Piriformis syndrome is an extremely painful condition caused by the tightening , shortening, thickening, and hypertrophy of the piriformis muscle.

A major disadvantage for patients suffering from piriformis muscle syndrome is the low level of awareness of this pathology.
A study by Silver and Leadbetter (1998) states that of 65 physicians surveyed, 7% denied the existence of this condition and 21% could not answer the question “what is it” or were vague.

As a result, this syndrome is often undiagnosed or confused with lumboischialgia .

The piriformis muscle can become overdeveloped (hypertrophy) and hardening, causing what is known as piriformis syndrome  .
A malfunction of the piriformis muscle can cause the pelvis to protrude.

Piriformis syndrome almost always occurs on the left side. This syndrome, also known as inflammation of the tendon attachment point at the greater trochanter of the femur, affects predominantly women (in a 6:1 ratio to men), and in the more severe cases daily activities can be impaired.
This muscle provides outward rotation of the thigh when the hip is in a neutral position; on the other hand, if the hip is bent more than 90°, he rotates it inwards.

In 80-90% of all people, the sciatic nerve runs in front of the piriformis muscle, in 10-15% it runs all or part of the way through the muscle, the remaining cases are divided into two: the fibula and tibia part, which runs behind and in front of the muscle respectively.
It is usually unilateral, but in some cases it can become bilateral over time.


Musculus piriformis anatomy

The piriformis muscle is a thin, pyramidal muscle divided into three fiber bundles that originates at the S2-S4 level of the sacrum; it is the only muscle with a direct origin on this bone. It runs horizontally and obliquely downwards, below the gluteus minimus, and above the twin muscles (musculi gemelli) and the internal obturator muscle (musculus obturator internus). The piriformis muscle tendon attaches to the tip of the greater trochanter (greater trochanter) and runs in the posterior pelvic region.

Symptoms of Piriformis Syndrome

People feel pain deep in the buttocks, possibly radiating down the back of the thigh to the knee. The pain is greatest during twisting movements, especially turning over in bed and crossing your legs while sitting. The painful stitches are most noticeable when sitting, because the weight is on the piriformis muscle; but the symptoms can also occur after a few minutes when walking.

Sciatic pain from “constriction”, not from the intervertebral disc

Sciatica can be caused by piriformis syndrome, which is when the sciatic nerve is pinched by the adjacent muscle.
The Lasègue test is usually negative, but the resisted retraction and retraction movements cause excruciating pain. If the pain extends to the knee , some patients limp when walking because every step causes great pain in this area; however, for the majority of those affected, walking and exercise bring relief.

Sciatic pain is almost unbearable pain and can be caused by herniated disc, tumoral mass, lumbar stenosis, bruising of the hamstrings (semimembranosus, semitendinosus and hamstrings), as well as the piriformis muscle, which increases in volume when inflamed, and the sciatic nerve compressed, causing painful stitches in the buttocks and leg.
This happens more often than you think; a study shows that in 240 patients pain in the course of the sciatic nerve was caused by piriformis syndrome in 40%.
Lumbar sciatica caused by a herniated disc is often confused with piriformis syndrome because both pathologies produce pain along the sciatic nerve.
In addition, this pain can be confused with the pain caused by the degeneration and tearing of the outer part of the disc, the fibrocartilage annulus; symptoms appear in the upper buttocks and iliac crest.
It rarely happens that the pubic nerve (nervus pudendus) is pinched at the ischial tuberosity.
In piriformis syndrome, there is hypertrophy of the muscle or narrowing of the sciatic nerve .
Compression occurs either by pushing the nerve against the outside of the greater ischial foramen (foramen ischiadicum majus) or by pinching the nerve between the fiber bundles of the piriformis.

The difference between piriformis syndrome and lumbar sciatica lies in the point of origin of the pain; in the first case, they arise from the sacral vertebrae, where they are of minimal intensity, while in the second case, they originate from the lumbar region and are very strong, especially when stretching while standing.
Dysfunction of the piriformis muscle can be accompanied by pain in the groin, abdomen, and throughout the thigh.

The causes of piriformis syndrome

The most common causes include:

  • direct trauma to the buttocks,
  • a violent movement
  • wrong posture ,
  • incorrect rolling of the foot,
  • a surgical procedure, which caused connective tissue adherences in this area.

Abdominal and pelvic surgeries often lead to the formation of adherences that alter the structure and dynamics of the trunk, which can lead to dysfunction and shortening of the piriformis muscle.
Pain that is not particularly intense can also be caused by dysmetria of the lower extremities or by a bad posture that leaves the muscle tense.
Athletes rarely suffer from this syndrome, mostly affecting runners and dancers, but it can occur as a result of an ankle sprain .

Diagnosis of piriformis syndrome

Who to contact if symptoms of piriformis syndrome appear? Alternative practitioners and orthopaedists are responsible. If piriformis syndrome is diagnosed, treatment must be carried out by an expert in manual therapy: physiotherapist or osteopath.
Various tests can be carried out:

  1. In the Freiberg test, the patient lies prone and internally rotates the hip, rotating the knee outward.
  2. The Pace and Nagle test is performed with the patient seated on the table, isometrically externally rotating and abducting the hip against resistance.
  3. Palpation of the gluteus maximus at the level of the greater trochanter insertion point and pressure on the central muscle belly; these are the two most painful points at which the patient suffering from piriformis syndrome usually “startles”.
  4. Other diagnostic tests: Saudek test , Mirkin test , Faber test.


A simple test to assess the condition of the piriformis and the other external rotators of the hip is to cross your legs, as men often do; Anyone who suffers from this pain syndrome will only be able to do this – if at all – with great difficulty.

Differential Diagnosis
Pain in the upper buttocks can also be due to sacroiliitis, ie inflammation of the sacroiliac (sacroiliac) joint; an X-ray can show the condition of the joint, a resonance gives a complete overview of this region; ankylosing spondylitis can cause these symptoms.

What to do? Treatment of Piriformis Syndrome

There are many treatment methods for this condition, medication can be taken or physiotherapeutic measures can be used.
The drugs of choice are nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants (muscle relaxants); some doctors also prescribe anesthetics or corticosteroids.
The orthopedist can inject cortisone directly into the muscle, which can reduce inflammation but does not relieve tension.

Of the physical therapies, massage ultrasound is recommended , ie the muscle must be massaged during the treatment; the symptoms are usually gone by the end of the treatment cycle; the therapy is a little painful, but has no contraindications as do drugs.
External rotation movements should be performed while performing instrumental physiotherapy, as this increases muscle temperature and promotes blood flow.

Physical therapies also include Tecar Therapy®, which is very effective in the treatment of piriformis syndrome if the handpiece is used to massage the piriformis muscle when performing it.
Many of my patients ask whether the use of magnet therapy makes sense; this form of treatment helps with broken bones and osteoarthritis , but it is not suitable for the muscles.
Myofascial manipulation, on the other hand, is very effective, although it is painful for the patient, but has the advantage that the cause of the problem is treated here and not the symptoms.
The piriformis muscle needs to be treated even if the patient is only suffering from low back paincomes to the practice because this muscle can rotate the pelvis and cause back pain .

The resumption of sports (or professional) activities must be gradual.
Get in the habit of not keeping your wallet in your back pocket; at night, a pillow placed between the legs will help relax the muscle.

There are orthopedic surgeons who surgically free the piriformis muscle, but the results are not particularly good and a scar of about 8-10 cm in length remains on the buttocks.

Which sports can be practiced?

Riding a bike can be painful so you should wait until it has fully healed.
Symptoms usually worsen after a few minutes of running, so it’s not recommended.
Freestyle swimming does not usually cause discomfort if the athlete keeps their legs relaxed; backstroke is also possible; Breaststroke, on the other hand, should be avoided.

Natural Remedies

Cold treatment delays the healing process, and the deep location of the piriformis muscle does not even relieve the pain for a short time.

There are no studies on the effectiveness of piriformis muscle massage or Rolfing, but this therapy has tension-relieving and loosening effects, thus reducing pressure on the sciatic nerve; it also loosens sticky scar adhesions.
The only negative aspect is the pain during the treatment.

One can perform a self-massage of the buttocks; To do this, place a tennis ball on the chair and place your piriformis muscle on the ball. Then move your body back and forth so that the ball massages the muscle.
This massage is also suitable for pregnant women.

If the treatments for sciatica are used, the desired results are not achieved because the symptoms of another condition are being treated.

Acupuncture is not suitable for piriformis syndrome.

Doctors often advise stretching exercises, but this type of exercise does not cure the patient, but can cause aggravation of symptoms for a day.

How long does recovery take? The prognosis of healing in piriformis syndrome

You cannot predict healing times.
If the patient only suffers from piriformis syndrome and there are no other complaints in the lumbar or sacrum area, he can recover in a few sessions (about 3 weeks) with appropriate treatment.
If the patient also suffers from back pain (e.g. inflammation of the sciatic nerve), the symptoms can last for months.

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