Piriformis Syndrome is a dysfunction relating to the sciatic nerve that originates from the lower portion of the lower back and sacrum, and travels bilaterally to the centre of the leg and down towards the back of the foot.

What Is Piriformis Syndrome?

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).

The Piriformis Muscle

The piriformis muscle:

• is a small muscle located deep in the buttock (behind the gluteus maximus)
• starts from the lower spine and connects to the upper surface of each femur (thighbone)
• functions by assisting in rotation of the hip and turning of the leg and foot outward
• runs diagonally, with the sciatic nerve running vertically directly beneath it (although in some people the nerve can run through the muscle)

The piriformis muscle is a small muscle located deep in the buttock

Causes of Piriformis Syndrome

The exact causes of Piriformis Syndrome are unknown. Suspected causes include:

• Muscle spasm in the piriformis muscle, either due to 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
• Anyone 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)

Symptoms

Symptoms of Piriformis Syndrome include tenderness and pain in the buttock area, accompanied by sciatica-like pain, numbness, and weakness that runs down the back of the thigh, calf, and foot. Pain from Piriformis Syndrome is often worse when walking up stairs, or after sitting for a prolonged period, or while walking or running.

Piriformis Syndrome is often confused with other conditions, especially lumbar spine conditions. Attaining a proper diagnosis of Piriformis Syndrome is important when considering treatment for low back and leg pain. Typical 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.

Diagnosis

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 diagnosed after going through the 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

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

Medical History

This 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 exist in the patient’s family, such as arthritis.

Diagnostic Tests

X-rays and other spinal imaging studies cannot detect the irritation of the sciatic nerve by the piriformis muscle. However, diagnostic tests (such as X-rays, MRI and nerve conduction tests) may be conducted to exclude other conditions that could cause similar symptoms to Piriformis Syndrome. An injection of anaesthetic with or without steroids may help to confirm if the piriformis muscle is the source of the symptoms.

Treatment

Treatment options may be recommended by a healthcare professional depending on the severity of the patient’s sciatica-type of pain and other symptoms. A comprehensive approach to managing Piriformis Syndrome may include a combination of the following nonsurgical treatments:

Ice Packs and Ice Massage

At the onset of pain, lie on your stomach comfortably 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.

Applying ice pads can provide a surprising amount of pain relief for most types of pain.

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 with a heating pad on, as this may lead to skin burns.

Heating pads can relieve muscle aches and cramps, and help injuries heal.

Medications

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.

NSAIDs are more than just pain relievers. They also help reduce inflammation and lower fevers.

Injections

For severe sciatica pain from Piriformis Syndrome, an injection may be part of the treatment.

• Local anaesthetic and corticosteroid may be injected directly into the piriformis muscle to help decrease the spasm and pain. The purpose of 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 anaesthetic/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 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 remain stretched and relaxed.

Injection into the right side of the piriformis muscle.

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.

TENS units work by delivering small electrical impulses through electrodes that come with adhesive pads to attach them to a person’s skin.

Piriformis Muscle Stretch and Physical Therapy

Almost every treatment approach for Piriformis Syndrome will include a focus on carefully and progressively stretching the piriformis muscle. 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 increase to hold for 30 seconds, and repeat 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 onto a towel that is wrapped behind the foot until a mild stretch along the back of the thigh is felt.

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 practitioners can develop a customised 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.

Below are two videos demonstrating the exercises performed to relieve Piriformis Syndrome.

Video of Sciatica Exercises for Piriformis Syndrome

Or view the video on the server at:
https://video.tsemtulku.com/videos/SciaticaExercisesForPiriformisSyndrome.mp4

How to Fix Piriformis Syndrome

“The videos above were sourced from legitimate video-hosting service offering these videos for free download. They are made available here for purely educational, non-commercial purposes.”
The above information were extracted from:

• Revord MD, John P., Spine-Health, ‘Knowledge from Veritas: What is Piriformis Syndrome?’, 14 September 2012, https://www.spine-health.com/conditions/sciatica/what-piriformis-syndrome (accessed: 11 February 2019)
• Web MD, ‘Piriformis Syndrome: Symptoms, Causes, Treatments, Exercises, And More’, 30 April 2017,
  https://www.webmd.com/pain-management/guide/piriformis-syndrome-causes-symptoms-treatments#1 (accessed: 11 February 2019)
• Blankner B, ‘How To Fix Piriformis Syndrome’ 13 April 2008, https://www.youtube.com/watch?v=tFtUgS69rPk (accessed 11 February 2019

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