This was a question from a patient I had several years ago. She had been sitting on hard bleachers for several hours over several days while her child competed in a high school band competition. Afterwards, she had difficulty sitting for anymore than 15 to 20 minutes at a time and had sciatica-like pain down her leg.  She thought she had piriformis syndrome and wanted some piriformis syndrome exercises to get rid of her symptoms. Â
I will admit to putting piriformis syndrome low on my list of potential causes of the sciatica. Piriformis syndrome is just not that common. However it was hard to ignore it in this case. All signs and symptoms were pointing straight to her piriformis (or a muscle in close proximity).  Read on for more information about piriformis syndrome and how to treat it.  Let’s start with anatomy!
What is piriformis syndrome?
Piriformis syndrome is a condition that involves the irritation of the sciatic nerve caused by the piriformis muscle. The piriformis muscle is a muscle in the buttock. It is located under the gluteal muscles and attaches to the sacrum and the upper part of the femur. The sacrum is the triangular bone at the base of the spine and the femur is the thigh bone.
The piriformis muscle helps rotate the hip outwardly when the leg is extended (behind the body). It also helps abduct (move the leg away from the body) the leg when the hip is flexed. The sciatic nerve usually runs right underneath the piriformis.
The sciatic nerve is the largest nerve in the body and is made up of 5 nerve roots. These nerve roots originate at the low back and pelvis. They then come together to make up the sciatic nerve. The sciatic nerve travels down the leg to activate different muscles and provide sensation. It innervates the muscles on the back of the thigh, the inner thigh, the calf, the front of the lower leg, and the some of the foot muscles. These include the hamstrings, adductors, gastrocnemius, soleus, and some of the intrinsic foot muscles. The sciatic nerve provides sensation to the back and outside of the lower leg and also to the bottom of the foot.
Because of the proximity to the sciatic nerve, the piriformis can cause sciatica-like symptoms if it becomes irritated or inflamed. Sciatica occurs when the sciatic nerve is injured, compressed, inflamed, or pinched. This will cause pain, numbness, tingling, and/or muscle weakness along it’s distribution down the leg.
Types of piriformis syndrome
There are two different types of piriformis syndrome.
- Primary piriformis syndrome – This type of piriformis syndrome has an anatomical cause and accounts for less than 15% of piriformis syndrome cases. There can be variations in the piriformis and sciatic nerve such as a split piriformis muscle or a split sciatic nerve. In these variations the sciatic nerve could pass through the piriformis muscle. Certain anatomical variations could theoretically lead to an increased risk of piriformis syndrome.
- Secondary piriformis syndrome – Secondary piriformis syndrome is caused by some event or action.  This is the predominant cause of piriformis syndrome. This includes trauma to the hip or buttocks, post-surgical injuries, and inflammation from overuse. Sitting for long periods of time can also cause piriformis syndrome. Wallet neuritis is another name for piriformis syndrome. It was named for irritation of the sciatic nerve caused by sitting on one’s wallet for long periods. Never sit on your wallet. There is no good that will come from it.
What are the symptoms of piriformis syndrome?
Piriformis syndrome is typically hard to diagnose because it creates sciatica-like symptoms and there are many potential causes of sciatica. However, it does have some typical symptoms associated with it. These include:
- Low back pain
- Chronic pain in the buttocks and hip area
- Pain that worsens with hip movements
- Pain may shoot, burn, or ache down the back of the leg
- Pain when getting out of bed
- Pain with sitting, squatting, or standing
- Inability to sit for long periods of time
- May have difficulty walking
- Numbness to the buttocks
- Tingling sensations along the distribution of the sciatic nerve
Controversial diagnosis
Piriformis syndrome is a somewhat controversial diagnosis. For one, it is not terribly common. When I have a patient with sciatica, I don’t automatically think piriformis syndrome.  It is estimated that only 0.3-6% of all low back pain and/or sciatica cases are the result of piriformis syndrome.
There is no easy way to test for piriformis syndrome. There are certain physical tests that can be indicative of piriformis syndrome but they are not terribly accurate. Also there are many muscles in the buttocks that could also be the potential causes of sciatica. For this reason, piriformis syndrome is also known as deep gluteal syndrome, extra-spinal sciatica, and wallet neuritis.
X-rays, CT scans, and MRIs can be used to rule out other potential diagnosis. An EMG with normal results of muscles above the piriformis and abnormal results for muscles below the piriformis can be indicative of piriformis syndrome. Also having an anesthetic or steroid injected into the piriformis muscle can help with a possible diagnosis.
Are there risk factors?
There are not a lot of risk factors for piriformis syndrome. It tends to occur in middle age and is more prevalent in women. This is most likely due to a wider pelvis in women.
What should I do if I suspect piriformis syndrome?
- Physical therapist – This is obviously a difficult diagnosis so going to a healthcare professional would be required for an accurate diagnosis. A physical therapist can help figure out the underlying cause of the pain or sciatica-like symptoms. PTs can also determine areas that need stretching and strengthening. Your PT can help improve your symptoms with manual therapy, dry needling, strengthening, stretching, taping, and a personalized home exercise program.
- Orthopedist – If your pain and/or symptoms do not respond to physical therapy, then seeing an orthopedist would be the next step. Your orthopedist can order imaging and run tests to determine the cause. Anti-inflammatory medication or an injection can also be prescribed by your orthopedic physician.
What can I do?
- Avoid activities that aggravate symptoms – This might mean that you need to avoid sitting for long periods. Try to stand and walk around every 20 minutes. Also make frequent stops to walk and stretch if you have a long drive. If there are any other activities that cause increased pain in the buttock or pain/numbness/tingling down the leg, try to avoid them as much as possible. This gives the piriformis and sciatic nerve time to calm down.
- Ice – Ice the buttocks in the area where the piriformis is located. This can decrease inflammation and possible swelling in the muscle. Ice with an ice pack for 15 to 20 minutes several times a day especially if the pain is interfering with daily activities.
- Soft tissue mobilization – Soft tissue mobilization helps release the piriformis muscle and decrease pain and inflammation. I find that rolling out the piriformis muscle prior to stretching will help get a deeper stretch. Roll on a massage ball or foam roller on the painful area of the buttocks. Spend a good 3 to 5 minutes rolling. Do not roll so hard that you bruise the area but it should be a pretty painful sensation. Roll out the area no more than a few times a week.  Below is a video on how to roll out the piriformis.
- Stretching – Stretching the piriformis is very important in improving its mobility and decreasing irritation in the muscle. Below is a video on how to stretch the piriformis
- Nerve mobilization – Mobilizing the sciatic nerve can help free up the nerve if it is stuck in an area of the buttocks. Below is a video of how to mobilize the nerve.
- Strengthening – Strengthening the areas of the core and hips that are weak is important in decreasing strain on the piriformis. Using a loop resistance band and ankle weights can add more difficulty and strength. Below are videos on strengthening the hips and core.
In review
- The piriformis muscle is a muscle in the buttock.
- Because of the proximity to the sciatic nerve, the piriformis can cause sciatica-like symptoms if it becomes irritated or inflamed.
- There are 2 types of piriformis syndrome.
- Primary – anatomical cause
- Secondary – external cause
- Piriformis syndrome causes pain in the buttocks and could cause pain/numbness/tingling down the leg.
- Piriformis syndrome is a controversial diagnosis because of the difficulty in testing for it.
- Physical therapists and orthopedic physicians can help with diagnosis and treatment.
- There are things that you can do to help decrease your symptoms.
- Avoid irritating activities
- Ice
- Soft tissue mobilization
- Stretching
- Nerve mobilization
- Strengthening
As always, If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.
Additional resources
https://www.ncbi.nlm.nih.gov/books/NBK448172/
https://www.physio-pedia.com/Piriformis_Syndrome
https://www.choosept.com/guide/physical-therapy-guide-lumbar-radiculopathy-sciatica