Piriformis Syndrome

Piriformis syndrome is a common condition whose clinical presentation is often mistaken with disc herniation and/or spinal stenosis.  The symptoms of piriformis syndrome include pain in the buttocks and, often times, sciatic nerve pain.

The piriformis is a small muscle situated deep in the buttocks that runs from the sacrum (tailbone) to the hip.  The piriformis, along with 5 other small muscles deep in the buttocks functions to externally rotate the hip (toes pointing outward).  Because of its position in the buttocks, the piriformis lies in close proximity to the sciatic nerve and its branches.  In about 10% of the population, the sciatic nerve will actually run directly through the muscle itself.

If the muscle becomes injured or irritated, it will have a tendency to contract resulting in a considerable increase in its diameter.  This increase in diameter can cause the adjacent branches of the sciatic nerve to become compromised, resulting in irritation and inflammation of the nerve itself, and creating a resultant sciatic nerve pain.

Piriformis muscle syndrome can, therefore, be described as an inflammatory response of branches of the sciatic nerve caused by pressure of an irritated or injured piriformis muscle. 

Symptoms of Piriformis Syndrome

Piriformis syndrome is typically characterized by a persistent lower back pain that extends into the buttocks, down the back of the thigh, over the outside portion of the knee, and down the outside portion of the lower leg to the top of the foot.  In severe cases the patient will complain of pain during sitting or squatting activities. 

Another common finding associated with piriformis syndrome is the “positive piriformis sign”.  A positive piriformis sign is characterized by a persistent external rotation of the leg that can be visualized when the patient is lying flat on their back and the foot on the side of symptoms points outward.

Sensitivity to direct pressure of the buttocks on the affected side is another finding associated with piriformis syndrome.  Complaints of buttocks pain with sitting is often reported and is especially tender to touch by physical examination. 

Diagnosis of Piriformis Syndrome

The diagnosis of piriformis syndrome is primarily based on physical examination and the patient’s history.  Most cases of piriformis syndrome are the result of activities leading to the onset of a sustained muscle contracture as a result of overstretching or direct trauma to the muscle.

Overstretching often results from excessive rotation of the leg such as the position of the foot on the accelerator when driving or with crossing one leg over the other.  Traumatic injury to the piriformis occurs when there is excessive pressure to the buttocks region.  A classic example of this type of trauma is the man who carries a thick wallet in his hip pocket and begins to experience sciatica pain.  Injuries to the pelvis or hip can also cause piriformis syndrome.

Because of irritation of the sciatic nerve and resultant sciatic nerve pain, piriformis syndrome is often overlooked as the source of a patient’s symptoms.  Instead clinicians tend to build their clinical case based solely on diagnostic imaging such as MRI or CT scan.  In these cases, evidence of a herniated disc or spinal stenosis are often found and attributed to the patient’s symptoms when, in reality, the problem lies well outside the spine and has nothing to do with these incidental findings.  This type of misdiagnosis is common and creates a “bottleneck” in terms of treating the true cause of the sciatica symptoms. 

An excellent summary of how piriformis syndrome is diagnosed can be found here: Back Pain Treatment

Treatment of Piriformis Syndrome

The primary consideration in the treatment of piriformis syndrome is the resolution of the muscle contraction associated with the condition.  In other words, by stretching the tight piriformis muscle, the pressure on the branches of the sciatic nerve will be reduced and sciatic nerve pain will be eliminated.

Sometimes, however, the muscle is so irritable that stretching will actually cause more pain.  It’s been my experience that when this type of reaction takes place, the best treatment is injection therapy.  Local injection of a steroid in addition to a numbing agent has excellent results when dealing with an irritated piriformis.  Once the muscle calms down, the stretching activities can be resumed.

In severe cases, surgical intervention may be considered but this is rare and I cannot recall any of my patients who have had to undergo surgical release of the piriformis muscle. 

In cases where a thick wallet is suspected as the cause of the problem, treatment involves simply taking the wallet from your hip pocket when sitting.  I have had many a patient over the years tell me that this simple recommendation has resulted in almost immediate relief of their symptoms.

A word of caution regarding treatment bears mentioning.  Some therapists are way too aggressive when attempting to treat the piriformis.  Specifically, I am talking about certain massage techniques where the clinician’s elbow is placed in contact with the muscle and pressure is applied in an attempt to elicit a “release” of the contracted tissue.  While this technique is useful with some other muscle groups, I have found it to be more harmful (and potentially damaging) when treating piriformis syndrome. 

Piriformis Syndrome Summary

In summary, piriformis syndrome will often produce symptoms related to sciatica and sciatica nerve pain.  These symptoms are often misdiagnosed to be attributed to a herniated disc or spinal stenosis based solely on the results of diagnostic imaging.  As a result, potentially ineffective and unnecessary surgery is often recommended when the problem could have efficiently been treated by addressing the source of the symptoms, namely the piriformis muscle.

The Erase Your Back Pain program addresses sciatica symptoms related to piriformis syndrome through a targeted exercise regimen designed to improve flexibility, restore muscle balance and function, and eliminate the causative factors associated with the condition. 

If you are suffering with sciatica or sciatica nerve pain and you think you have piriformis syndrome, I would like to offer you a free phone consultation. Sign up by clicking here ===> Free Phone Consultation

Written by Malton A. Schexneider, PT, MMSc