What is piriformis syndrome, and how is it addressed?

Updated: Sep 16, 2020
  • Author: Milton J Klein, DO, MBA; Chief Editor: Ryan O Stephenson, DO  more...
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Piriformis syndrome, caused by a neuritis of the proximal sciatic nerve, results from compression or irritation of the sciatic nerve by the piriformis muscle due to spasm and/or contracture, with patients characteristically suffering hip and buttock pain. There is no definitive method to accurately diagnose piriformis syndrome, but treatment with a home stretching program is among the therapies that should be provided to the patient. [1]

A controversial diagnosis since its initial description in 1928, piriformis syndrome, which can mimic a diskogenic sciatica, is also referred to as pseudosciatica, wallet sciatica, and hip socket neuropathy.

In many musculoskeletal practices, piriformis syndrome can be considered a reasonable primary or secondary diagnosis if the symptoms, history, and physical examination are supportive. Due to the traumatic etiology of most cases, however, piriformis syndrome usually is associated with other, more proximal causes of low back pain, sciatica, or buttock pain (thereby further clouding the diagnosis).

Piriformis syndrome signs and symptoms

These include the following:

  • Piriformis muscle spasm often is detected by careful, deep palpation
  • The reproduction of sciatica-type pain with weakness results from resisted abduction/external rotation (Pace test) [2]
  • The Freiberg test is another diagnostic sign that elicits pain, upon forced internal rotation of the extended thigh [3]
  • The Beatty maneuver reproduces buttock pain by selectively contracting the piriformis muscle [4]
  • A painful point may be present at the lateral margin of the sacrum
  • Shortening of the involved lower extremity may be seen
  • The patient may have difficulty sitting due to an intolerance of weight bearing on the buttock
  • The patient may have the tendency to demonstrate a splayed foot on the involved side when in the supine position

Piriformis syndrome workup

Diagnostic imaging of the lumbar spine may be helpful in excluding associated diskogenic and/or osteoarthritic contributing pathology should conservative treatment of clinically diagnosed piriformis syndrome fail to provide therapeutic benefit. Diagnostic ultrasonographic imaging of the piriformis muscle for the assessment of muscle morphology has demonstrated a significant correlation of piriformis muscle morphology abnormality.

Piriformis syndrome management

Because there is no definitive method to accurately diagnose piriformis syndrome, treatment regimens are controversial and have not been subjected to randomized, blind clinical trials.

In most cases, conservative treatment (eg, stretching, manual techniques, injections, activity modifications, natural healing, modalities such as heat and ultrasound) is successful in managing the condition.

Consider the use of ultrasound and other heat modalities prior to physical therapy sessions. Before piriformis stretches are performed, the hip joint capsule should be mobilized anteriorly and posteriorly to allow for more effective stretching. Soft-tissue therapies for the piriformis muscle can be helpful, including longitudinal gliding with passive internal hip rotation, as well as transverse gliding and sustained longitudinal release with the patient lying on his/her side. Addressing sacroiliac joint and low back dysfunction also is important.

A home stretching program should be provided to the patient. These stretches are an essential component of the treatment program.

Surgical management is the treatment of last resort for piriformis syndrome. Surgery for this condition involves resection of the muscle itself or of the muscle tendon near its insertion at the superior aspect of the greater trochanter of the femur (as described by Mizuguchi). [5]

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