Piriformis Syndrome: Symptoms, Diagnosis and Treatment

The piriformis muscle is located in the buttocks under your glute muscles. It’s important for activities that involve leg rotation, such as walking up stairs or playing sports. Next to the piriformis muscle runs the sciatic nerve, the longest nerve in the human body.

When the piriformis muscle becomes inflamed or moves in an unnatural way, it can lead to irritation or pressure on the sciatic nerve, which causes sciatica – sharp, severe pain that radiates from the lower back or glute area possibly all the way down one leg.

Piriformis syndrome is one of the more uncommon causes of sciatica (1). Both the piriformis muscle and the sciatic nerve pass through the sciatic notch in the hipbone, which is where irritation commonly occurs (2).

Piriformis syndrome can manifest in a number of ways, including:

• Tingling or numbness, especially in the buttocks and lower back
• Pain radiating downward from the back or buttocks
• Difficulty sitting or shifting on one side
• Pain when rotating your hip or leg outward

Causes of piriformis activity include sitting for too long and muscle hypertrophy from exercising. It can also happen due to trauma from an accident, a fall, or a severe impact on the buttocks (4).

Piriformis Syndrome Versus Sciatica

Piriformis syndrome is one of several conditions that can result in sciatica, which is caused by any irritation of the sciatic nerve. Piriformis syndrome and other causes of sciatica are similar, which is why piriformis syndrome can be difficult to diagnose. One tell-tale hint of piriformis syndrome is the presence of pain specifically in the buttocks, near the glute muscles.

Because of the location of the piriformis muscle in your body, it can be challenging for doctors to diagnose piriformis syndrome. Doctors most commonly assess the presence of piriformis syndrome through a physical examination. Your doctor will ask you to perform a set of movements with your leg and hip to see if any pain is present. If you feel pain specifically in your buttocks, thighs, or lower back, there’s a good chance you may have piriformis syndrome (5).

Other medical tests can rule out different forms of sciatica. For example, you might have a magnetic resonance imaging (MRI) or computerized tomography (CT) scan to make sure that nothing else is putting pressure on the sciatic nerve. None of these tests can confirm a positive diagnosis for piriformis syndrome. It’s unlikely that you’ll be able to treat piriformis syndrome without professional medical care.

There are several different treatment options for piriformis syndrome. Medical professionals begin with the least invasive options and progress from there, depending on how the condition responds.

Physical therapy is the standard first-line treatment for piriformis syndrome (6). Range of motion exercises like stretching and other sports medicine treatments can help reduce inflammation and relax pressure on the sciatic nerve.

In some cases, physical therapists may use movement re-education. This technique teaches you how to perform physical movements like jumping, walking, and running in a way that puts minimal pressure on the piriformis muscle (7).

Another option for piriformis syndrome treatment is dry needling. Studies indicate that the use of dry needling with ultrasound guidance can ease pressure and pain felt by people with piriformis syndrome.

Treating Piriformis Syndrome With Medication

If physical therapy doesn’t work, your doctor will likely put you on a course of medication.

Doctors primarily rely on three classes of drugs to treat lower back pain from the piriformis muscle:

• Non-steroidal anti-inflammatory drugs (NSAIDs) including naproxen, ibuprofen and acetaminophen. Research shows these medicines take about a week to reduce inflammation of the piriformis muscle (8).
• Muscle relaxants are another common treatment for piriformis syndrome (9). Medications like cyclobenzaprine and other muscle relaxants are used to treat all types of lower back pain related to spasm and inflammation, including piriformis syndrome (10).
• Botulinum toxin (botox) can also relieve sciatic nerve compression from a tight or inflamed piriformis muscle (11). Injections of both Botulinum toxin type A and B have been shown to be effective in treating piriformis muscle syndrome (12). 

‍Medical data shows that a majority of patients who are treated for piriformis syndrome with a combination of physical therapy, medication, rest, and icing experience relief.

Surgical Treatment for Piriformis Syndrome

As a last resort, if all other treatment options fail, your doctor may recommend an operation for treatment of piriformis syndrome. Operative treatment is often used for patients whose piriformis syndrome is a result of severe trauma to the buttocks or lower back.

In the unlikely event surgery is required to treat your piriformis syndrome, you can expect to spend around two months in recovery. Post recovery, most patients can successfully resume normal daily activities.

Physical therapy for piriformis syndrome carries few risks outside of some peripheral pain and discomfort while performing exercises. For NSAIDs used in treatment of piriformis syndrome, the most common side effects are heartburn and indigestion. However, cardiovascular symptoms like edema and hypertension are also possible when taking these medications.

Muscle relaxants are stronger medications and therefore generally have more severe side effects than NSAIDs. The most common adverse effects from muscle relaxants are dizziness, fatigue, and drowsiness (13). In certain rare cases, local injections of muscle relaxants and botox can cause infections. Surgery for piriformis syndrome can also give rise to infection, though this is uncommon.

Piriformis syndrome is a condition in which the piriformis muscle compresses the sciatic nerve due to inflammation or an unexpected shift in position. Piriformis syndrome can result in sciatica, though sciatica is more commonly caused by herniated spinal discs. If you’re experiencing lower back pain or pain in the back of the leg, a physical examination is the best way to determine whether or not you have piriformis syndrome.

Most cases of piriformis syndrome can be treated successfully with a program of rest, ice, and physical therapy, and NSAIDs, supplemented by stronger medications like muscle relaxants and botulinum toxin when necessary. In rare or serious cases, surgery may be required, but the prognosis for a full recovery is good.

If you think you may have piriformis syndrome, schedule a physical examination to get medical advice and an appropriate course of treatment as soon as possible.