What Is Piriformis Syndrome

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Introduction

If you've been experiencing persistent, nagging pain that lingers in your buttocks and lower back, travelling down your leg, you might be dealing with Piriformis Syndrome- a condition that can be both uncomfortable and disruptive. Fear not, for you're not alone in this journey. In the following article, we'll unravel this lesser-known, rare syndrome.

Piriformis syndrome is a neuromuscular condition where the piriformis muscle, which is located in the buttocks, compresses or irritates the sciatic nerve (the longest and largest nerve in the body). This compression can lead to pain, tingling and numbness in the buttocks and down the leg. 

Curious to learn more about Piriformis Syndrome and how you can effectively manage its symptoms? Continue reading to discover valuable insights into the treatment options for this often-overlooked condition.1

Piriformis syndrome is a rare condition that affects the piriformis muscle and sciatic nerve. The sciatic nerve is the biggest nerve in the body; it runs from each hip down to each leg. The piriformis muscle, a slender muscle located in the buttocks, facilitates hip rotation and external flexion of the leg and foot. Piriformis syndrome is a disorder that arises when the piriformis muscle compresses the sciatic nerve. Patients typically experience tingling or numbness along the sciatic nerve. Long periods of sitting, stair climbing, walking, or running might exacerbate the pain. 

Robinson is credited with coining the term piriformis syndrome in 1947.3,7,21 About 5–6% of people with lower back pain or one-sided sciatica have pain from piriformis muscle issues.7

Anatomy and function of the piriformis muscle

The piriformis muscle is situated in the pelvic region, deep within the buttocks. It originates from the anterior sacrum and attaches to the greater trochanter of the femur. Functionally, the piriformis functions as an external rotator of the hip, a key player in hip rotation and abduction, contributing to the overall stability and movement of the hip joint.

Connection to the sciatic nerve and its significance in motion

The piriformis muscle is situated in close proximity to the sciatic nerve, a significant nerve that travels from the lower back down to the back of each leg. The sciatic nerve may go through or under the piriformis in certain people. Because it stabilises the hip joint and makes a variety of hip movements possible, the piriformis muscle is crucial to mobility. For hip-rotational activities like walking, jogging, and even sitting, a healthy piriformis is essential. 

Causes of piriformis syndrome

  • Muscle spasms and inflammation 
  • Trauma or injury to the piriformis muscle: Trauma to the buttocks, such as a fall or blunt force, can lead to muscle inflammation and subsequent compression of the sciatic nerve
  • Overuse or Repetitive Strain: Activities that involve repetitive movements or prolonged sitting may contribute to muscle overuse and the development of piriformis syndrome
  • Muscle Imbalances: Weaknesses or imbalances in surrounding muscles may place extra stress on the piriformis, leading to dysfunction
  • Anatomical variations leading to compression of the sciatic nerve: The sciatic nerve may run through the piriformis muscle in some individuals, making them more prone to compression.
  • Myositis ossificans can also be a rare cause of piriformis syndrome18
  • Hip arthroplasty, neoplastic mass effect (a cancerous mass compressing the surrounding structures)20

Classification of the causes of Piriformis Syndrome can be done in the following manner:7

  • Functional/Non-Organic causes
    • Issues like muscle spasm, shortening, and hypertrophy
  • Organic Disorders:
    • Conditions such as anatomical variations, swelling, scarring of muscle or nerve, adhesions, bleeding, muscle wasting, cysts, bursitis, abscesses (a collection of pus), abnormal bone formation, endometriosis, and tumours

Symptoms 

Pyriformis syndrome presents the following symptoms: 1,2,3,7,11

  1. Buttock Pain: Irritation of the sciatic nerve (SN), pain (sciatica), and tingling in the lower back and buttocks are prevalent symptoms. Pain can be described as shooting, burning or aching
  2. External Tenderness: Tenderness is often felt over the outer part of the hip, known as the greater sciatic notch
  3. Aggravation through Sitting: Pain tends to worsen when sitting for extended periods
  4. Augmentation with Muscle Tension: Manoeuvres or activities that increase tension in the piriformis muscle can intensify the pain

Effects on other structures

  1. Irritation of the inferior gluteal nerve leads to the shrinking of gluteal muscles
  2. Irritation of the posterior femoral cutaneous nerve causes pain and tingling in the back of the thigh
  3. Irritation of the pudendal nerve results in pudendal neuralgia, painful intercourse, sexual issues, and problems with urination and bowel movements
  4. Irritation of the inferior gluteal artery causes pain due to reduced blood flow in the buttocks
  5. Irritation of the inferior pudendal artery causes pain, sexual problems, and issues with urination and bowel movements
  6. When the inferior gluteal and pudendal veins become inflamed due to the decreased blood flow, stagnation of blood occurs in the affected areas

Diagnosis 

Piriformis syndrome has been documented for more than 50 years. Yet its diagnosis still remains confusing at times.14 Let us delve into its sequential diagnosis:5,6,7

  • Patient history: information from the patient about their symptoms 
  • Physical Examination: The doctor checks for signs and symptoms during a physical exam
  • A group of signs you might notice, like pain in the buttocks, tenderness when pressing on a certain spot near the hip, increased pain when doing specific movements that stretch the piriformis muscle, and worsened pain when sitting down, can be useful for figuring out the diagnosis1
  • Electromyoneurography (EMNG): A test checks the electrical activity in muscles and nerves.
  • Injection with anaesthesia around the piriformis muscle
  • Radiological Exams: Medical tests, like MRI scans, look at the pelvis and the muscles around the hip, including the piriformis muscles. Another test, called MR Neurography, examines the nerves in the lower back (lumbar sacral plexus) and the sciatic nerve15

It comprises between 0.3% - 6% of all low back pain cases.17 Owing to the dearth of accurate and established diagnostic procedures, the syndrome is frequently used as an exclusion diagnosis after all other potential explanations have been ruled out.13

Differential diagnosis

Given that Piriformis Syndrome and other disorders, including herniated discs, lumbar canal stenosis, and disc inflammation, share symptoms of lower back and buttock discomfort, it is critical to accurately differentiate the two in order to determine an effective course of treatment.1,4

Table 1: Differential Diagnosis for Piriformis Syndrome4,16

Piriformis Syndrome  Herniated DiscsLumbar canal stenosis Disc inflammation 
Involves sciatic nerve compression by the piriformis muscle

It involves the displacement of intervertebral disc material, often pressing on spinal nerves


It involves the narrowing of the spinal canal, putting pressure on the spinal cord or nerves

Involves inflammation of the intervertebral discs

Characterised by buttock pain, aggravated by sitting, and tenderness over the greater sciatic notchPresents with radiating pain, numbness, or tingling along the sciatic nerveCharacterised by leg pain, numbness, and weakness, often worsened with walking or standingSymptoms include back pain, possibly radiating to the legs; stiffness; limited mobility
May present with radiating pain resembling sciaticaWeakness in the affected leg may be presentThe pain extends into the legs and possibly the buttocksPain typically centres the spine and may not follow the sciatic nerve distribution
--Symptoms often worsen with vertical movement of the spine (standing and walking) and improve with sitting or bending forwardMovements that involve the spine, such as bending or twisting, may worsen symptoms

Importance of accurate diagnosis

  1. Targeted/Tailored treatment plans: Piriformis syndrome may respond to physical therapy and injections, while herniated discs may require a mix of conservative measures and, in rare but severe cases, surgery
  2. Avoidance of unnecessary interventions: For instance, surgery for herniated discs may not address the underlying issue in piriformis syndrome
  3. Improved patient outcomes minimise the risks associated with inappropriate interventions, promoting optimal patient care

Treatment options conservative treatment options

Initial treatment options should be non-surgical.13

Physical therapy and exercises for rehabilitation

  1. Stretching exercises, deep transverse friction massage, and neuromuscular therapy such as the Proprioceptive neuromuscular facilitation technique
  2. Maintain regular exercise and physical activity, Practise good posture, Incorporate stretching into your routine3

Injections

Acupuncture

  • Using a traditional Chinese medicine technique for pain relief

Medications

Surgical consideration: like releasing the piriformis muscle or decompressing the sciatic nerve

  • Surgical intervention (endoscopic decompression) is a gold standard
  • Reserved for cases where conservative measures fail and symptoms significantly impact daily life
  • Endoscopic Approach Preferred:8
    • Endoscopic decompression, with or without piriformis release, is preferred over open surgery
    • Notable for improved outcomes and reduced complications

Further research is necessary to establish precise diagnostic metrics and standardised diagnostic criteria for accurate diagnosis and treatment planning.

Prevention

Tips to Reduce Piriformis Syndrome Risk include the following “Lifestyle Modifications”:

  • Ergonomic adjustments: To reduce pressure on the piriformis muscle
  • Regular exercise: Engage in regular physical activity, emphasising exercises for hip flexibility and strength.4,3
  • Maintain good posture: Be mindful of posture, especially during prolonged sitting or standing.6
  • Incorporate stretching: Regularly include stretching exercises, particularly those targeting the hip and piriformis muscles3
  • Body mechanics education

    Emphasis on the importance of early diagnosis and proactive management

    1. Prevention of progression:

    • Early diagnosis allows for timely intervention, preventing the progression of piriformis syndrome
    • Proactive management can address underlying issues, reducing the risk of chronic pain and complications

    2. Minimisation of discomfort:

    • Proactive management strategies, such as physical therapy and targeted exercises, can minimise discomfort and improve quality of life

    3. Enhanced treatment efficacy:

    • Proactive management, including tailored exercises and lifestyle modifications, enhances treatment efficacy, potentially avoiding the need for invasive procedures

    4. Preventive measures help minimize or avert recurrence.

    5. Improved functional outcomes:

    • Initiating physical therapy and other interventions in the early stages can enhance muscle strength, flexibility, and overall functionality

    6. Quality of life improvement:

    • Proactive management, including pain management strategies and patient education, improves the overall quality of life for individuals with piriformis syndrome
    • Early intervention contributes to a faster return to regular activities

    7. Avoidance of complications:

    • Surgical interventions may be avoided or reserved for severe cases where conservative measures prove insufficient

    Many locations where the sciatic nerve may become pinched or trapped have been identified thanks to advances in our knowledge of the anatomy of the rear part of the hip and the sciatic nerve's movement. When buttock pain is caused by a pinched sciatic nerve, unrelated to spinal discs, or occurs outside the pelvic area, it is becoming more common to refer to the condition as "deep gluteal syndrome" rather than "piriformis syndrome."9

    FAQs

    Can piriformis syndrome be cured?

    While it may not always be completely cured, proper management and treatment can significantly alleviate symptoms and improve the quality of life for individuals with piriformis syndrome.

    Are there specific exercises to help with piriformis syndrome?

    Yes, stretching exercises targeting the piriformis muscle, along with other supportive exercises, can be beneficial. However, it's essential to consult with a healthcare professional to determine the most suitable exercise routine based on individual needs.

    How long does it take to recover from piriformis syndrome?

    Recovery time varies from person to person. With consistent treatment and lifestyle adjustments, many individuals experience improvement within a few weeks or months.

    Summary

    In this article, we've explored Piriformis Syndrome, a condition causing discomfort in the buttocks and lower back. Common causes include muscle spasms, trauma, or irritation, and the symptoms may mimic those of other conditions like herniated discs, lumbar stenosis, and disc inflammation. Treatment often involves a combination of stretching exercises, physical therapy, and, in some cases, medication to alleviate the discomfort and restore normal muscle function. If you suspect you have piriformis syndrome, consulting with a healthcare professional for a proper diagnosis and personalised treatment plan is crucial.

    Emphasising the need for early detection of piriformis syndrome and aggressive management is crucial in preventing development, reducing pain, and improving overall outcomes. Early intervention not only alleviates immediate symptoms but also promotes long-term musculoskeletal health and well-being.

    Understanding its causes, symptoms, diagnosis, and treatment options is crucial for effective management. Whether you're seeking relief from existing symptoms or aiming to prevent the onset of Piriformis Syndrome, the insights provided here offer valuable guidance.

    References

    • Hicks BL, Lam JC, Varacallo M. Piriformis Syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Mar 22]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK448172/.
    • Piriformis Syndrome | National Institute of Neurological Disorders and Stroke [Internet]. [cited 2024 Mar 22]. Available from: https://www.ninds.nih.gov/health-information/disorders/piriformis-syndrome.
    • Hopayian K, Song F, Riera R, Sambandan S. The clinical features of the piriformis syndrome: a systematic review. Eur Spine J [Internet]. 2010 [cited 2024 Mar 22]; 19(12):2095–109. Available from: http://link.springer.com/10.1007/s00586-010-1504-9.
    • Boyajian-O’Neill LA, McClain RL, Coleman MK, Thomas PP. Diagnosis and Management of Piriformis Syndrome: An Osteopathic Approach. Journal of Osteopathic Medicine [Internet]. 2008 [cited 2024 Mar 22]; 108(11):657–64. Available from: https://www.degruyter.com/document/doi/10.7556/jaoa.2008.108.11.657/html.
    • Vij N, Kiernan H, Bisht R, Singleton I, Cornett EM, Kaye AD, et al. Surgical and Non-surgical Treatment Options for Piriformis Syndrome: A Literature Review. Anesth Pain Med [Internet]. 2021 [cited 2024 Mar 22]; 11(1). Available from: https://brieflands.com/articles/aapm-112825.html.
    • Probst D, Stout A, Hunt D. Piriformis Syndrome: A Narrative Review of the Anatomy, Diagnosis, and Treatment. PM&R [Internet]. 2019 [cited 2024 Mar 22]; 11(S1). Available from: https://onlinelibrary.wiley.com/doi/10.1002/pmrj.12189.
    • Grgić V. PIRIFORMIS MUSCLE SYNDROME: ETIOLOGY, PATHOGENESIS, CLINICAL MANIFESTATIONS, DIAGNOSIS, DIFFERENTIAL DIAGNOSIS AND THERAPY. Liječnički vjesnik [Internet]. 2013 [cited 2024 Mar 22]; 135(1–2):0–0. Available from: https://hrcak.srce.hr/clanak/254450.
    • Martin HD, Shears SA, Johnson JC, Smathers AM, Palmer IJ. The Endoscopic Treatment of Sciatic Nerve Entrapment/Deep Gluteal Syndrome. Arthroscopy: The Journal of Arthroscopic & Related Surgery [Internet]. 2011 [cited 2024 Mar 22]; 27(2):172–81. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0749806310006870.
    • Martin HD, Reddy M, Gomez-Hoyos J. Deep gluteal syndrome. Journal of Hip Preservation Surgery [Internet]. 2015 [cited 2024 Mar 22]; 2(2):99–107. Available from: https://academic.oup.com/jhps/article-lookup/doi/10.1093/jhps/hnv029.
    • Sharma S, Kaur H, Verma N, Adhya B. Looking beyond Piriformis Syndrome: Is It Really the Piriformis? Hip & Pelvis [Internet]. 2023 [cited 2024 Mar 22]; 35(1):1–5. Available from: https://www.hipandpelvis.or.kr/journal/view.html?doi=10.5371/hp.2023.35.1.1.
    • Menu P, Fouasson-Chaillou A, Dubois C, Dauty M. Piriformis syndrome diagnosis: On two professional cyclists. Annals of Physical and Rehabilitation Medicine [Internet]. 2014 [cited 2024 Mar 22]; 57(4):268–74. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1877065714000402.
    • Miller TA, White KP, Ross DC. The Diagnosis and Management of Piriformis Syndrome: Myths and Facts. Can J Neurol Sci [Internet]. 2012 [cited 2024 Mar 22]; 39(5):577–83. Available from: https://www.cambridge.org/core/product/identifier/S0317167100015298/type/journal_article.
    • Douglas S. Sciatic Pain and Piriformis Syndrome: The Nurse Practitioner [Internet]. 1997 [cited 2024 Mar 22]; 22(5):166???181. Available from: http://journals.lww.com/00006205-199705000-00009.
    • Chitranjan, Kandpal H, Madhusudhan KS. Sciatic hernia causing sciatica: MRI and MR neurography showing entrapment of sciatic nerve. BJR [Internet]. 2010 [cited 2024 Mar 22]; 83(987):e65–6. Available from: https://academic.oup.com/bjr/article/83/987/e65-e66/7474656.
    • Kreiner DS, Shaffer WO, Baisden JL, Gilbert TJ, Summers JT, Toton JF, et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). The Spine Journal [Internet]. 2013 [cited 2024 Mar 22]; 13(7):734–43. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1529943013004233.
    • Papadopoulos EC, Khan SN. Piriformis syndrome and low back pain: a new classification and review of the literature. Orthopedic Clinics of North America [Internet]. 2004 [cited 2024 Mar 22]; 35(1):65–71. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0030589803001056.
    • Beauchesne RP, Schutzer SF. Myositis Ossificans of the Piriformis Muscle: An Unusual Cause of Piriformis Syndrome. The Journal of Bone & Joint Surgery [Internet]. 1997 [cited 2024 Mar 22]; 79(6):906–10. Available from: http://journals.lww.com/00004623-199706000-00016.
    • Son B, Kim D, Jeun SS, Lee S. Decompression of the Sciatic Nerve Entrapment Caused by Post-Inflammatory Scarring. J Korean Neurosurg Soc [Internet]. 2015 [cited 2024 Mar 22]; 57(2):123. Available from: http://jkns.or.kr/journal/view.php?doi=10.3340/jkns.2015.57.2.123.
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