Piriformis syndrome: Symptoms, diagnosis, and treatment

What is Piriformis Syndrome? spine-health.com – By John P. Revord, MD – Sept 2012

Piriformis syndrome is a condition in which the piriformis muscle, located in the buttock region, spasms and causes buttock pain.

The piriformis muscle can also irritate the nearby sciatic nerve and cause pain, numbness and tingling along the back of the leg and into the foot (similar to sciatic pain).

The Piriformis Muscle

The piriformis muscle is a small muscle located deep in the buttock (behind the gluteus maximus).  

The piriformis muscle:

  • Starts at the lower spine and connects to the upper surface of each femur (thighbone)
  • Functions to assist in rotating the hip and turning the leg and foot outward
  • Runs diagonally, with the sciatic nerve running vertically directly beneath it (although in some people the nerve can run through the muscle).

I am one of those people whose sciatic nerve passes right through the muscle, creating an obvious choke point.

Below is a diagram of the area from the back:

Causes of Piriformis Syndrome

The exact causes of piriformis syndrome are unknown. Suspected causes include:

  • Muscle spasm in the piriformis muscle, either because of irritation in the piriformis muscle itself, or irritation of a nearby structure such as the sacroiliac joint or hip
  • Tightening of the muscle, in response to injury or spasm
  • Swelling of the piriformis muscle, due to injury or spasm
  • Bleeding in the area of the piriformis muscle.

Any one or combination of the above problems can affect the piriformis muscle (causing buttock pain) and may affect the adjacent sciatic nerve (causing pain, tingling, or numbness in the back of the thigh, calf, or foot).

Symptoms and Diagnosis of Piriformis Syndrome

There is no simple diagnostic test for piriformis syndrome causing irritation of the sciatic nerve.

The condition is primarily diagnosed on the basis of the patient’s symptoms and on a physical exam, and after excluding other possible causes of the patient’s pain.

Symptoms of Piriformis Syndrome

Most commonly, patients describe acute tenderness in the buttock and sciatica-like pain down the back of the thigh, calf and foot. Typical piriformis syndrome symptoms may include:

  • A dull ache in the buttock
  • Pain down the back of the thigh, calf and foot (sciatica)
  • Pain when walking up stairs or inclines
  • Increased pain after prolonged sitting
  • Reduced range of motion of the hip joint

Symptoms of piriformis syndrome often become worse after prolonged sitting, walking or running, and may feel better after lying down on the back.

When I suffered from this, I noticed progressive weakness in my affected leg. That scared me more than the pain.

Diagnosing Piriformis Syndrome

Diagnosis of piriformis syndrome is based on a review of the patient’s medical history, a physical examination and possibly diagnostic tests.

Piriformis syndrome is often a diagnosis made through a process of ruling out other possible conditions that may be causing the patient’s symptoms, such as a lumbar disc herniation or sacroiliac joint dysfunction.

I was referred to a local doctor who specialized in piriformis syndrome. In his exam, he pressed down on the spot where the sciatic nerve sometimes passes through the muscle.

I instantly felt excruciating pain and my leg almost gave out, proving to him that this was the source of my trouble.

Stretch and Physical Therapy

Almost every treatment approach for piriformis syndrome will include a focus on carefully and progressively stretching the piriformis muscle.

Stretches for Piriformis Syndrome

A number of stretching exercises for the piriformis, hamstrings and hip extensors may help decrease the painful symptoms along the sciatic nerve and return the patient’s range of motion.

Physical Therapy for Piriformis Syndrome

In addition to basic stretching, a comprehensive physical therapy and exercise program can be developed for each patient’s individual situation.

Range of motion exercises

A physical therapist, physiatrist, chiropractor or other qualified health practitioner can develop a customized program of stretching and range of motion exercises to help stretch the muscle and decrease spasm.

Deep Massage

Deep massage (manual release) by a physical therapist or other qualified specialist is thought to enhance healing by increasing blood flow to the area and decreasing muscle spasm.

In my desperate search for relief, I allowed a physical therapist to do a “deep massage” of my problematic hip/buttock. I endured the excruciating pain in the hopes that there would be relief afterward, but the only relief was that the massage eventually ended.

The pain of the massage faded over the next minutes, but my piriformis pain was unchanged.

Treatment

A comprehensive approach to managing piriformis syndrome may include a combination of the following nonsurgical treatments:

Ice Packs and Ice Massage

At the onset of pain, lie in a comfortable position on the stomach and place an ice pack on the painful area for approximately 20 minutes. Repeat as needed every 2 to 4 hours.

It may be more helpful to combine a gentle massage with the ice. Lie on the stomach and have someone gently massage the painful area with a large ice cube. If ice is applied directly to the skin (instead of a cold pack), limit it to 8 to 10 minutes to avoid an ice burn.

If specific activities are usually followed by increased pain, it may be a good idea to apply ice immediately following the activity.

Heat Therapy

Some people find it helpful to alternate cold with heat. If using a heating pad, lie on the stomach and place the heating pad on the painful area for up to 20 minutes. Be sure to avoid falling asleep on a heating pad, as this may lead to skin burns.

Medications for Sciatica Pain

Since most episodes of pain include some type of inflammation, non-steroidal anti-inflammatory medications (NSAIDs), such as ibuprofen or naproxen, may help decrease inflammation in the affected area.

Piriformis Injections

For severe sciatica pain from piriformis syndrome, an injection may be part of the treatment.

Piriformis injection

A local anesthetic and corticosteroid may be injected directly into the piriformis muscle to help decrease the spasm and pain. The purpose of an injection is usually to decrease acute pain to enable progress in physical therapy.

Botox injection

For persistent piriformis spasm that is resistant to treatment with anesthetic/corticosteroid injections, an injection of botulinum toxin (e.g. Botox®), a muscle weakening agent, may be useful. The goal of the injection is to help the muscle relax and help reduce pressure on the sciatic nerve.

This should have been my next effort, but since my pain seemed to be a result of nerve entrapment, my doctors and I decided to do the release surgery instead to permanently fix the problem. (This was in in 1995, before I learned that there is rarely a complete “fix” for any of our body’s malfunctions.)

The goal with both injections is to help the patient progress with stretching and physical therapy, so that when the effect of the injection is over the muscle will be remain stretched and relaxed.

This is the goal of opioid therapy as well: to allow pain patient to continue various physical therapies.

Too high a pain level keeps patients sedentary, which eventually only worsens their pain.

Electrotherapy for Piriformis Syndrome

The application of electrical stimulation to the buttock with a transcutaneous electrical nerve stimulation (TENS) unit or interferential current stimulator (IFC) can help to block pain and reduce muscle spasm related to piriformis syndrome.

In persistent cases, the piriformis muscle can be cut to relieve symptoms, but this is rarely performed.

The last page of this article contains a video, for which they have helpfully provided a transcript:

Video Transcript

Piriformis syndrome occurs when the piriformis muscle spasms and irritates or compresses the sciatic nerve. It often causes symptoms similar to sciatica, though it is not caused by a spinal problem like sciatica is.

The piriformis is a small muscle located deep in the buttock, behind the gluteus maximus. It runs diagonally from the lower spine to the upper surface of the femur, with the sciatic nerve running underneath or through the muscle.

The piriformis muscle helps the hip rotate, turning the leg and foot outward.

As a result of overuse, injury, or strain, the piriformis muscle can tighten, swell, or spasm.

Sports that involve repetitive forward movement of the legs, or problems in surrounding joints like the sacroiliac joints are typical causes of piriformis syndrome.

Having EDS, it’s difficult to pinpoint a single source of any problem or pain because the tissue by which body parts are held together is defective. 

Any misalignment is both passed on to and in turn affected by any other muscles/ligaments/tendons that are attached to the problem area.

The location of the piriformis muscle near the sciatic nerve means that when the piriformis muscle is irritated or injured, it can affect the sciatic nerve as well.

Symptoms of piriformis syndrome include tenderness and pain in the buttock area, accompanied by sciatica-like pain, numbness, and weakness that runs down the back of the thigh, calf, and foot.

Pain from piriformis syndrome is often worse when walking up stairs, after sitting, or while walking or running.

Piriformis syndrome is often confused with other conditions, especially lumbar spine conditions.

Attaining a proper diagnosis of piriformis syndrome is important when considering treatment for low back and leg pain.

Here is a more recent article mentioning the possibility of a surgical remedy:

Piriformis syndrome: Symptoms, diagnosis, and treatment – Medical News Today –

As a last resort, surgery is an option.

One option is to cut the piriformis tendon where it attaches to the hip. The other is to cut into the piriformis to relieve pressure on the sciatic nerve.

I had this surgery and it instantly restored the strength to my affected leg, but my familiar pain remained, probably due to my unstable sacroiliac joint.

Preventing piriformis syndrome

The same stretches that help with piriformis pain can also reduce the risk of developing piriformis pain.

Many people develop piriformis syndrome due to repetitive movements. Developing good technique can prevent these repetitive motions from damaging the piriformis.

Investing in comfortable, well-fitting running shoes is important. Shoes should ensure that a person moves properly and should not pinch or hurt in other ways. Ill-fitting shoes can undermine posture and form.

Avoid sitting or lying down for long periods of time in a position that puts too much pressure on your buttocks.

Also,

Piriformis Syndrome Update- A Season of Relief – a whole website devoted to one person’s struggle with this pain syndrome

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5 thoughts on “Piriformis syndrome: Symptoms, diagnosis, and treatment

  1. Laura P. Schulman, MD, MA

    I have this also. It became unbearably painful when I was riding my horses for hours daily, often half-standing in the stirrups, which caused the piriformis muscle to get larger and thereby get squished in the bony fossa it has to pass through. After many unsuccessful treatments I finally arrived at a highly trained Rolfer. 12 excruciating Rolfing sessions later, I was free of pain. That was in 1997. Years and years of pain erased after 12 weeks! It hasn’t come back.

    Liked by 1 person

    Reply
    1. Zyp Czyk Post author

      I had not only pain, it also progressive weakness and atrophy in my right leg, so I opted for the nerve-release surgery. That fixed my weakness but only eased my pain to bearable levels.

      About 7 years later , my physical therapist asked me to do one of those “clamshell” piriformis exercises and I felt something tear with sudden burning pain on my bad side. Since then, I’ve resumed my “normal” piriformis pain off and on, but have no weakness, so the surgery seems to have been at least half successful :-)

      Like

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      1. Laura P. Schulman, MD, MA

        Meh. That’s miserable…..

        Back when I was having the most trouble with it, again it was hard to parse out what was spine and what was piriformis. No MRI then. Since your nerve is mashed up with your muscle, I guess surgery was your only choice. Mine was just stuck to surrounding structures with scar tissue, and my Rolfer was able to break it loose (ouch).

        Liked by 1 person

        Reply
  2. DELINDA BROOKS

    The really sad thing is that the Doctor didn’t care about talking it over with the Patient, he even ask her twice to lean over the table so he could exam her, and never did. The irony is that he says he’s a Sport’s Specialist Physician.
    My wife ask him if he was a runner and he didn’t answer, she ask him again and he answered her I run a little. Runners don’t run a little, runners run all the time and my wife hasn’t been able to run for two months because of her injury, that he barely even addressed. He told her it was probably just a pinched nerve. It’s not a pinched nerve, the only pinched nerve she has is the Doctor himself and he hit her last nerve yesterday. Her problem is she is suffering with Piriformis Syndrome, which he acted like he had never heard of. Hopefully she will find a true Sports Physician that can help her. This place is only interested in helping people with Accident injuries related from a car accident or a Workers Comp claim. They ask that question on every visit.

    Please contact me if you know of a good Doctor in the Tampa Bay area that she could make an appointment with, she needs to put this behind her, (no pun intended)

    Liked by 1 person

    Reply
    1. Zyp Czyk Post author

      Well, he’s right – it IS a pinched nerve: the sciatic nerve becomes compressed by the spasm of the piriformis muscle!

      It seems to be so random whether you get a bad or good doc – and the odds seem far more favorable for getting a bad one :-(

      Like

      Reply

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