into a medial rotator, and then to laterally rotate the thigh at the hip joint.  Keeping in mind that when the thigh is flexed the piriformis can also horizontally abduct, we would also want to minimize horizontal abduction or perhaps even add a little bit of horizontal adduction in order to make the stretch more effective.  If you have a tight piriformis, or if you experience knee pain in Pigeon pose, try these variations:

The "Z-Sit"

Sukhasana, the "comfortable posture," with the pelvis elevated and a rolled blanket under the legs

Supine Ankle-to-Knee pose

Standing Ankle-to-Knee pose (be sure to anteriorly tilt the pelvis)

Photography by Steward Noack, House of Indulgence Photography.

If your hips are a little more open, you can stretch the piriformis in these postures:

Pigeon pose

Pigeon variation (foot in front of arms)

Ankle-to-Knee

Gomukhasana ("cow-faced pose")

Photography by Steward Noack, House of Indulgence Photography.

PIRIFORMIS SYNDROME
The last thing I’d like to share with you about the piriformis is a pathology that is very similar to sciatica.  Sciatica manifests as traveling pain along the posterior buttocks, thigh, calf and foot that has a kind of tingly, electric pain that seems to move around.  It is most often caused by a herniated disc or stenosis in the lumbar spine, which puts pressure on the sciatic nerve.  With piriformis syndrome, there is also pressure on the sciatic nerve that creates the same symptoms,  but the cause is a tight and/or inflamed piriformis muscle… not a disc pathology.

Image: Staker Chiropractic Piriformis Syndrome or Sciatica?

Causes
Piriformis syndrome can be caused by trauma to the area,  repetitive strain due to vigorous exercise (e.g., long-distance running), or prolonged sitting.   Because the symptoms so closely resemble those found with sciatica, an MRI may be required to rule out nerve compression due to a herniated disc.

Treatment
If pain is caused by sitting or certain activities, try to avoid positions that trigger pain.  Rest and ice to alleviate swelling may help relieve symptoms.  You can also try gentle piriformis stretches like Supine Ankle-to-Knee and the Z-Sit, but it may aggravate your symptoms if you stretch too deeply.  Light massage may also help, but again, if you do too much you may aggravate your symptoms.   If you are unable to find relief through the above, you can explore anti-inflammatory medication, muscle relaxants, or injections with a corticosteroid or anesthetic.

CHECK IT OUT
A couple of years ago I posted a video illustrating how to prepare for Flying Crow, which includes a lot of the piriformis stretches we’ve just discussed.  Check it out when you have some time… it was super fun to put together.

As usual, we appreciate any thoughts, questions or feedback you have.  Om Shanti!

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This post brought to you by: Jason Ray Brown

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18 Responses to Great Muscles to Know: The Piriformis
The following responses were copied over from our original blog post:

Elizabeth Armenta September 20, 2013 at 1:34 am
Great post. Thanks.

    Jason Ray Brown September 21, 2013 at 11:03 am 
    You’re welcome, Elizabeth… thanks for reading!

Helene Kerherve September 21, 2013 at 12:12 am
Dear Jason, only you could explain about the piriformis in such an easy and understandable way !

    Jason Ray Brown September 21, 2013 at 11:06 am
    Thanks Helene! Looking forward to seeing you in ASFYT-3 again, whenever you can drop in

susan rhoades September 22, 2013 at 2:42 pm
I think that most docs would first refer pt to a PT prior to ordering a MRI. While MRIs are the gold standard for Dx herniated disk or lumbar misalignment it is not always the whole story. There are many reasons why people have pain in low back and buttock with referred pain down legs. Pain in and of itself is not very diagnostic.

Brenda Bell September 22, 2013 at 2:44 pm
Thank you for this well detailed article. I look forward to reading more of your articles.

    Jason Ray Brown September 22, 2013 at 2:49 pm
    You’re welcome, Brenda. Thank you for reading

Rogelio Nunez September 22, 2013 at 2:51 pm
I have a tight rt periformis, but i keep up after it and causes no pain, but it does misalign my pelvis, which i work on… i have also noticed that my rt. iliopsoas muscle is tight, so i have made that connection that they interact w each other, creating more disharmony.  so look to you psoas if you have periformis issues..

    Jason Ray Brown February 4, 2014 at 1:42 am
    Thanks for your input Rogelio… very interesting about the connection between the iliopsoas and the piriformis. As both the piriformis and the iliacus cross the sacroiliac joint, I can see how they would interact with each other.

Jenny September 22, 2013 at 11:06 pm
Thanks so much for sharing this article. As a fellow teacher with a year long stint in sales this past year, my piriformis is killing me!! I just took an amazing class with a young girl who taught many of these poses and I can’t wait to integrate this into a sneaky piriformis sequence for my students–they would love one legged flying crow

Thanks again - Jenny

Pat September 23, 2013 at 4:30 pm
Really helpful article. Explains some of the problems I’ve had in the past and the tightness I experience in many poses.  Thanks

    Jason Ray Brown February 4, 2014 at 1:42 am
    Happy that you found it helpful, Pat

dave January 19, 2014 at 12:08 am
Jason, this is fantastic. Thank you. I was having a lot of trouble understanding how something like pigeon could be a “stretch” and not a contraction of your piriformis. Your article cleared it up right quick.

    Jason Ray Brown February 4, 2014 at 1:40 am
    Hi Dave – I totally agree. I was always told that the piriformis was a lateral rotator… but then people would tell me that to stretch it you should do postures with the thigh laterally rotated. Very confusing, until I learned through Joseph Muscolino’s most excellent book, The Muscular System Manual, that the piriformis becomes a medial rotator if the thigh is flexed sufficiently.

Mike August 6, 2014 at 3:48 pm
Thank you, very useful information! I’m glad I’m not the only one who’s puzzled over how you can stretch a lateral rotator by laterally rotating it. But, I’m still having a bit of trouble mentally picturing exactly what happens at 60 degrees to reverse what the piriformis does; would it be too much to ask you to do a video using the band and model pelvis from the picture above?

There’s also one thing I still don’t understand about piriformis syndrome that I was wondering if you could help me with. When the cause of the pain is described, sometimes it sounds like it’s merely the muscle pressing against the sciatic nerve which causes it. However, sometimes it sounds like the muscle pressing against the nerve is NOT itself what immediately causes the pain. Rather, on this second way of understanding its cause, the piriformis pressing into the nerve causes the nerve to become injured and inflamed, and it’s the injury and inflammation of the nerve that causes the pain. On the first way of understanding the cause of the leg pain, merely getting the muscle to loosen up and stop spasming would be sufficient to stop it; but on the second way, relieving the pressure the muscle puts on the nerve is only a first step toward stopping the pain –you then have to wait for the damaged nerve to heal before pain is alleviated.

I also find the same ambiguity in descriptions of other sciatic leg pain. E.g., in the case of sciatica from a ruptured disc, sometimes it sounds like the ruptured disc hitting the nerve by itself causes the pain, but sometimes it sounds like the disc (or fluid from inside it) hitting the nerve causes the nerve to become injured and inflamed, and that its this consequent injury and inflammation that is causing the pain.

So I guess my question is this: is it merely sufficient for something that ordinarily doesn’t touch the sciatic nerve to start hitting it to cause sicatic pain, or does the thing hitting the nerve cause the pain more indirectly, that is, by causing inflamation which itself is the proximal cause of the pain. Any insight you have would be appreciated.

    Jason Ray Brown August 6, 2014 at 6:55 pm
    Hey Mike -thanks for leaving a comment. I think I might have some video somewhere showing how the line of pull of the piriformis changes when the thigh is sufficiently flexed. I just need to track it down. I’ll add it to my to-do list, I promise! But in the meantime, perhaps I can help you visualize it. When standing, the piriformis travels from the lateral aspect of the sacrum to the greater trochanter of the femur, and the line of pull is posterior to the hip joint (imagine the muscle traveling posterior to the neck of the femur). So when the muscle contracts and shortens, it pulls the posterior aspect of the greater trochanter toward the sacrum… laterally rotating the thigh. When the thigh is flexed, the greater trochanter moves downward as the distal femur moves upward, and somewhere between 60-90 degrees of flexion the piriformis ends up anterior to the hip joint (it’s now traveling superior and slightly anterior to the neck of the femur). So now when it contracts and shortens it pulls the lateral aspect of the greater trochanter toward the ceiling, medially rotating the thigh.

    As to your second question: “is it merely sufficient for something that ordinarily doesn’t touch the sciatic nerve to start hitting it to cause sicatic pain, or does the thing hitting the nerve cause the pain more indirectly, that is, by causing inflammation which itself is the proximal cause of the pain.” I think it’s a combination… as the nerve can get entrapped and therefore irritated, or the inflammatory response (from either a herniated disc or an injured piriformis) can also irritate the nerve. In my understanding, you’d want to address the root cause first, but then the nerve itself would also need to be given time to quiet down, so to speak, after having been irritated.

For more, you can check out http://www.spine-health.com/conditions/sciatica/what-piriformis-syndrome.

Best, Jason

Mike August 6, 2014 at 9:11 pm
Thanks Jason, that extra explanation actually was helpful and I think I get it now. Still, I would love to see the video and will be on the lookout for it in case you do find it.

Thanks also for your answer to my second question. So essentially, piriformis syndrome (and other similar sciatic ailments) are like a blister you get from wearing shoes that don’t fit right. Except with the sciatic nerve, you don’t have the option of riding it out and building up a callous or using bandaids, you’ve got to, so to speak, stop wearing the shoes (stop irritating the nerve) and give the irritated nerve time to heal. I think this is kind of important and relates to another thing you mention in your piece, to wit: that stretching the piriformis while you are suffering from piriformis syndrome can make things worse. I’m going though my second bout of piriformis syndrome now (first one was 3 years ago), and though virtually EVERY website I’ve come across says that you should immediately start stretching the piriformis, my experience is that doing pretty much anything at all including external rotations of the hip makes the pain worse within an hour or two. I think this is because “the blister” needs to heal and virtually anything you do is likely ultimately to make the muscle hit the nerve again and make it worse. In my experience, doing anything even remotely active before the injury heals just lengthens the recovery time and the only good advice is unfortunately what no one wants to hear, namely, to “wait and hope”.