The BEST Deep Gluteal Syndrome Treatment (Science-based)

You might have been diagnosed with “Piriformis Syndrome”. In this blog article, I will show you, why “Deep Gluteal Syndrome” is actually the correct term for this condition. And at the end of the article you will learn, what the Best Gluteal Syndrome Treatment looks like (according to science)!

Understanding the Problem – Cause of Deep Gluteal Syndrome

To understand the issue, let me first explain the background of Deep Gluteal Syndrome. The Piriformis muscle extends from the sacrum to the femur, and the sciatic nerve typically runs below the Piriformis muscle.

The hypothesis is that when the muscle is too tense, it presses on the sciatic nerve, causing the symptoms. However, since many other structures besides the piriformis can also lead to sciatic nerve compression, it is no longer called Piriformis Syndrome but Deep Gluteal Syndrome.

Examples of other structures that can cause this compression include the Gemelli-Obturator Internus complex, the hamstrings, and some ligaments. Nowadays, it is also uncertain whether the compression of the sciatic nerve is really the cause of these deep buttock pains.

Six different types of sciatic nerve paths have now been documented. If you look at Type 2 in the following illustration, it should actually cause the most problems, as part of the sciatic nerve runs through the Piriformis muscle.

This Type 2 is actually quite common. Bartret et al. conducted a study in 2018, examining over 1000 hips of adult humans and found this Type 2 in 20% of people.

However, the particularly interesting aspect of this study was that they found no connection between this Type 2 variation and Piriformis Syndrome. Therefore, it can really be questioned whether a compression of the sciatic nerve is the actual cause of these deep buttock pains. Interestingly, this study showed that Type 2 individuals did not suffer from Piriformis Syndrome more frequently than those with a different sciatic nerve path.

Another point arguing against sciatic nerve entrapment is that with nerve entrapment symptoms, you usually experience numbness in the area, significant loss of strength, and tingling, radiating pain. Only about 6-8% of people with ischiadic nerve issues have Piriformis Syndrome.

Thus, if your sciatic nerve is affected, the cause is most likely a disc problem. In that case, the pain could be radiating from a herniated disc into the gluteal muscles and thigh.

---

---

What Helps with Deep Gluteal Syndrome – Diagnosing the Problem

First, it would be useful to examine the lumbar spine to see if there is any disc problem. You can check if the problem runs along the entire sciatic nerve or is localized, for example, just in the buttock area.

Active Straight Leg Raise

If it’s only in the buttock area, it’s most likely not a disc problem.

Another way to test this is with an Active Straight Leg Raise or Lasegue Test. Simply lie on your back and lift the leg on the painful side while keeping it straight.

If you feel a sharp, shooting pain, it’s most likely a nerve root issue.

Additionally, you should examine the sacroiliac joint (SI joint) using the Laslett Cluster, which consists of five tests.

Active Piriformis Test

Now let’s move on to testing the piriformis itself, along with all other external rotators, since you can’t isolate the piriformis.

To test your piriformis, you can do the Active Piriformis Test. This test is essentially a Clamshell held against resistance.

For the Clamshell, hold the end position while a second person presses against your upper knee. If this triggers your buttock pain, it’s likely Piriformis Syndrome or Deep Gluteal Syndrome.

If you don’t have someone to press against your upper knee, you can use a firm resistance band to perform the test.

Palpation of the Muscle

Another very simple test is to manually palpate the piriformis area with your hands. Apply firm pressure to see if it provokes pain. It’s crucial to also test the other side because pressing firmly will hurt everyone.

For persistent lower back pain, especially in the lower back, the pain may radiate into the buttock area.

Lastly, it’s important to mention that pain can be influenced by many different factors. So, also pay attention to things like relationships in your life, anxiety, depression, sleep quality, diet, etc.

What Helps with Piriformis Syndrome – Treating the Problem

Short-Term Symptom Relief (Stretching, Massage…)

Let’s start with things that provide short-term pain relief. Possible measures include stretching exercises for the gluteal muscles, massage, dry needling, or foam rolling. You can do all these things to alleviate symptoms in the short term.

If the pain is very severe, you can also take painkillers for relief, but I would advise against injections.

In the acute phase, it’s also crucial to reduce activities that trigger your pain. For most people, this includes prolonged sitting or standing. Using a cushioned pillow while sitting can help many people.

For those who find sleeping on their side problematic, using a pillow between your knees can help so that the gluteal muscles aren’t constantly under tension.

---

---

Piriformis Syndrome Treatment – long term

To manage the pain long-term, I recommend a progressive strengthening program for the gluteal muscles.

Although the evidence is not entirely conclusive, it suggests that weak muscles are often tense muscles (Bruner & Romkes 2008).

I’ll now introduce a progression of exercises to get you started. These aren’t the only exercises you can do, and you can certainly substitute them with others.

Piriformis Syndrome Exercises

You can start with Clamshells. This exercise is very isolated and puts little load on the gluteus maximus. If you’re unfamiliar with the exercises I suggest, just check the YouTube video.

Additionally, you can start with Glute Bridges.

This is a simple bodyweight exercise, super easy. Start with both legs, then progress to single-leg bridges.

Next are Hip Thrusts. These are essentially Glute Bridges but allow you to progressively increase the weight. Hip Thrusts can also be done with both legs or one leg.

Squats are also a great exercise for the gluteal muscles that you can progressively increase.

Lastly, I recommend doing Split Squats or Front Foot Elevated Split Squats.

These exercises further engage the glutes, which is what we aim to strengthen.

Depending on your current phase and pain intensity, select two or three exercises from the list. Do these exercises 2–3 times a week for 3 sets of 12 repetitions each.

It’s crucial to monitor your pain levels. During the exercises, your pain should ideally be below 3 out of 10 on a scale of 0 to 10, with 10 being the maximum pain.

It’s acceptable if the pain occasionally reaches 5 out of 10, but it shouldn’t exceed that. Even 24 hours after the exercises, the pain should ideally remain below 3 or 5.

If you want to learn more, I recommend the article “How to activate your Glutes (& Fix Gluteal Amnesia)“.

---