I’m a runner who currently cannot run. I’m on a rehabilitation journey to correct the hip impingement and subsequent sciatic nerve pain that has kept me from the activities that I love, and I want to share what I’m learning along the way.
How I Got Hurt: December 2017
The onset of my “injury” is still frustratingly unclear; it began not due to an acute incident but more as a nagging pain that appeared one day and never subsided. In December 2017, I was consistently running and feeling strong, mostly on trails, and extremely active in the mountains as a backcountry skier, climber, and hiker. Although I was comfortable running in the 15 mile range, I had been hoping to progress to higher mileage trail races, something that I’d been attempting to execute for years but had been thwarted multiple times by vague overuse injury or pain that would prompt months of physical therapy and reset my training.
One night, on a casual five mile run with a friend, I began to feel a light but persistent burning in the back of my right thigh with two miles to go. I was immediately alarmed, as a few years back I’d been sidelined for almost a year by a similar pain in my left leg, and had never really figured out the cause or cure. After unsuccessfully seeing several physical therapists and chiropractors, it finally disappeared as mysteriously as it had come. I finished the run, my leg hurting slightly worse, and tried to talk myself off the ledge: it was probably just sore and a few days of rest would alleviate the pain.
A Year of Pain
After taking a week off, I attempted an easy run and was crushed to find the pain returning around mile three, so I made an appointment with the sports chiropractor that I’d been seeing for routine maintenance. To her credit, she immediately (and correctly) diagnosed my pain as a nerve-derived, not muscle. She told me that I had what is known as Piriformis Syndrome, where the sciatic nerve becomes pinched, stuck, or compressed, usually in the glute area and sometimes by the piriformis muscle, sending sharp pain from the bottom of the butt cheek down to the calf. She prescribed exercises to strengthen my glutes and hamstrings and nerve glide routines to help loosen the nerve from the surrounding tissue. For several months, I dutifully performed my exercises and returned to the clinic for manual massage cupping, meant to pull the fascia and skin from the muscle and free up the nerve. None of this helped at all: when I began to ease back into running, the now-familiar pain returned.
With no progress, my chiropractor referred me for dry needling from an awesome sports medicine doctor who specializes in outdoor athletes, and is a mountain athlete himself. Dry needling, performed by M.D.s, is predictably a more clinical, less holistic, and unspiritual form of acupuncture. It uses long, thin needles to reach deep into the muscle, aiming to release pressure points that cannot be reached by external massage. In my case, my doctors hoped that dry needling could alleviate tightness in my low back and glutes, potentially releasing the trapped nerve.
Although I’ve heard many stories about how dry needling has alleviated sports injuries of my friends, the benefits of dry needling plateaued after a few treatments. I could still get through an easy two or three mile run every other day or so (just enough to keep me slightly sane), but I was clearly not back to normal. Fortunately, although confusingly, I could still hike 10+ hour days in the mountains with a heavy pack, bike, and do everything else with no pain. Although my providers couldn’t figure out exactly why, my pain specifically arose during running, and only after a few miles, suggesting that something about my form deteriorated after some fatigue set in, causing nerve compression. Feeling that more dry needling wouldn’t further alleviate my symptoms, my doctor sent me along to see a true physical therapist.
Encouragingly, this new therapist agreed with my chiropractor and doctor that my sciatic nerve was being compressed, likely by the piriformis or glute muscle, or possibly at the spot where the nerve feeds through the sacroiliac (SI) joint. Even before the onset of the thigh pain, I’d been feeling tightness, pain, and clicking in my low right back/SI joint area, especially after long runs. I had preemptively been seeking treatment for this preliminary pain, focusing on core strength to stabilize my SI joint, which my therapist suspected was hypermobile and causing the pain and tightness. Unfortunately, this work didn’t alleviate the back pain, and clearly didn’t prevent my nerve pain. Although my three providers had independently come to the same diagnosis, I was frustrated that three experts weren’t able to actually fix my issue. My physical therapist and I worked together for months on core and glute strengthening, stretching and rolling to loosen my extremely tight spots (low back and glute). After I showed improvement, he designed a run-walk plan to reintroduce my body to running. Initially I was excited to manage short bouts of pain-free running, but I was never able to progress past the three mile mark. Recognizing that we were missing something about my underlying condition, back I went to my sports medicine doctor for reevaluation.
Since my pain persisted despite me getting stronger and more stable, the doctor worried that I might have a back issue that could be causing my sciatic nerve pain. True sciatica originates from the spine, where bulging discs or weak muscles supporting the spine can cause compression on the sciatic nerve root, while piriformis syndrome refers to nerve pain that originates lower down in the muscle. Although everyone agreed I likely had the latter, he sent me to get an MRI on my lower back to rule out sciatica or a more serious spinal problem. As he predicted, my MRI was negative, which was good to know but also propelled me no further to a course of action. At this point, my doctor suggested trying a new physical therapist to get a fresh perspective.
Injury, Year Two: 2019
At this point, I entered a bit of a dark period where I didn’t know how to proceed and reluctantly gave up on running for a bit. I could still participate in my other activities, so although it killed me to abandon running, I tried to forget it and focus on rock climbing, mountaineering, and skiing. I won’t detail everything I tried, but I didn’t improve at all. Early in 2019, I returned to the doctor who had performed the dry needling, who told me he had recently begun working with a musculoskeletal sports medicine doctor (Dr. Leslianne Yen, Swedish Medical Centers, Seattle, WA) who specializes in issues like mine. I called that same day to get on her extremely busy schedule and had my consultation appointment in March.
Dr. Yen, an incredibly bright and diligently scientific doctor, agreed with my previous three providers that my sciatic nerve was somehow trapped in muscle. However, she explained that piriformis syndrome is a misnomer for a collection of causes of nerve entrapment. She believes that automatically blaming the piriformis for any sciatic nerve symptoms is simplistic and may overlook more complicated neuropathies, as nerve compression is not limited to the piriformis muscle itself. To better understand the origin of my pain, she used an ultrasound to make an informed guess about where exactly my nerve was restricted. After taking a look at my ultrasound, she suggested I undergo a hydrodissection, an ultrasound-guided injection that forces saline between muscle and fascia, creating a deformity in the tissue that allows the nerve more space to move. I came back for the procedure the following month, after traveling to Spain for a two week, extremely strenuous bikepacking trip in the mountains, where, as usual, I’d had no pain since I wasn’t running. However, Dr. Yen told me that some people felt immediate relief from their hydrodissections and that I could try running again in a week. I couldn’t wait.
The procedure went well, and Dr. Yen reviewed the ultrasound videos to confirm that she had achieved the desired technical result. However, three days later, I started feeling intense nerve pain not only in my hamstring area, where I’d always had it, but in my glute around the injection site and down into my calf. Additionally, it hurt constantly no matter what I was doing, but even worse with any activity. I returned for a follow up that week, and she couldn’t find a reason why my pain was increased, but told me to rest for several weeks to allow any potential inflammation in the injection site to subside.
Again, I won’t go through all the details, but I’ll just say that for about four months, my pain never subsided (at least for long), and I couldn’t hike, bike, sit, walk, or even work without pain. I spiraled pretty hard. Although Dr. Yen assured me that the needle went nowhere near my actual nerve and that I didn’t have any permanent damage, she wasn’t sure why the procedure made me worse. I want to be clear: she is an amazing doctor (she eventually cracked the case) and I know two people who were drastically helped by hydrodissection, but something about my specific problem was exacerbated by the injection. Dr. Yen referred me to her physical therapist of choice who had a few hypotheses on why my underlying problem was made worse. He thought that the hydrodissection had successfully freed my nerve, allowing my already unstable hips to rotate into an even more unbalanced position, further stressing the nerve. We spent a couple months working together on hip stability, and although my hip mechanics and glute strength improved, my pain remained unchanged. Completely devastated, I returned to Dr. Yen for help.
The Correct Diagnosis
Dr. Yen evaluated me with a fresh eye, and this time picked up on a crucial clue: my pain increased with external rotation of my legs, prompting her to suspect that hip impingement was at play. Hip impingement is a condition where the head of the femur does not correctly fit into the hip socket, potentially causing pain, cartilage degeneration, labral tears, and downstream nerve entrapment due to incorrect hip positioning. The impingement can be caused by structural deformities, where the femur head isn’t round or the hip socket is either too shallow, causing hypermobility, or covers too much of the femur ball, restricting movement. It can also be caused by muscle imbalances that pull the femur too far forward, causing it to make inappropriate contact with the hip socket. Dr. Yen sent me to get a pelvic MRI, which can help visualize exactly where the nerve is trapped or inflamed.
Unfortunately, barring extreme cases such as tumors or clusters of vasculature that obstruct nerves, typical nerve compression isn’t visible on these MRIs, and mine didn’t reveal any new information about the specific site of nerve compression. However, it did confirm that I have some structural bilateral hip impingement, likely exacerbated by poor hip mechanics and muscle imbalances.
Although I was relieved to finally, after two years, have an explanation for my mysterious nerve pain, this diagnosis sent me into another panic spiral. A quick search for hip impingement revealed horror stories of invasive surgeries that may or may not help and treatment suggestions that simply said to “cease activities that cause pain.” I spent a weekend moping, contemplating my new sedentary life and already mourning the loss of my identity as an athlete at age 28. Dr. Yen, however, was more hopeful and directed me to a local physical therapist (Dr. Sarah Haran, Arrow Physical Therapy, Seattle, WA), an ex-dancer and athlete who specializes in hip impingement and suffers from it herself, thus making her an expert in its management. Heartbroken and contemplating a consultation with a hip surgeon, I sent Dr. Haran a distraught late-night email. She responded the next morning with extreme kindness and patience, sent me a few additional links to relevant information, and got me an appointment the following week.
In the second post in this series, I’ll detail exactly what Dr. Haran found to be my problem, and how she’s helped me drastically decrease my pain. Getting the correct diagnosis from Dr. Yen (hip impingement-derived nerve compression) was absolutely essential, as was finding a hip specialist. In just three months, Dr. Haran helped me make more progress than I had achieved in almost two years. Although I’m too much of a scientist and realist to believe that anything happens for a reason, I do think that without the unfortunate outcome of the hydrodissection, we may not have gotten to the root cause. I’m trying to frame the experience as things needing to get worse before they ultimately get better (hopefully for good), and I’m excited for my continued rehabilitation back to running and the mountains.
Continue on this journey with me in part two, where I’ll explain how I finally began to improve and how I’m continuing to rehabilitate my hips and legs. I hope my experience will be useful to any other runners suffering from hip impingement and related nerve pain. It’s definitely a tricky issue, but I’m determined to return to running and the mountain activities I love.