Piriformis Syndrome

Due to various factors, including direct injury to the piriformis muscle, prolonged sitting, and overuse, the piriformis muscle can become scarred, inflamed, or shortened due to muscle tightness or spasms.

Because the piriformis muscle and the sciatic nerve are within very close proximity to each other within the buttock, spasms, inflammation, or shortening of the piriformis can cause it to rub against or compress the sciatic nerve (called sciatic nerve entrapment), resulting in pain, numbness, or tingling sensations, as well as limited range of motion or painful movement in the hip joint.

Pain and numbness can also radiate down the sciatic nerve into the legs and feet. This pain is often triggered by long periods of sitting, running, stair climbing, or other actions that strain the piriformis muscle.

The symptoms of piriformis syndrome are often located in the buttock and hip area, but can also radiate into the thigh, lower leg, and foot.

Symptoms include:

• Stiffness in the hip joint
• Dull ache in the buttock or hip
• Tingling or numbness in the hip, thigh, or lower leg
• Burning sensation in the buttock, hip, thigh, or lower leg
• Sharp or shooting pain down the back of the thigh
• Pain that worsens with prolonged sitting, stair climbing, or hip movements

An estimated 0.3% to 6% of reported lower back or sciatic pain is caused by piriformis syndrome. It is most commonly seen in people of middle age and is more common in women than men (6:1 ratio) (Hicks et al. 2023).

While most risk factors are related to lifestyle and injury to the piriformis muscle, a small segment of the population has an anatomical anomaly in their sciatic nerve, where it branches early and either passes around or through the piriformis muscle, rather than running beneath the muscle prior to branching; this increases the risk of developing piriformis syndrome.

Some common risk factors include:

• Injury to the hip or buttock area
• Prolonged sitting
• Weak piriformis muscles
• Overuse of the piriformis muscle, such as with long-distance running or heavy weight lifting
• Poor body mechanics with lifting
• Lack of exercise (sedentary lifestyle) causes muscle tightness
• Anatomical abnormality in which the sciatic nerve branches early and runs either through or around the piriformis muscle (called primary piriformis syndrome)

In order to diagnose piriformis syndrome, other causes of a patient's symptoms must be ruled out; these conditions include a herniated disc, spinal stenosis, sciatica, sacroiliac joint dysfunction, and hip bursitis.

Diagnosis will involve a medical appointment to get a complete medical history, including any past injuries to the hip or buttock area; a physician will also discuss your symptoms, what type of movements or activities provoke them, and other lifestyle habits; you will also undergo a physical examination, performing various stretches and movements, to help identify the source of your symptoms.

Following this assessment, you may also be sent for diagnostic testing, such as an ultrasound, CT scan, MRI, or nerve conduction test, to better understand what may be causing your symptoms.

After a diagnosis of piriformis syndrome, the approach to your treatment will vary depending on a number of factors, including the severity of your pain and limitations, your lifestyle habits, and other health factors.

Some treatment options include:

• RICE – rest, ice, heat, and exercise (specialized exercises and stretches that aim to gradually stretch and strengthen the piriformis muscle)
• NSAIDs (non-steroidal anti-inflammatory drugs) to reduce pain and inflammation
• Other oral medications specific to treating pain and inflammation
• Physiotherapy
• Aquatics or pool therapy program
• Acupuncture and acupressure
• Massage therapy
• Occupational therapy (including improving the ergonomics of your workstation, if applicable)
• Exercise – ensuring proper exercise routine and form (including a proper warm-up and stretch, as well as avoiding overuse of the piriformis muscle) —  Consultation with a personal trainer may be beneficial
• Dietary changes to reduce inflammation
• Assistive devices such as TENS
• Orthotics

At the Wilderman Medical Clinic, we offer a variety of interventional and non-interventional pain management options, including:

Interventional pain management for piriformis syndrome:

• Ultrasound-guided injections with cortisone for piriformis syndrome
• Dextrose (prolotherapy) injections for piriformis syndrome
• PRP (platelet-rich plasma) injections for piriformis syndrome
• Botulinum toxin (Botox) injections for piriformis syndrome
• Trigger point injections for piriformis syndrome

Non-interventional pain management for piriformis syndrome:

• Psychotherapy
• Kinesiology education sessions

Surgical intervention is considered a last resort for piriformis syndrome when all other options have failed to provide adequate relief from pain. With severe piriformis syndrome, however, surgery may be required in order to relieve pressure on the sciatic nerve and prevent permanent nerve damage.

If this is the case, a surgeon will discuss the alternatives with you, including making an incision in the piriformis muscle or actually removing a small portion of the muscle in order to alleviate pressure on the sciatic nerve.

Recovery from this procedure will require working with a physiotherapist for several weeks to several months, depending on the type of procedure.

Hicks BL, Lam JC, Varacallo M. Piriformis Syndrome. [Updated 2022 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448172/

Piriformis syndrome. Cleveland Clinic. Retrieved from https://my.clevelandclinic.org/health/diseases/23495-piriformis-syndrome.

Wheeler, Tyler. Piriformis syndrome. WebMD. Retrieved from https://www.webmd.com/pain-management/guide/piriformis-syndrome-causes-symptoms-treatments.