Piriformis Syndrome

author : AMSSM

comments : 1

How to quiet incessant pain from hip, back, leg nerves

Question from member mdg2003: Piriformis Syndrome Help

"I'm in so much pain. I've had a cortisone injection and deep tissue therapy so far. So far, no luck. Monday I'm seeing a chiro/acupuncture guy to see if he can help me. I get these deep searing waves of pain from my hip socket and it rolls down to the front of my shin where it flares and then returns deep in my lower spine. If I sit for more than 20 minutes, I get floored with pain upon standing. The pain stays with me for a few steps and then it fades. Tylenol 3 barely scratches the surface and ibuprofen fares no better. Ice and heat help a little."

Answer by Troy M. Smurawa, M.D.
Member AMSSM

The piriformis muscle is a flat pyramidal shaped muscle located in the posterior buttock musculature. Its origin is on the anterior surface of the 2nd, 3rd, and 4th sacral vertebrae, sacrotuberous ligament and the superior margin of the sciatic notch. It exits the pelvis through the sciatic notch and inserts on the superior aspect of the posteromedial corner of the greater trochanter. The sciatic nerve exits the greater sciatic notch below the piriformis muscle in the infrapiriformis canal. It functions as a hip external rotator. 

Piriformis syndrome is poorly understood. It results from compression of the sciatic nerve by the piriformis muscle in the infrapiriformis canal. It presents as sciatic type pain with tingling and numbness in the buttocks and often radiates to the posterior thigh and lower leg. It is thought to result from either acute or repetitive trauma to the piriformis muscle resulting in muscle inflammation and hypertrophy. Gait abnormalities and leg length discrepancies have been postulated to contribute to the development of piriformis syndrome. Anatomic variations in the relationship between the piriformis muscle and the sciatic nerve may also contribute to developing piriformis syndrome. There is no reliable single finding or gold standard test for the diagnosis of piriformis syndrome. It is often a diagnosis of exclusion. Often lumbar spine nerve compression etiology must be ruled out as the cause. Robinson (1947) proposed six cardinal features of piriformis syndrome:

1. A history of trauma to the sacroiliac or gluteal area


2. Pain in the sacroiliac joint, greater sciatic notch and the piriformis muscle

extending down the leg and causing difficulty walking

3. Acute exacerbations brought on by stooping or lifting and relieved by traction on the affected leg


4. Presence of a tender, sausage shaped mass over the priiformis


5. A positive Lasegue sign


6. Gluteal atrophy

Physical exam may demonstrate the following findings:

1. Nonspecific posterior pain that may originate from the gluteus maximus or irradiate from the lumbar spine


2. Palpation may elicit pain, tenderness or irradiated sciatic nerve pain


3. A positive straight leg raise test which may be difficult to differentiate from lumbar spine radicular pain


4. Passive hip external rotation with the hip extended may produce tension in the piriformis muscle and compress the sciatic nerve


5. Piriformis area pain elicited by resisted external rotation of the hip


6. Pain with resisted hip abduction with the hip in flexion


7. Pain with passive hip adduction and internal rotation with the hip in flexion

There exists no gold standard of treatment and physical therapy. Standard conservative therapy includes activity modification, anti-inflammatory medication and physical therapy.

Physical therapy focuses on piriformis stretching, correcting gait abnormalities, correcting any leg length discrepancies, modalities and strengthening. Local ultrasound guided injections with either cortisone or Botulinum toxin type A has shown promising results. Cortisone acts as an anti-inflammatory treatment and Botulinum type A acts by inhibiting muscle contraction.

Surgical treatment is reserved for chronic, recalcitrant symptoms and involves either open or endoscopic surgical release of the piriformis tendon and decompression of the sciatic nerve.

Troy M. Smurawa, M.D.
Children’s Health Andrews Institute

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date: June 30, 2016