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Piriformis Syndrome  

Piriformis syndrome — another irritation to the sciatic nerve

Piriformis syndrome and sciatica pain
Piriformis syndrome is a condition in which the piriformis muscle irritates the sciatic nerve and causes pain in the rear and may cause pain along the back of the leg and into the foot (similar to sciatica pain). Piriformis syndrome is most common among women, and is thought to be common among active individuals (such as runners and walkers).

While there is some controversy in the medical community, many health professionals believe that an accurate diagnosis and comprehensive management approach are critical to alleviate the sciatica type of pain caused by piriformis syndrome.

What is the piriformis muscle?
The piriformis muscle is a small muscle located deep in the rear (deep to the gluteus maximus).

The piriformis muscle:

  • Starts at the lower spine and connects to the upper surface of each femur (thighbone).
  • Functions to assist in rotating the hip.
  • Runs horizontally, with the sciatic nerve running vertically directly beneath it.

Piriformis syndrome can develop when the piriformis muscle becomes tight or spasms and places pressure on the sciatic nerve that runs beneath it. The pressure on the sciatic nerve can cause low back pain and/or pain that radiates to the rear and down the leg (similar to sciatica pain).  From a technical standpoint, piriformis syndrome does not cause true sciatica (as sciatica is usually defined as a radiculopathy, or compression of a nerve root as it exits the spine). However, just like sciatica, piriformis syndrome can cause pain, numbness and tingling along the sciatic nerve, which runs down the back of the leg and into the foot.

Diagnosis of piriformis syndrome

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.

Symptoms of piriformis syndrome
Most commonly, patients describe acute tenderness in the rear and sciatica-like pain down the back of the leg. Typical symptoms of piriformis syndrome may include:

  • A dull ache in the mid-rear
  • Pain down the back of the leg (a radiculopathy or sciatica)
  • Pain when walking up stairs or inclines
  • Increased pain after prolonged sitting

Symptoms of piriformis syndrome often become worse after prolonged sitting, walking or running, and may feel better after lying down on the back.

Physical exam to diagnose piriformis syndrome
The physical exam will include examination of the hip and legs to see if movement causes increased low back pain or leg pain (sciatica pain). Typically, motion of the hip will recreate the pain.

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 (such as a disc herniation).

Comprehensive management of piriformis syndrome and sciatica pain

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 pain along the sciatic nerve from piriformis syndrome may include a combination of:

Chiropractic manipulation of the lumbar and sacral joints can restore proper motion to the spine and create an inhibitory reflex to shut down a spasm of the piriformis.

Stretching exercise 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.

Ice for piriformis syndrome
At the onset of pain, lie in a comfortable position on your stomach and place an ice pack on the painful area for approximately 15 minutes. Repeat as needed every 2 to 4 hours.

If specific activities are usually followed by increased pain, it may be a good idea to apply ice immediately following the activity.

Range of motion exercises
A physical therapist 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 is thought to enhance healing by increasing blood flow to the area and decreasing muscle spasm.

Heat /Ice
Some people find it helpful to use either ice or heat or to alternate cold with heat.

Medications for sciatica pain
Since most episodes of pain include some type of inflammation, non-steroidal anti-inflammatory medications (NSAID’s) (such as ibuprofen or naproxen) may help decrease inflammation in the affected area.

Injections for sciatica pain and piriformis syndrome
For severe sciatica pain, a local anesthetic and corticosteroid may be injected in directly into the piriformis muscle to help decrease the spasm and help alleviate the sciatica pain. The purpose of an injection is usually to decrease acute pain to enable progress in physical therapy. For persistent piriformis spasm that is resistant to anesthetic/corticosteroid injections, an injection of botulinum toxin (a muscle weakening agent) may be useful.

Electrotherapy and ultrasound for piriformis syndrome
The application of electrical stimulation and ultrasound to the rear with can help to block pain and reduce muscle spasm related to piriformis syndrome.