Definition

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).

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).

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.

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.

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.

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.

Physical exam
The physical exam will include an examination of the hip and legs to see if movement
causes increased low back pain or lower extremity pain (sciatica pain).

Typically, motion of the hip will recreate the pain. The exam will also identify or rule out
other possible causes of the sciatica pain, such as testing for local tenderness and
muscle strength.

Medical history
A medical history includes an in-depth review of the patient’s symptoms, such as what
positions or activities make the symptoms better or worse, how long the symptoms
have been present, if they started gradually or after an injury, and what treatments have
been tried.

It will also include a review of conditions that may be in the patient’s family, such as
arthritis.

Diagnostic tests
X-rays and other spinal imaging studies cannot detect if the sciatic nerve is being
irritated at the piriformis muscle. However, diagnostic tests (such as X-rays, MRI and
nerve conduction tests) may be conducted to exclude other conditions that can cause
similar symptoms to piriformis syndrome.

An injection of anesthetic with or without steroids may help to confirm if the piriformis muscle is
the source of the symptoms.
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.

Piriformis stretches
There are a number of ways to stretch one's piriformis muscle. Two simple ways
include:

 Lie on the back with both feet flat on the floor and both knees bent. Pull the right
knee up to the chest, grasp the knee with the left hand and pull it towards the left
shoulder and hold the stretch. Repeat for each side.
 Lie on the back with both feet flat on the floor and both knees bent. Rest the
ankle of the right leg over the knee of the left leg. Pull the left thigh toward the
chest and hold the stretch. Repeat for each side.

Each piriformis stretch should be held for 5 seconds to start, and gradually increased to
hold for 30 seconds, and repeated three times each day.

Hamstring stretches
Stretching the hamstrings (the large muscle along the back of each thigh) is important
to alleviate any type of sciatic pain. There are a number of ways to stretch the
hamstrings:

 Place two chairs facing each other. Sit on one chair and place the heel of one
leg on the other chair. Lean forward, bending at the hips until a gentle stretch
along the back of the thigh is felt, and hold the stretch.
 Lie on the back with both legs straight. Pull one leg up and straighten by holding
on to a towel that is wrapped behind the foot until a mild stretch along the back
of the thigh is felt.

Again, try to work up to holding each stretch for 30 seconds and repeat three times
each day.

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.

Depending on the severity of the patient’s sciatica-type pain and other symptoms, a
number of treatment options may be recommended by a health care professional.

A comprehensive approach to managing piriformis syndrome may include a

combination of the following nonsurgical treatments:

Ice and Heat Therapy for Piriformis Syndrome

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.

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.

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.

8 Tests to Diagnose Piriformis Syndrome

Test #1 - Lasègue
This range of motion test (ROM) involves letting you laying on your
back and flexing your hip at a 90 degree angle. If there is pain when
you flex your knee straight, it is a positive sign for piriformis
syndrome.

Test #2 - Freiberg
This is another ROM test. Your doctor will have you lying on your
back before lifting and rotating your leg. Pain in the buttocks is
considered a positive sign of the syndrome.

Test #3 - Pace
This ROM test requires you lie on the side without any pain. Then
your doctor will move your hip and leg through several motions.
Pain indicates piriformis syndrome.
Test #4 - Sciatic Notch Palpitation
This is not a ROM test but a manual test. While lying down, your
doctor will press and release your sciatic notch with their finger.
This notch is located on your pelvic bone and is where the
piriformis muscle passes over the nerve. Again, pain will indicate a
positive result for the syndrome.

Test #5 - Sensory Evaluation

This manual test requires your doctor lightly touch the affected leg,
or he can use an implement to make your leg have sensation. They
are looking for an increase in sensitivity, or a loss of sensation in
the leg. The piriformis syndrome test result that is positive is loss
of sensation. An increase in sensitivity may indicate another
condition.

Test #6 - Muscle Evaluation

With this test, your doctor is going to examine and measure several
aspects of the condition of your muscles in your leg and gluteus.
The gluteus is the large muscle that gives your buttocks shape.
They will check if the muscle has tightened, weakened or
atrophied. An atrophied muscle is weak and will lose volume
because it has not had regular uses. You may not have used the
muscle because you have been compensating with others to avoid
the pain the atrophied muscle experiences due to the syndrome.
When your doctor presses on an atrophied or contracted muscle,
there will be an increase in pain.

Test #7 - CT or MRI scan

Once your doctor has to eliminate other possible causes of your
pain, they can request a CT or MRI scan. The advanced imaging of
these scans allows your doctor see if there are any abnormalities or
arthritic conditions that would be causing your pain. They will also
be able to see the muscle itself and see if there is any
misalignment to it. Which one they use will depend mostly on which
test your insurance company will allow. Neither is considered to be
capable of producing a definitive diagnostic result, but both allow
for greater detail to be seen to rule out other causes.

Test #8 - Electromyography
This is often used when your doctor has to figure out if it is
piriformis syndrome test or a herniated disc. This test allows for
your doctor to stimulate muscles with an electric current. They may
use electrodes to be taped to your skin for sending the current to
the muscle, or they may insert a small needle directly into your
muscle. If you do have piriformis syndrome, both the piriformis
muscle and gluteus will have abnormal muscle reaction to the
electrical stimulation, but the muscles around your piriformis can
react normally.If the muscles around also have abnormal reaction,
you may have a herniated disc. This is rarely performed as the first
test because it is invasive and the other tests may show enough
positive signs to diagnose piriformis syndrome.
Note: There are many tests for piriformis syndrome. Bear in mind
that you have to get your doctor to refer you to a specialist for
these tests. This is not just because the tests may involve
advanced diagnostic equipment, but the rarity of this syndrome can
cause that many doctors aren't trained to do a test of piriformis
syndrome. The other issue is that many of the symptoms can also
be caused by other types of syndromes and issues. Only a
specialist will be able to make an informed diagnosis. Specialists
who are familiar with the different types of testing for this
syndrome include orthopedists, osteopaths and specialists in
physical medicine.