Piriformis syndrome and sciatica
We see many patients who are not really sure what is wrong with them, or, they are diagnosed with a problem that they do not really understand. Such is the case with Piriformis syndrome.
A typical Piriformis syndrome diagnosed patient we see is someone who exercises or works out a lot, or, competes in demanding levels of sport. For this person their problems start sometimes suddenly as severe lower back pain, pain in the hamstrings, and sciatica like symptoms of burning, numbing pain radiating down one of both legs.
Many of these patient / athletes will tell us that they did try to work their way through these problems. They continued to run, swim and cycle, and managed the pain these activities were causing with anti-inflammatories, ice, massage and stretching. Treatments they found, would sometimes make their problems worse. In fact some people had to eliminate all stretching exercises as they had become injury causing.
For some, since lower back pain is a problem, a trip to the chiropractor was made. It is here that some of these patients were first made aware of Piriformis syndrome.
When all conservative treatments fail, a recommendation for surgery will be made.
Piriformis syndrome, is it really a syndrome? What is this diagnosis?
Piriformis syndrome is often overlooked as a cause of patient problems because it displays symptom similarities with other more diagnostically recognizable problems such as sciatica.
- Piriformis syndrome centers on the piriformis muscle as it rubs on the sciatic nerve causing irritation.
- In Piriformis syndrome, like sciatica, the pain can often travel down the back of the thigh and/or into the low back. Some patients will report spasms in addition to muscle pain in addition to tingling, and numbness in the butt, leg, and thighs.
Many times a patient will come in with an MRI that may show sciatic nerve and piriformis muscle abnormalities. However, because of the difficulty in making a piriformis syndrome diagnosis via MRI, the primary diagnosis is usually made following a physical examination.
Doctors writing in the European Journal of Orthopaedic surgery & traumatology gave an updated assessment of the challenges of diagnosing piriformis syndrome as the true cause of a patient’s radiating pain.
They write that Piriformis syndrome can be defined by a quartet of symptoms and signs. The most common symptoms reported were:
- buttock pain,
- pain aggravated on sitting,
- external tenderness near the greater sciatic notch and
- pain on any maneuver that increases piriformis muscle tension
They also warn that doctors should be aware that the simple straight leg raising test may not be adequate and more testing would need to be done to determine if Piriformis syndrome is the pain culprit or contributor to the patient’s pain.
They also agree that piriformis muscle pathology can cause sciatica as this has been clearly demonstrated.(1)
While the cause of sciatica varies, piriformis syndrome is almost always caused by either loose sacroiliac ligaments or loose hip ligaments. It has been suggested that as many of half the patients diagnosed with piriformis syndrome have had a history of acute trauma to the buttocks (a bad fall) or a low back/hip area hyperextended or twisting.
Piriformis syndrome physical therapy and exercises
When a patient visits the sports medicine physician, chiropractor, or other health care provider for treatment, it may be suggested to them that the symptoms and pain they are dealing with is being caused by the tight piriformis muscle. The patient and doctor would then work to loosen up the piriformis muscle, through exercises, manipulation, massage, and physical therapy.
Doctors at the Spinal Surgical Service, Weill Medical College of Cornell wrote in The Orthopedic clinics of North America journal that
- Physical therapy is the mainstay of conservative treatment of Piriformis muscle syndrome as it aims at stretching the muscle and reducing the vicious cycle of pain and spasm.
- Physical therapy is usually enhanced by local cortisone injections or in some instances Botulinum toxin (Botox).
- Surgery should be reserved as a last resort in case of failure of all conservative modalities.(2)
Other researchers agree with this treatment methodology. Writing in the journal Practical Neurology doctors say: “owing to a lack of clinical trials and a lack of consensus on diagnosis, treatment of piriformis syndrome largely utilizes conservative methods, such as stretching, manual techniques, injections, NSAIDs, muscle relaxants, ice and activity modifications. The mainstay of treatment is piriformis stretching, which focuses on relaxing tight muscles to relieve nerve compression.”(3)
Understanding treatment: The piriformis muscle does not just tighten up on its own
At Caring Medical, we look deeper into the cause of the problem. The piriformis muscle does not just tighten up on its own. We have found that in many patients with this condition a sacroiliac ligament injury or a hip ligament injury is the cause. Basically, the sacroiliac or hip ligaments are stretched out and loose. Consequently, when the piriformis muscle tries to contract, it can’t, so it starts to spasm. When the piriformis spasms, it pinches the sciatic nerve, which causes the pain, tingling, and numbness that the person experiences.
Trying to loosen the piriformis muscle is not going to work to alleviate the patient’s symptoms. For these patients, in our opinion, the symptoms of piriformis syndrome can only be alleviated by treating the underlying cause of the problem which is loose sacroiliac and/or hip ligaments.
As mentioned, the sciatic nerve runs between the two heads of the piriformis muscle. When the piriformis muscle is spastic, the sciatic nerve may be pinched. Lumbosacral and hip joint weaknesses are two main causes of piriformis muscle spasm. Stretches and physical therapy directed at the piriformis muscle to reduce spasm help temporarily, but do not alleviate the real problem. Prolotherapy to the hip and lower back strengthens those joints, thus eliminating the piriformis muscle spasms.
If you have questions about Piriformis muscle syndrome treatment, get help and information from our Caring Medical Staff
1 Hopayian K, Danielyan A. Four symptoms define the piriformis syndrome: an updated systematic review of its clinical features. European Journal of Orthopaedic Surgery & Traumatology. 2017 Aug 23:1-0. [Google Scholar]
2 Papadopoulos EC, Khan SN. Piriformis syndrome and low back pain: a new classification and review of the literature. Orthop Clin North Am. 2004 Jan;35(1):65-71. Review. [Google Scholar]
3. Norbury JW, Morris J, Warren KM, Schreiber AL, Faulk C, Moore DP, Mandel S, Mohnot D, Kalueff AV, DuRapau Jr VJ, Mohnot S. Diagnosis and management of piriformis syndrome. Pract Neurol. 2012 May:24-7. [Google Scholar]