How to Sleep Better With Piriformis Syndrome

Piriformis pain and poor sleep create a vicious cycle. The pain makes it hard to get comfortable, and a restless night in the wrong position can leave the muscle even more irritated by morning.

“The key is to maximize good sleep because our recovery happens during our rest,” says Rajan Cheema, registered physical therapist and founder of Richmond Physiotherapist (Richmond, BC). “If you’re sleeping for eight hours, you want to make sure you’re in a good alignment so that the piriformis isn’t in a bad position and inflaming that sciatic nerve.”

The good news: A few small changes can take the pressure off (literally) while you sleep. Here’s what a physical therapist recommends for the best sleeping positions, mattress firmness, and pre-bed stretches for piriformis syndrome. 

What is piriformis syndrome, and how does sleep aggravate it?

Piriformis syndrome is a muscular disorder where the piriformis muscle, located in the lower spine and buttock, spasms and compresses the adjacent sciatic nerve.

Symptoms typically include a painful burning, aching, or tingling feeling in the buttock, hip, or upper leg. There are several potential causes of piriformis pain, including overuse, muscle imbalance, and spinal issues.

Piriformis pain often flares up at night. The piriformis is a stabilizer muscle. It compensates for weak glutes. By the end of the day—after you’ve been walking, moving, and sitting for hours on end—it’s done a lot of work.

And if you’re sleeping in the “wrong” position or your mattress isn’t supportive enough, the piriformis can be overstretched, causing it to hurt even more.

Sometimes, piriformis syndrome can be confused with sciatica. The biggest difference between the two conditions is whether or not you’re having low back pain. 

“Sciatica stems from the low back,” Cheema says. “True sciatica [is] nerve root compression happening at the low back.”

Piriformis syndrome, on the other hand, happens at the glute—and while it’s the same nerve, you don’t get that lower back pain, although both conditions will refer down the leg, explains Cheema.

If you’re experiencing painful numbness and tingling, you’re having trouble sleeping, and your pain is impacting your daily life, it’s important to get checked out by a professional. 

Best sleeping positions to relieve nerve pressure

The best sleeping position for piriformis syndrome is side sleeping on the unaffected side. Place a pillow between your knees. This keeps your hips and pelvis in alignment, maintaining a neutral spinal alignment between the spine, hips, and femur.

With piriformis pain, it’s best not to sleep in the fetal position, on your stomach, or on your back.

“The biggest reason is your pelvis is going to sink down or it’s going to sink up depending on the position,” says Cheema.

Sleeping on your back with a pillow underneath your knees, he notes, might be OK, though.

“Everyone is different,” says Cheema. “There’s no universal rule. We just know that sleeping on your unaffected side, with the pillow, is probably the best scenario.” 

What if you’re falling asleep in the right position but waking up twisted? When you’re in a deep sleep, there’s only so much you can do to control the position your body is in.

Doing some dynamic stretches before bed, however, can help keep the piriformis muscle happy so you’re not unconsciously looking for relief while asleep. 

Pillow ergonomics: knee and hip positioning techniques

A pillow between your knees can help you maintain correct spinal alignment all night long. 

Depending on the size of the pillow, you may also want to add a second pillow, this one from knee to ankle. 

“At home, I have a really large pillow, so I just use that,” Cheema says. “If your pillow’s a bit small…having the one between your ankles is good too.”

Either way, the goal is for your hips, knees, and ankles to all remain neutral. 

Nighttime stretches to relax the piriformis muscle before bed

Set yourself up for a good night of rest by doing some gentle dynamic stretching about three to five minutes before you go to sleep.

According to Cheema, keeping this nighttime routine low-key is the best way to go.

“Before you sleep, you don’t really want to do a lot of strengthening, he says. “You want something that’s a little bit more relaxing.”

He also says that “gentle discomfort” is the goal: “You don’t want to go to the point of aggravation and you don’t want any deep long stretches because when you stretch really deeply, you are overstretching that piriformis and that’s going to compress your sciatic nerve.”

Try these stretches for piriformis syndrome before bed:

• Windshield wipers: Lie on your back with your arms extended (making a T shape with your body). Bend your knees and place your feet flat on the floor. Then tip your knees from side to side. Do three sets of 20 reps each.
• Supine piriformis stretch: Lie on your back with your knees bent and feet flat on the floor. Cross one ankle over the opposite thigh (creating a 4 shape). Clasp your hands behind your bent thigh and gently pull toward you. Do two to three reps per side for 20 to 30 seconds each.
• Figure four stretch: For a beginner version of the supine piriformis stretch, sit in a chair and cross one leg over the other. Push down into that figure four position. Cheema recommends three sets of 30 seconds “where you’re pulling, going into that stretch position, and then slightly coming out.”

Factors like your age and body composition make a big difference in your flexibility. All of these stretches essentially do the same thing, so you don’t have to do them all. Find what feels most comfortable personally and what gives you relief. 

Choosing the right mattress firmness for sciatic/piriformis relief

The best mattress for piriformis syndrome is a medium-firm mattress. While everyone has a different preference, a mattress that’s too firm or too soft can interfere with your alignment. Medium-firm tends to be a good middle ground. 

“If the mattress is too firm, what happens is your hips start to arch,” Cheema explains. “Your hips might rise a bit and that’s going to overstretch the piriformis.”

When your hips are out of alignment, the piriformis muscle is either very stretched or very compressed. Either way, this impacts the sciatic nerve. You can check to see if a mattress is too firm for you by seeing if someone can put their hand underneath your hips. If so, there’s too much of an arch—your pelvis is out of alignment between your femur and your lower back, and you likely need a softer mattress.

By the same token, however, you don’t want to swing too far the other way. A mattress that’s too soft can also make the pelvis sink out of alignment, affecting the piriformis. 

“That’s why, as a blanket statement, we usually say medium-firm is the best for most people,” says Cheema. “There’s going to be outliers for that, but usually medium-firm is good for somebody that has a history of piriformis syndrome.”

Additional factors that can affect your mattress preference include your body composition (a firmer mattress is best for heavier folks, and vice versa) and your sleeping history (what you’re used to sleeping on and whether you’ve had long-term pain). 

Morning routine to avoid stiffness upon waking

Your nighttime habits aren’t the only daily routines that matter for piriformis syndrome. What you do in the morning is important too.

“Anytime you have some sort of muscle issue or a tendon issue, you don’t want to just get out of bed,” Cheema says. “[The muscle has] probably been stuck in a weird way for the entire night. If you just jump right out of bed, you’re going to overstretch it.”

Follow this five-minute morning routine for piriformis syndrome to safely ease into your day:

• Stretch: Repeat the light stretching you did as part of your pre-bed routine. 
• Gentle self-massage: Use your hand or a percussion massager on gentle mode to help warm up the piriformis muscle. 
• Heat or ice: If you like the feeling of a hot pack, use a hot compress. If you prefer ice to calm down inflammation in the nerve, try a little bit of ice. “We don’t really stick to one or the other,” says Cheema. “It’s more preference now.” 

It’s also helpful to avoid long, deep holds right away, and to do some activation—like a walk around the neighborhood—before any intense exercise. If your healthcare provider has prescribed medication for ongoing inflammation, you’ll want to keep up with that too. 

Finally, while alleviating pain in the short term can be helpful, the way to reduce or eliminate piriformis pain is to focus on strengthening your glutes. 

“The piriformis is trying to stabilize you,” says Cheema. “The culprit was your weak glutes all along. So we really want to get into strengthening your glutes at least two to three times a week. That way your glutes can help stabilize your pelvis and then your piriformis doesn’t have to work as hard.”

A physical therapist can create a program with the correct exercises, like clamshells and glute bridges. While piriformis syndrome can come back, with the right movements at the right pace, many people can resolve piriformis pain in two to six weeks. 

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FAQs

What’s the best sleeping position for piriformis syndrome?

The best sleeping position for piriformis syndrome is side sleeping on the unaffected side. Try to avoid sleeping on your stomach, back, or in the fetal position. 

Should you place a pillow between your knees for piriformis pain?

Yes—sleeping with a pillow between your knees is helpful for piriformis pain. This keeps your hips and pelvis in alignment, maintaining a neutral spinal alignment between the spine, hips, and femur.

Can mattress firmness make piriformis symptoms better or worse?

Mattress firmness can certainly make piriformis pain either better or worse. If your mattress is too firm or too soft, your pelvis can get out of alignment, impacting the piriformis muscle and increasing pain. Typically, a medium-firm mattress is best for piriformis syndrome.