Piriformis Syndrome and Sciatica Pain

Ross Hauser, MD.

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. 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 that Piriformis syndrome may be the problem for them.

In the chiropractor’s office, the patient may have been given an explanation that their problem is not one of a bulging or herniated disc pressing on a sciatic nerve, but it is the piriformis muscle that has entrapped the sciatic nerve and causing “herniated disc like symptoms.”

In this article I will cover various treatments and difficulty in diagnosing Piriformis syndrome.

Article summary

Many of you reading this article are probably familiar with the information in this infographic

Piriformis syndrome. When you have numerous tests, no one knows what to make of them

For others, confusing diagnoses lead them to a lot of research and a self-diagnosis. These are people who became frustrated with their lack of progress. You can read it in their emails that go something like this:

Numerous tests, no one knows what to make of them.

I have had an MRI, I have had a nerve conduction study. I had an EMG that suggested a sciatica problem with radiculopathy. I don’t think it is sciatica because I am not responding to all the medications I am getting for my “back pain.” Now my doctor is talking to me about epidural steroid injections but I am also showing tendinopathy on some of my scans. My physical therapist is talking to me about the possibility of greater trochanteric pain syndrome or hip bursitis. MAYBE it is Piriformis syndrome.

I think I have piriformis syndrome

Having been given this explanation, the patient then seeks out a treatment plan. Hopefully, they will find the one that works for them.

I told my doctor I think I have piriformis syndrome. Maybe it is wishful thinking but a recommendation for sciatica surgery is not the route I want to go right now.  But my doctor is telling me my nerve test showed lumbar radiculopathy pinpointed to the L5/S1, but I believe it is piriformis, as another scan showed tendinitis and another doctor recommended I look into this being a problem of deep gluteal syndrome or piriformis syndrome.

Piriformis syndrome: It started like this

A typical Piriformis syndrome diagnosed patient we see is someone who exercises or works out a lot, or, competes in demanding levels of sports. For this person, their problems start sometimes suddenly as:

Many of these patients/ 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. A foam roller is always in their sports kit.

Unfortunately, these treatments, as they found, would sometimes make their problems worse. In fact, some people had to eliminate all stretching exercises as they had become injury-causing.

Understanding piriformis syndrome, is it really a syndrome? What is this diagnosis? How can we treat this?

The difficulty in understanding Piriformis syndrome and making the correct diagnosis and getting the right treatment is highlighted in a February 2021 paper in the journal Anesthesiology and pain medicine. (1) The study authors described the problem in this way:

“Piriformis syndrome is an important differential diagnosis in the workup of lower back pain and should not be ruled out with proper examination and testing. Clinicians should consider medical management and conservative management in the initial treatment plan for piriformis syndrome. There are many options within the conservative management and the literature shows much promise regarding these. Physical therapy, steroid injections, botulinum toxin injections, and dry needling are all potentially effective therapies with few adverse effects.”

The point to highlight here is that doctors should not rule out piriformis syndrome until it is examined.

Piriformis syndrome centers on the piriformis muscle as it rubs on the sciatic nerve causing irritation.

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 describe the challenge of a correct diagnosis: For the patient, a second opinion should be considered to diagnose of not diagnose Piriformis syndrome

Doctors writing in the European Journal of Orthopaedic Surgery & Traumatology (2) 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:

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.

“Piriformis muscle pathology can cause sciatica as this has been clearly demonstrated.” Not all sciatica-like manifestations are of lumbar spine origin.

A study from October 2020 (3) gives a more detailed list of sciatic mimics.

“Not all sciatica-like manifestations are of lumbar spine origin. Some of them are caused at points along the extra-spinal course of the sciatic nerve, making diagnosis difficult for the treating physician and delaying adequate treatment.

While evaluating a patient with sciatica, straightforward diagnostic conclusions are impossible without first excluding sciatica mimics.

Examples of benign extra-spinal sciatica are piriformis syndrome, walletosis (or Wallet Neuritis or Wallet Sciatica so called because men with fat wallets would put them in their back pocket and as they sat on them the wallet would cause compression in the lower buttocks and lower hip), quadratus lumborum myofascial pain syndrome (painful and somewhat isolated trigger points in the big muscle in your lower back between your pelvis and lower rib,) cluneal nerve disorder (see just below), and osteitis condensins ilii (usually seen in pregnant women as their pelvis reshapes and this can cause sciatica-like pain).

What is causing Piriformis syndrome related problems?

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 the two main causes of piriformis muscle spasms. Stretches and physical therapy directed at the piriformis muscle to reduce spasms help temporarily, but do not alleviate the real problem.

The iliotibial band/tensor fascia lata extends from the pelvis over the hip joint to the lateral knee. Its job is to help abduct the leg (taking a step to the side), especially during walking so the legs do not cross when walking.

When this band/muscle is tight, it puts a great strain on the sacroiliac and lumbosacral ligaments. Stretching this muscle is beneficial to many people with chronic hip/back problems. Stretching and massages feel good to people with chronically “tight IT bands.” Take this one step further to understand why the bands/muscles become tight in the first place, which is joint instability generally in the hip or the knee. This instability needs to be properly identified and treated for the chronic tightness to be eliminated, along with the need to regularly stretch or massage the area in order to feel relief. Once the joint becomes stable, the continual tightness subsides.

The problem of finding any comfortable sleep position with Piriformis syndrome

Another thing we are accustomed to hearing from our patients is that they are spending a lot of time trying to find answers on how to sleep better. They are “side sleepers,” they move around at night in bed with all sorts of pillows jammed between their legs, under their backs, basically wherever a pillow needs to be. They cocoon themselves up in a ball of blankets trying to maintain sleep while in their back sleeping position. You know what happens next, you wake up an hour or two later with pain in your hip and you have rolled yourself up back in a fetal position.

So these people go online and look for all sorts of piriformis syndrome sleep aids and exercises and what they run into is a piriformis syndrome vs sciatica debate. This is what a patient will explain to us and why their first treatments centered on sciatica pain management to help them sleep better.

What are the cluneal nerves? Are they the cause of your Piriformis syndrome?

The cluneal nerves are sensory nerves, not motor nerves. This means that the messages that travel through them sense your environment but not how to react or move because of it. So the sensation of pain would be a primary function of the cluneal nerves. The cluneal nerves are divided into three branches. The inferior branch, the medial branch, and the superior branch. The inferior branch can be affected by piriformis syndrome and send out pain signals.

A March 2018 paper in the journal Neurospine (4) gives further detail: “Low back pain is encountered frequently in clinical practice. The superior and the middle cluneal nerves are cutaneous (sensation to the skin) nerves that are purely sensory. They dominate sensation in the lumbar area and the buttocks, and their entrapment around the iliac crest can elicit low back pain.

The reported incidence of superior cluneal nerve entrapment in patients with low back pain is 1.6%–14%.

Both superior cluneal nerve and middle cluneal nerve entrapment produce leg symptoms in 47%–84% and 82% of low back pain patients, respectively.

In such patients, pain is exacerbated by lumbar movements, and the symptoms mimic radiculopathy due to lumbar disorder. As patients with failed back surgery or Parkinson’s disease also report low back pain, the differential diagnosis must include those possibilities. “

In essence, the inferior branch of the cluneal nerve may be involved in piriformis syndrome. Possibly affects about one in seven low back pain patients. About four in five patients may have pain radiating down their legs. Patients who underwent back surgery and continued to have pain radiating down their legs may have had the wrong surgery.

Our colleagues, James Inklebarger, MD & Nikforos Galanis, MD, wrote this in the Journal of Prolotherapy (5) about cluneal nerve entrapment.

“The diagnosis of cluneal nerve entrapment may be challenging. Pain over the medial portion of the iliac crest and in the gluteal or lumbosacral area are often attributed to a facet syndrome, lower lumbar disc problem, or an iliolumbar syndrome (involvement of the iliolumbar ligament).

 Clinical symptoms of cluneal nerve entrapment have been described as low back pain, which may radiate to the ipsilateral leg (the leg on the same side). Clinical signs include tenderness at the iliac crest rim just above the dimple at the buttock and decreased touch sensation of the buttock just below the iliac crest. A diagnosis of medial cluneal nerve entrapment is made by palpation of the iliac crest or long posterior sacral ligament resulting in marked local tenderness and pain relief after local anesthetic injection.”

What are we seeing in this image below?

A lot of cross conditions, symptoms makers, and other problems clearly demonstrate that piriformis muscle syndrome is rarely a problem in isolation.

Here are some explanatory points of what is going on in this image

The point of this illustration is to suggest in some people, there is much more going on beyond piriformis syndrome.

Piriformis muscle syndrome is rarely a problem in isolation

When a patient comes in with a diagnosis of Piriformis muscle syndrome, we may also find that the patient may also suffer from signs and symptoms related to trochanteric bursitis  (please see our article Greater trochanteric pain syndrome – It is not sports-related bursitis?) and weakness in the iliotibial band. (Please see our accompanying article Iliotibial band friction syndrome Knee pain in Runners.) These problems can also cause “sciatica.”

When examining the patient with Piriformis muscle syndrome, we may also find weakness in the sacroiliac joint, hip joint, sacrotuberous and sacrospinous ligaments, trochanteric bursa, and iliotibial band/tensor fascia lata.

All this is in addition to those conditions just mentioned in the research. So there can be a lot going on beyond a suspected Piriformis syndrome.

The difficulty in getting to this point of diagnosis is demonstrated by the stories people tell of their medical histories. One such story goes like this:

“I am 32 years old and for 16 years I have suffered from pain in my buttocks that shoots down my leg when I bend forward or walk. The pain has been excruciating and gradually led to weakness in my leg. At first I thought that it was sciatica. I have done therapy, exercise, stretches, etc., but only gotten mild relief. Some days the pain is so excruciating that I could barely walk. Because of this pain I have gotten injuries to both knees as a result of joint instability when I play soccer. I would like to get relief for my leg. Just to be able to run on the soccer field without wobbling. Run for a mile without dragging one leg and limping in pain. I just recently learned about piriformis syndrome and nerve entrapment.”

Making sense of why treatment focused only on the Piriformis muscle is not helping you

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 are 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 (6) journal of the typical expectations of treatment a patient may receive. This will likely sound very familiar to you:

Corticosteroid injections for piriformis syndrome

A 2020 study (7) comes to us from the National and Kapodistrian University of Athens, University General Hospital in Greece. Here the doctors assessed cortisone injection effectiveness in piriformis syndrome patients who were not responding to conservative care management. In this study, twenty patients were examined who had a previous cortisone injection for their piriformis syndrome diagnosis. The doctors found that in these 20 patients, pain symptoms were significantly reduced. Two of the patients had a second injection within 10 days after the first. The doctors noted ultrasound-guided cortisone injections seem to be “a feasible, efficacious, and safe approach for pain reduction and mobility improvement in patients with symptomatic piriformis syndrome.”

Many of you reading this article may have had initial success with cortisone. That you are reading this article is indicative that this “success” was off and you are now seeking other treatment methods.

Botulinum toxin injection can help. How much help? Not sure.

A July 2022 paper in the Journal of clinical orthopaedics and trauma (10) suggests botulinum toxin injection can help. How much help? Not sure. The researchers write: “There is fair quality of evidence to suggest botulinum toxin is safe to reduce pain in piriformis syndrome. There is insufficient data to quantify pain reduction and to describe other functional outcomes. The optimal dose of botulinum toxin A remains unclear.”

Hydro-dissection for Piriformis syndrome

Two case histories presented in The American journal of case reports in February 2022 (12)  found “Hydro-dissection by ultrasound-guided injection of a very low concentration of local anesthetic is effective and has lower risk of adverse effects, thus making it more convenient for the treatment of piriformis syndrome than conventional treatments, such as local anesthetics, steroids, and botulinum toxin injection.”

For many of you reading this article, you have found that these treatments were not effective and you are facing the surgical recommendation, the “last resort.”

Yet other researchers agree with this treatment methodology. Writing in the journal Practical Neurology (8) 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.”

Indeed, for some these treatments may be effective. If you are reading this article, it is probable that they were not effective for you.

Surgery: endoscopic piriformis release with a sciatic nerve neurolysis

When all conservative treatments fail, a recommendation may then be made for an MRI or CAT scan to confirm that what this person needs is surgery. A surgery that most patients do not want when they are told of the four-month recovery time. This is when these people will contact our office seeking a surgical alternative and a treatment that will help them compete or get back to work again.

A January 2022 review study published in the journal Arthroscopy, sports medicine, and rehabilitation (11) asked patients about their satisfaction following endoscopic piriformis release with a sciatic nerve neurolysis.

Before the surgical procedure the patients had suffered an average 34 months with symptoms associated with piriformis syndrome.

Understanding treatment: The piriformis muscle does not just tighten up on its own

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 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.

The patient is a long-distance runner, who developed sacroiliac joint pain, iliotibial band problems, piriformis syndrome, patella femoral syndrome, and pain all along her entire right side.

In the Journal of Prolotherapy a case history of successful treatment with Prolotherapy (see below on what Prolotherapy is) is presented:

An acute episode occurred when during a run the patient “heard a crack and felt searing pain through the inner thigh and groin.”

After visiting numerous doctors the patient was advised she had a “pulled groin muscle,” and to “stop running.” Since the patient was already experiencing extreme difficulties in simply walking, the doctor’s advice was of no help.

According to the patient: “Months of dedicated, daily physiotherapy treatments proved mostly futile until finally the physiotherapist, a marathoner herself, informed me of a treatment called Prolotherapy. She believed this would address the laxity of the ligaments of my right SI joint, which had culminated in what was in fact a fracture of the inferior pubis ramus resulting from multiple biomechanical problems, and laxity of the ligaments of the SI, exacerbated by many miles of running.”

Prolotherapy injections for Piriformis syndrome

Prolotherapy involves injections of dextrose, a simple sugar, into damaged ligaments. The treatment causes an inflammatory response which causes the growth of new and stronger ligaments. After the initial treatment, the patient was informed to refrain from all vigorous activity for 48 hours as to not add any additional stress during that healing period, followed by no impact activities for two weeks.

The patient reported: “After two weeks of refraining from running, I gently eased back into my routine, seeing increased strength and decreased pain. Several months later, I had trained for and completed a half marathon, although with some SI pain. Another Prolotherapy treatment and several more months of smarter training, and I registered for and completed the marathon that I had fractured out of and was sidelined from almost exactly one year earlier. Arguably, 42.2 kms of impact is about as good a test as you will find anywhere to demonstrate the efficacy of a treatment.

In the two years since that pelvic fracture and subsequent Prolotherapy treatments, I have run four marathons, competed in numerous other road races of varying distances, as well as several triathlons. After a year of continuous training, I required one isolated Prolotherapy treatment for the same SI joint. Considering the amount of stress I have put on it with my running, if a minor tune-up is called for in order to keep me moving and being an active participant in my own life, then so be it.”

Prolotherapy may be an excellent treatment to help cause permanently strong tissue to form where a weakened sports injury exists. Prolotherapy stimulates the healing process and, therefore, decreases the length of time it takes for soft tissue sports injuries to heal. Prolotherapy, because it triggers the growth of normal collagen tissue, causes stronger ligaments and tendons to form. Consequently, the athlete returns to his or her game stronger. After Prolotherapy treatments, not only is the athlete able to return to the sport but often the particular area that was injured will be stronger than before the injury and performance will be enhanced.

Platelet Rich Plasma Injections for Piriformis syndrome

An August 2021 paper in the Journal of Back and Musculoskeletal Rehabilitation (9) describes patient outcomes following PRP injections for Piriformis syndrome.

“Piriformis syndrome is the common entrapment neuropathy causing buttock pain. Patients are conventionally treated with lifestyle modification, exercise, non-steroidal anti-inflammatory drugs, corticosteroid or botulinum toxin injections. However, some patients may not respond to these conventional treatment methods.”

The researchers noted that Platelet-rich plasma (PRP) injection has been shown to be beneficial in various muscular injuries, but its effects have not yet been investigated in piriformis syndrome. The aim then of this study was to explore the effect of PRP on pain and functional status in patients with piriformis syndrome.

To do this, the study authors selected 60 patients with piriformis syndrome and randomly separated them into two groups (PRP and control groups).

For more information on the combined use of PRP and Prolotherapy please see Prolotherapy treatments for lumbar instability and low back pain.

Summary

The various treatment options for Piriformis syndrome are presented here. Many patients have found success with conservative care options other than surgery. If you have read this article is very likely that you have not yet found your success. If you have questions about Piriformis muscle syndrome treatment, get help and information from our Caring Medical Staff

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References:

1 Vij N, Kiernan H, Bisht R, Singleton I, Cornett EM, Kaye AD, Imani F, Varrassi G, Pourbahri M, Viswanath O, Urits I. Surgical and Non-surgical Treatment Options for Piriformis Syndrome: A Literature Review. Anesthesiology and Pain Medicine. 2021 Feb 28;11(1). [Google Scholar]
2 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]
3 Siddiq MA, Clegg D, Al Hasan S, Rasker JJ. Extra-spinal sciatica and sciatica mimics: a scoping review. The Korean Journal of Pain. 2020 Oct 1;33(4):305. [Google Scholar]
4 Isu T, Kim K, Morimoto D, Iwamoto N. Superior and middle cluneal nerve entrapment as a cause of low back pain. Neurospine. 2018 Mar;15(1):25. [Google Scholar]
5 Inklebarger J, Galanis N. The management of cluneal nerve referred pain with prolotherapy. Journal of Prolotherapy. 2018;10:e982-91.
6 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]
7 Filippiadis D, Gkizas C, Velonakis G, Flevas DA, Kokkalis ZT, Mavrogenis AF, Mazioti A, Brountzos E, Kelekis N, Kelekis A. Computed Tomography-Guided Percutaneous Infiltrations for Piriformis Syndrome: A Single-Center Retrospective Study. Journal of Long-Term Effects of Medical Implants. 2020;30(2). [Google Scholar]
8 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]
9 Öztürk GT, Erden E, Erden E, Ulašlı AM. Effects of ultrasound-guided platelet rich plasma injection in patients with piriformis syndrome. Journal of Back and Musculoskeletal Rehabilitation. 2021(Preprint):1-7.
10 Koh MM, Tan YL. Use of botulinum neurotoxin in the treatment of piriformis syndrome: A systematic review. Journal of Clinical Orthopaedics and Trauma. 2022 Jul 9:101951. [Google Scholar]
11 Vanermen F, Van Melkebeek J. Endoscopic Treatment of Piriformis Syndrome Results in a Significant Improvement in Pain Visual Analog Scale Scores. Arthroscopy, sports medicine, and rehabilitation. 2022 Apr 1;4(2):e309-14. [Google Scholar]
12 Kaga M, Ueda T. Effectiveness of hydro-dissection of the piriformis muscle plus low-dose local anesthetic injection for piriformis syndrome: A report of 2 cases. The American Journal of Case Reports. 2022;23:e935346-1. [Google Scholar]

This page was updated July 22, 2022

 

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