Pilates guide
Piriformis syndrome means pain deep in the buttock, sometimes down the back of the leg, put down to the piriformis muscle irritating the sciatic nerve. It's real but debated: there's no reliable test, and most buttock and leg pain comes from the back. No trial has tested Pilates for it, but Pilates can deliver the plan that makes sense: hip and trunk strength, gentle movement, comfortable stretches and less sitting.
Pilates sits beside care from your GP or a physiotherapist, never in place of it, and leg symptoms that spread need assessing. This guide covers what piriformis and deep gluteal syndrome are, how to tell them from sciatica from your back, what the small trials show, the Pilates moves to use and the stretches to keep only if they help, why to build up gently, which classes to follow, and the warning signs.
There's no accepted test. Reviews describe four common features: buttock pain, pain worse sitting, tenderness deep in the buttock, and pain when the muscle is stretched or tensed. Many clinicians now call it deep gluteal syndrome (DGS).
Estimates of how often piriformis syndrome causes sciatica vary widely, from under 1% to about 15%, depending on how it's defined, and they come second-hand from small clinic studies. A slipped disc is the commonest cause of sciatica.
The trials are small and mostly compare two treatments. Reviews advise following the usual back pain and sciatica care first: physiotherapy and staying active.
We found no trial of Pilates for piriformis syndrome. Pilates can deliver the general plan: hip and trunk strength, such as bridges, clamshells and side kicks, gentle movement and less sitting.
Stretching was part of most trial programmes, and programmes that added other treatment did better than stretching alone. Stop a stretch that sends pain or tingling down your leg, and build up slowly if you're new to classes.
Sciatica in both legs, numbness around your genitals or bottom, or new trouble peeing or pooing needs 999 or A&E (accident and emergency), not a class.
The piriformis runs from the base of the spine (the sacrum) to the top of the thigh bone, deep under the big buttock muscle. The sciatic nerve usually leaves the pelvis just below it, and in some people part of the nerve runs through it. A review describes piriformis syndrome as "a form of sciatica caused by compression of the sciatic nerve by the piriformis muscle", and "a relatively uncommon, but not insignificant, cause of sciatica".
Across 55 studies, mostly single cases, the commonest features were buttock pain, pain worse sitting, tenderness near the notch of bone where the nerve leaves the pelvis, and pain when the muscle is tensed. The 2018 update says these four define it, but "the accuracy of these tests and the symptoms cannot be concluded from studies to date", and that a straight-leg raise doesn't rule it out.
Its existence "remains controversial", the 2010 review says: in one survey only 21 of 29 US rehabilitation doctors believed it exists, and it has been called both over- and under-diagnosed.
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Many clinicians now use the wider label deep gluteal syndrome: the sciatic nerve trapped in the buttock by something other than a disc, such as the piriformis, the small hip muscles beside it or the top of the hamstrings. A US family-medicine review calls piriformis syndrome "a subset of deep gluteal syndrome", with "deep buttock pain that is aggravated by sitting and sciatica symptoms". A review of 14 studies (853 people) found clinicians "are not confident" in diagnosing it.
The usual story is a tight muscle. One case report found weak hip muscles instead and treated the pain with strengthening alone, and in a study of 91 people the muscle wasn't thicker in those with the syndrome. Neither shows what causes it.
Pain mainly deep in the buttock, worse sitting and tender there, points towards the piriformis. But a straight-leg raise "may or may not be positive, and therefore is not useful in differentiating DGS from spinal sciatica", and a magnetic resonance imaging (MRI) scan of the lower back "does not visualise the deep gluteal space".
Pain that runs below the knee into the foot, with pins and needles, numbness or weakness, or leg pain that started with back pain, points to a nerve root in the back: sciatica. The NHS sciatica page doesn't mention the piriformis, and the NHS has no piriformis page.
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The lower back, the sacroiliac (SI) joint, the hip joint and the hamstring tendon at the sitting bone all cause buttock pain. Our buttock pain guide sorts them by where it hurts.
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A review of 13 studies (508 people) found low-quality evidence; all its randomised trials tested injections. Its advice: "Clinicians should follow general guidelines on the management of back pain and sciatica for first line treatment, namely physiotherapy." A 2019 editorial by the same lead author found no controlled trial of physiotherapy at all.
The NHS says to start gentle exercise as soon as you can and not to sit or lie down for long periods. The National Institute for Health and Care Excellence (NICE) suggests considering a group exercise programme for back pain with or without sciatica; it doesn't name Pilates.
The first review of stretching (12 studies, 572 people, only 4 randomised trials) found that "Combined interventions generally demonstrated greater improvements in pain, function, and range of motion than stretching alone", but warned of small samples and no long-term follow-up. In trials of 40 to 48 people, two stretching or lengthening techniques, or two hands-on techniques both with stretching, all helped, with no untreated group to compare. In 45 people with deep gluteal pain, self-stretching did better for disability than self-compression.
Dry needling did no better than a 3-week exercise programme in 44 people, and shock wave therapy no better than dry needling in 48 people who all stretched. Injections are a second step, from low-quality studies.
In one case report, hip strengthening and movement retraining alone eased the pain after testing found weak hip muscles that turn the thigh out and move it sideways. A single session of bridges and clamshells improved one-leg balance but not pain in 12 people. That's not trial evidence, but strength work is low-risk and helps the back pain and sciatica that this pain is often confused with.
Our search of Europe PMC found no trial of Pilates for piriformis or deep gluteal syndrome. The only Pilates-specific report is a single case of severe piriformis syndrome in a 60-year-old woman after three yoga and Pilates sessions, started after nearly a year of inactivity; the authors suggest these classes can involve extreme hip positions. One case shows it can happen, not how often.
Pain worse sitting is one of the commonest features. Break up sitting every 30 to 45 minutes (our piriformis syndrome guide's plan), and do seated Pilates moves on a cushion or a chair.
Two or three sessions a week of hip and trunk strength: bridges, clamshells, side kicks, the bird dog and standing leg work at a wall. Keep the stretches that ease your pain and drop those that don't.
Some discomfort during exercise is fine, and it does not mean you are doing damage: the WHO counts "hurt does not necessarily mean harm" among the messages people with back pain need. Aim for pain you would call mild to moderate, no more than about 5 out of 10. It should settle within an hour or so, and your back should be no worse the next morning. If it is worse, do less next time (fewer reps, a smaller range, a lighter load), not nothing.
Leg symptoms are the exception: stop or shrink any movement that sends pain, pins and needles or numbness further down your leg. If leg symptoms move back towards your spine, that is a good sign, even if your back aches a little more for a while.
If you're new to classes or coming back after a break, start with the gentler class below and add one change at a time. Don't force deep hip stretches or hug a knee hard across your body.
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If a ball helps, keep it moving and off the middle of the buttock: in a single case report, a sciatic nerve injury followed ball self-massage there. Stop if tingling spreads.
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No trial has tested it. Footwork, bridging and side-lying leg work on light springs train the hip muscles; keep long seated work short if sitting is what hurts (our suggestion).
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Lateral breathing, 5 to 8 breaths at the start of every session; hip windshield wipers, 10 slow passes side to side, 2 rounds (the moves' pages); one knee to chest, 2 to 3 holds of 20 to 30 seconds; reclined figure four, 2 to 3 holds of 20 to 30 seconds each side, only if it eases the pain; glute bridge, 2 sets of 10 (our piriformis syndrome guide's plan); pelvic tilts, 8 slow reps (our editorial starting point).
3D demoLateral breathing (Pilates breathing)Beginner · No equipment
3D demoPelvic tilt into bridgeBeginner · No equipment
3D demoHip windshield wipersBeginner · No equipment
3D demoSingle knee-to-chest stretchBeginner · No equipment
3D demoReclined figure four (eye of the needle, Sucirandhrasana)Beginner · No equipment
3D demoGlute bridgeBeginner · No equipmentClamshell and side-lying leg raise, 2 to 3 sets of 10 to 12 (our piriformis syndrome guide's plan); side kick, 8 to 10 each side; belt press (supine isometric hip abduction), 3 to 5 holds of 5 to 10 seconds, twice a day, at a light effort; knee folds and fall-outs, 2 sets of 5 to 10 each side, every other day (the moves' pages); knee side plank, 2 holds of 15 to 20 seconds each side (our editorial starting point).
3D demoClamshellBeginner · No equipment
3D demoSide-lying leg raiseBeginner · No equipment
3D demoSide kick (Pilates side kick series)Beginner · No equipment
3D demoSupine isometric hip abduction (belt press)Beginner · A band
3D demoKnee foldBeginner · No equipment
3D demoBent-knee fall-outBeginner · No equipment
3D demoKnee side plankBeginner · No equipmentBird dog, 2 sets of 8 each side (our piriformis syndrome guide's plan); wall side leg lift, 10 to 12 each side; standing wall-press hip abduction, 3 to 5 holds of 5 to 15 seconds each side, twice a day (the moves' pages); glute kickback and sit to stand, 2 sets of 10 (our editorial starting point); later, single-leg glute bridge, 3 sets of 8 to 10 each side (our sciatica guide's plan).
3D demoBird dogBeginner · No equipment
3D demoGlute kickback (quadruped hip extension)Beginner · No equipment
3D demoWall side leg lift (standing side kick at the wall)Beginner · A wall
3D demoStanding wall-press hip abductionBeginner · A wall
3D demoSit to stand from a chairBeginner · A bench or box
3D demoSingle-leg glute bridgeIntermediate · No equipmentLying figure-four stretch, hold 20 to 30 seconds, 2 to 4 times each side (the move's page); pigeon preparation, 2 to 3 holds of 30 seconds, if you enjoy it (our piriformis syndrome guide's plan); standing figure four, 2 holds of 20 to 30 seconds each side with a hand on a wall (our editorial starting point); foam rolling, about 90 seconds for each muscle you roll (the move's page). Stop any stretch that sends pain or tingling down your leg.
3D demoReclined figure four (eye of the needle, Sucirandhrasana)Beginner · No equipment
3D demoLying figure-four stretch (ankle on the knee)Beginner · No equipment
3D demoStanding figure four (chair pigeon, Eka Pada Utkatasana)Intermediate · A wall
3D demoPigeon preparation (Eka Pada Rajakapotasana prep)Intermediate · No equipment
3D demoGlute and piriformis foam rollingIntermediate · A foam rollerNo trial has tested a list of Pilates moves to avoid with piriformis syndrome; these are our suggestions, from what makes it worse and our move pages' cautions.
The saw, spine twist, mermaid and spine stretch keep you sitting on the sore buttock: sit on a cushion or block, or on a chair, and keep them short.
Don't force the knee across your body or the hip into a deep turn-out, and never press down on a crossed knee. Ease off if pain or tingling spreads.
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Leave it out; keep any ball moving and off the middle of the buttock.
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Start with the Pilates for hip pain class while the buttock is irritable, then move on to the glute class; keep its closing figure-four stretch only if it eases your pain. Use the sciatica yoga class if leg symptoms are the main problem.
A 20-minute Pilates class for hip pain: bridges, outer-hip holds, standing leg work and balance, without deep bends, crossed legs or lying on the sore side.
20 minBeginner14 movesA band, A wallA 25-minute Pilates class for your glutes: bridges, the side kick series, face-down kicks and standing work at a wall, with a band to make it harder.
25 minBeginner16 movesA wall, A bandStiff hips and glutes: a few minutes of rolling the glutes and thighs, two stretches while the extra range lasts, then strength work to keep it. About 15 minutes.
15 minBeginner7 movesA foam rollerA gentle 25-minute yoga sequence for sciatica: breathing, a nerve glide, poses chosen by how your leg responds, and standing strength, with no straight-leg folds.
25 minBeginner16 movesNo equipmentA 25-minute glute workout with bodyweight and a mini band: bridges, clamshells, band walks, kickbacks and lunges.
25 minBeginner9 movesA wall, A bandThe beginner Pilates plan builds up over 4 weeks; swap any long seated move as this guide suggests.
These are the warning signs from our back pain, hip pain, sciatica and piriformis syndrome guides, word for word. This is general information, not a diagnosis. In the US, call 911 for 999, and use your doctor's urgent line or urgent care for NHS 111.
Call 999 or go to A&E: loss of feeling or numbness around the genitals or bottom, new trouble peeing or controlling your bladder or bowels, changes in genital sensation during sex or problems with erections or orgasm, or pain, tingling, weakness or numbness in both legs. These are signs of cauda equina syndrome, which needs treating in hospital urgently. Don't drive yourself.
Same day (urgent GP appointment or NHS 111): throbbing pain in one leg (rarely both), usually the calf or thigh; swelling in one leg (rarely both); red, blue or darkened skin around the painful area, which may be harder to see on brown or black skin; or swollen veins. This can be a deep vein thrombosis (DVT). It is more likely after surgery, a hospital stay, 3 or more days in bed, a journey of over 4 hours, pregnancy or a recent birth, cancer, a previous clot, or contraception or hormone replacement therapy (HRT) that contains oestrogen.
Same day: leg weakness that is getting worse.
Same day (urgent GP appointment or NHS 111): new difficulty lifting the front of your foot or toes (foot drop), or a foot that slaps down or catches as you walk, especially if it is getting worse. Weakness in both legs, or with numbness around the genitals or bottom or bladder or bowel changes, is the 999 emergency above.
Same day (GP or NHS 111): back pain and you feel hot, cold, shivery or generally unwell, or severe pain that starts suddenly or is getting worse quickly.
Ask for an urgent GP appointment or get help from NHS 111 if you have severe hip pain that started suddenly but you've not had a fall or injured your hip, your hip is swollen and feels hot, the skin around your hip has changed colour, or you have hip pain, feel generally unwell and have a high temperature (or feel hot, cold or shivery). A hot, swollen hip with a high temperature can be a joint infection.
Low back, buttock or groin pain in an older person after a minor fall, or with no clear injury, making walking very hard.
This can be a fragility fracture of the sacrum or pelvis, which a plain X-ray can miss: get it checked.
Sudden mid or lower back pain after a minor fall, lift, cough or sneeze, especially from 50 or with long-term steroid tablets.
Often worse moving or changing position and eased by lying down. It can be an osteoporotic spinal fracture, so see a GP; height loss or a new curve in the upper back are other signs.
Pain that spreads below the knee with pins and needles, numbness or weakness: read about sciatica and get assessed.
If your sciatica hasn't improved after a few weeks of looking after it at home, is getting worse, or is stopping you doing your normal activities. In many areas you can refer yourself to NHS physiotherapy for back problems.
Unexplained weight loss, or a lump, swelling or change in the shape of your back.
Pain that doesn't improve with rest or is worse at night, or pain that is worse when you sneeze, cough or poo.
Call 999 if:
Call 999 or go to A&E (accident and emergency) straight away for severe difficulty breathing (gasping, choking or not able to get words out), a chest that feels tight or heavy, pain that spreads to your arms, back, neck and jaw, lips or skin turning very pale, blue or grey, or sudden confusion. If you're more short of breath than usual, or your heart is racing, fluttering or skipping beats, contact NHS 111.
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You feel any pain or become unwell, as the NHS advises for its Pilates videos, and especially for chest pain or pressure, unusual breathlessness, dizziness or fainting. If you have a health problem, an injury or any symptoms, get advice from a healthcare professional, such as a GP, before you start.
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The NHS advises getting advice from a healthcare professional first if you have a health problem, an injury or symptoms, or have recently had a heart attack or an operation.
Most sciatica comes from the back, often a disc. Estimates for piriformis syndrome vary from under 1% to about 15%, depending on definitions.
No treatment has been shown better than another, stretching trials are few and small, and combined programmes did better than stretching alone. Stop a stretch that spreads pain down the leg.
We found no trial. Pilates is a reasonable way to build hip and trunk strength, not a tested treatment.
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In one case the problem looked like weak hip muscles, and strengthening helped; in another study the muscle wasn't thicker in people with the syndrome.
A case report describes a sciatic nerve injury after ball self-massage of the buttock. Keep any ball moving and off the middle of the buttock.
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It may help as a gentle way to build hip and trunk strength, but no trial has tested it. Reviews advise following the usual back pain and sciatica care first, physiotherapy and staying active, because no treatment has been shown better than another.
Usually not, if you build up gently. One case report describes severe piriformis syndrome starting after three yoga and Pilates sessions in a woman who'd been inactive for a year, so start low and don't force deep hip positions.
Hip strength moves: bridges, clamshells, side kicks, the bird dog and standing leg lifts at a wall. In one case, strengthening weak hip muscles alone eased the pain, but that's a single case, not a trial.
The reclined figure four is the gentlest: keep it only if it eases your pain, and never press down on the crossed knee. Stretching trials are small, and programmes that added other treatment did better than stretching alone.
It can be: footwork, bridging and side-lying leg work on light springs train the hip muscles. No trial has tested it, and long seated work is best kept short if sitting is what hurts.
You often can't tell on your own. Pain mainly deep in the buttock and worse sitting points towards the piriformis; pain below the knee with numbness or weakness, or pain that began with back pain, points to the back. A lower back scan doesn't show the deep buttock, so get it assessed.
It seems rare: one case report describes it after yoga and Pilates classes. Building up gradually and not forcing deep hip stretches is sensible for anyone new to classes.
Yes: pain worse sitting is one of the commonest features. Break up sitting every 30 to 45 minutes, and do seated Pilates moves on a cushion or a chair.
If it helps, gently and keep it moving. A case report describes a sciatic nerve injury after ball self-massage in the middle of the buttock, so stay off that spot and stop if tingling spreads.
Neither has been tested for it. Pilates leans towards strength and yoga towards stretching; a mix of hip strength and gentle stretches you enjoy is reasonable.
If pain spreads below the knee with pins and needles, numbness or weakness, or isn't settling after a few weeks, get it assessed. Call 999 for sciatica in both legs, numbness around your genitals or bottom, or new trouble peeing or pooing.
Exercise education, not a personal prescription, and clinical review of these guides is pending. If you are pregnant, have a health condition or have had recent surgery, check with a doctor, midwife or physiotherapist before starting, and stop for sharp or increasing pain. Health disclaimer.
