Q Do you have any advice for training for a marathon with a problematic piriformis? I’ve been dealing with pain and tightness in the area ever since my last marathon last October. I did physical therapy for two months (in April and May), which included lots of stretching, massage, weight training, and little to zero running. After that, I was doing my stretches, exercises, and foam rolling while slowly building back up my mileage. I did a 15km run and felt completely fine, but then my next long run of 18km brought back the pain and tightness all over again. I’m now starting to panic that I’ll never be able to get ready in time for my marathon. Should I give up now or is there a way to build up my mileage in time without having a battle with my piriformis every run? Also, when it’s feeling particularly bad, should I avoid using it completely or should I still be doing leg-strengtheners?
A The piriformis is one of six muscles that form the external rotator group at the hip, often referred to as the “deep six.” The muscle group is responsible for rotating the femur “out” as you would to turn a corner. The group also stabilises the pelvis when the foot is on the ground, which is critical to running, and keeps the opposite hip from dropping toward the ground. This muscle group must be strong to tolerate the repetitive forces of running.
The piriformis is often singled out as it’s located along the pathway of the sciatic nerve. Muscle spasm in the piriformis can irritate the nerve and is a common cause of sciatica, pain in the buttock and leg, caused by pressure on nerves in the lower back. I often see the piriformis in spasm if the pelvis is not optimally aligned. The pelvis can rotate out of neutral when the sacroiliac (SI) joint is not in its usual position. Sometimes this rotation can be caused by something as simple as unexpectedly stepping in a pothole or off a curb.
This is another victim-culprit issue that will require you to find the root cause of your pain. I think you would be best served by a medical provider who can assess your kinetic chain motion and pelvis alignment to develop a plan to correct any mechanical or alignment deficits that may be causing your piriformis to act up. Someone skilled in manual therapy will likely give you the quickest pain resolution. Then it is a matter of strengthening to a level that will support your distance running.
I am not sure that you will have time to safely build your mileage for your marathon if race day is looming soon, but if you do not address this problem and find resolution, you will have difficulty building up for future races.