• Excessive pronation causes the foot to roll too far inward, rotating the leg and hip inward. This forces the hip muscles to pull harder to re-supinate the foot at push off. If the excess pronation forces the knee to rotate inward, the gluteal muscles can be irritated due to over-stretching.
• If the piriformis muscle is inflamed, overdeveloped and enlarged from repetitive use, or stretched excessively against the sciatic nerve, there can be nerve irritation (sciatica). This can produce a variety of symptoms that may or may not radiate down the leg.
• Lateral pain that is higher in the gluteal area can have the same cause, but it is most commonly due to stepping up or sinking into the hip (noted by the other hip dropping below the level of the standing one). The stepping up occurs when climbing, and the sinking will occur while compensating for unequal leg lengths, weak gluteal muscles, and striking the ground with higher impact. Increased impact can come from overstriding, particularly when yoga downhill – meaning that the leg is landing with the knee locked straight. In this case, the hip absorbs the impact usually accepted by the thigh muscles (when the knee is slightly flexed).
• Lack of flexibility in the hip muscles may be a cause, but less often. Some studies show that women are five times more likely than men to suffer this injury, which may indicate that lack of strength may be part of the problem. Extreme tightness can be a cause, but it is unlikely that moderate tightness is as much of a problem as muscle weakness.
• Many people experience a torque or a turning of the pelvis. This can be from previous injury, compensation for a leg length difference, asymmetric strength, and sometimes genetic issues. In each case, extra stress is absorbed by the gluteal and deeper muscles.
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• Most athletes will experience short periods of soreness in this area which is of little concern. A couple of days of rest from the offending motion will allow for healing. If not responsive, or if it keeps reoccurring, additional treatment should be used. This is a deep injury, so a longer recovery time is advised. If there is surface inflammation, use ice. If the muscle swells, it may irritate the nerve. Massage is almost always helpful. Get a shoe check to ensure that you are receiving the needed stability to control/eliminate overpronation. Consider a gait analysis to note yoga form irregularities. Gentle stretching of the hip may help, but be careful. This means both inwardly and outwardly rotating the thigh bone in the hip joint. When doing this, get instruction from a professional. Do not stretch or rotate into pain of any type.
• If the pain persists, an evaluation of the hip should be considered, especially if there is any radiation of the pain downward or upward toward the lower back or tailbone. This can be done by a doctor so that other medical reasons can be eliminated or diagnosed. An X-ray is helpful to rule out hip, joint and back problems. If nerve pain is the primary symptom, an MRI is a good idea. These are not very effective for diagnosing muscular pain, however.
• Physical therapy is the most effective treatment for this problem. An evaluation of the back, hip position, muscular strength and flexibility, unequal leg length, and related weakness such as abdominal strength, can be necessary to construct a rehabilitation program. More difficult cases require addressing each of these. Manual therapy is very useful, and can help to straighten a rotated pelvis. A comprehensive PT program can also apply specific massage techniques to improve muscle function and healing. This often involves strengthening the non-injured hip muscles.
• Extreme cases may require injections by an orthopedist, with mixed results. Recent evidence indicates that in certain cases Botox injections can atrophy the muscle and relieve pressure on the nerve to reduce the random and excessive firing, but long-term effects are not known.
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