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Piriformis syndrome has been recognised as a source of buttock and leg pain for 80 years, but it is still a controversial diagnosis. The pain is thought to be related to the proximity of the muscle to the sciatic nerve in the buttock and irritation or compression of the nerve have been suggested as causes. Physiotherapists diagnose and treat piriformis syndrome regularly, as it can often be mistaken for sciatica.

The piriformis (”pear shaped”) is a small, flat muscle in the buttock, running centrally from the sacral areas across the buttock to the upper part of the greater trochanter of the femur, the large bony lump on the side of the hip. With the leg straight it turns the leg outwards, when the hip is bent it moves the leg away from the centre of the body. There is some anatomical variation in the relationship between the piriformis muscle and the sciatic nerve in the buttock. In most people the nerve lies in front of the muscle but in some the muscle belly is divided into two with parts of the nerve passing through the division.

Piriformis syndrome has no clear cause of onset and may occur with sacro-iliac and lumbar spinal syndromes. Direct damage to the buttock could cause scar tissue around the muscles and the nerve, while continual pressure over time could also alter the nerve’s function. Other factors could be an increased lumbar curve, strong activity and hip replacement, with some cases imitating back pain problems such as sciatic pain. Diagnosis and treatment of piriformis syndrome is performed by physiotherapists on clinical findings due to the lack of diagnostic and imaging investigations.

Little consideration is given to piriformis syndrome as a reason for back and leg pain but it can imitate sciatic leg pain, presenting as back pain with nerve root compression due to disc prolapse or joint enlargement. Due to the insertion of the piriformis tendon into the greater trochanter this syndrome can have a connection with trochanteric bursitis. Clinical examination by the Physio shows an acutely painful trigger point in the mid buttock, some loss of hip lateral rotation, pain and loss of strength in the hip abductors and lateral rotators and a feeling of sitting on a golf ball.

No scientific evidence exists for the usefulness of any particular physiotherapy treatment, especially as there are no agreed diagnostic criteria. Physiotherapy examination includes finding the physical restrictions such as tight muscles (piriformis, hip adductors, hip external rotators), joint stiffness and dysfunction (sacro-iliac joint and lumbar spine), walking with an outwardly turned hip, an apparently short leg and a shorter length of stride.

If the physiotherapist finds that the piriformis and other muscles are tight then treatment consists of loosening up the hip joint followed by stretches of the muscle. Stretching the muscle is performed in lying with the hip flexed, pulling the hip into adduction and internal rotation. A home stretching programme is important, with regular stretching every two or three hours in the acute phase. If the piriformis is looser than expected the Physio may exercise the muscle to tighten it up and stretch out the tight structures which oppose this tendency.

The tight muscle area in the buttock is often very tender indeed but responds to local manipulation. Soft tissue mobilisations over the muscle are used such as transverse friction massage, with a cold spray and stretching technique also popular. The examination and the treatment of the lumbar spine and sacro-iliac joints are also used. Conservative treatment is usually successful using these stretches, manual techniques, injections and modification of activity and posture. Surgery is sometimes used in persistent cases to cut the muscle or the tendon near the trochanter.

Tags: Health & Fitness //