Piriformis Syndrome

Other names
Piriformis tendinitis, Piriformis impingement, Piriformis pain syndrome.

Pronunciation link
https://dictionary.cambridge.org/pronunciation/english/piriformis
https://www.spine-health.com/video/piriformis-syndrome-
video?source=tdw
https://www.youtube.com/watch?v=-mzKFaSjERc
https://www.youtube.com/watch?v=KLRBrjCUVzI

Definition
Piriformis syndrome is a neuromuscular disorder that occurs when
contractures in the piriformis muscle compress the sciatic nerve, resulting
in a range of symptoms that include pain, tingling, and numbness in the
posterior hip, thigh, and down the back of the leg. (Therapeutic
Kinesiology: Musculoskeletal Systems, Palpation, and Body Mechanics, Mary Ann
Foster, page – 421)

Anatomy
Piriformis is the most superior muscle among the (deep gluteal muscles)
six lateral rotators of the hip joint. It is a thick, pear-shaped muscle arises
from sacrum. It passes slightly downwards and laterally.
Piriformis muscle
✓ Origin – Anterior surface of the sacrum
✓ Insertion – Superior surface of the greater trochanter
✓ Nerve supply – “nerve to piriformis” originate from the sacral plexus
(S1, S2)
✓ Action – Laterally rotates and abducts hip.

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Sciatic nerve
The sciatic nerve, is a large nerve in human body begins in the lower part
of the sacral plexus and runs through the hip joint and down the lower limb.
It is the longest and widest single nerve in the human body. The sciatic
nerve provides innervation to the muscles of the back of the thigh, and
those of the leg and foot. It is derived from spinal nerves L4 to S3.

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Epidemiology
Research shows that 6-44% LBP diagnosed as piriformis syndrome.
(Cummings M. Piriformis syndrome. AcupunctMed. 2000; 18(2):108–121.)

Male female ratio

Male: Female = 1:6 (Therapeutic Kinesiology: Musculoskeletal Systems, Palpation,
and Body Mechanics, Mary Ann Foster, page – 421)

Causes
• It is often aggravated by prolonged cross-legged sitting. (Therapeutic
Kinesiology: Musculoskeletal Systems, Palpation, and Body Mechanics, Mary
Ann Foster, page – 421)
(Brukner, P. (2012). Brukner & Khan's clinical sports medicine. North Ryde: McGraw-Hill. 4th
ed. Page -506).
• Trauma to the buttock.
• Overuse injury.

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Pathology

Piriformis syndrome usually results from compression of the sciatic nerve by

the piriformis muscle after its pathological change.(Injury, fibrosis, spasm
etc.)

Piriformis syndrome usually occurs with a combination of three conditions:

• Nerve and vascular entrapment
• myofascial pain from piriformis Trigger points
• and sacroiliac joint dysfunction
(Therapeutic Kinesiology: Musculoskeletal Systems, Palpation, and Body Mechanics,
Mary Ann Foster, page – 421)

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Piriformis is the “double devil” because spasms or chronic contractions in it can
put pressure on the underlying sciatic nerve and also cause debilitating trigger
points.
When the piriformis becomes dysfunctional, it develops two trigger points: one
directly laterals to the fifth sacral segment and the other midway between the
sacrum and the greater trochanter. Both trigger points refer intense pain locally
and produce spillover pain that radiates over the hamstrings and can even radiate
up into the lower back. (Travell, J. G., & Simons, D. G. (2019). Myofascial pain and dysfunction: the
trigger point manual, Wolters Kluwer.)

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Symptoms /Chief complaint
• Pain in deep sacroiliac region, buttock and posterior hip region.
• Pain aggravated by prolonged sitting especially with the legs crossed and
activity.
• Pain when raising from sitting position
• Climbing stairs, walking, squats, and internal rotation of the leg may
increase pain. (Brukner, P. (2012). Brukner & Khan's clinical sports medicine. North Ryde:
McGraw-Hill. 4th ed. Page -506).
• Pain, numbness, burning may feelt back of thigh, knee and leg (Along
with the course of Sciatic nerve) [Sciatica].

Signs/On Examination (O/E)

• Tenderness either in the belly of the piriformis or, more distally, near
its insertion into the greater trochanter.
• Spasm (a sausage like palpable structure may be felt).
• Passive internal hip rotation is reduced
• R – test (Movement against resistance) may positive for abduction
of hip and external rotation of the hip with the knee flexed.

Figure: Tenderness testing

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Confirmatory tests
• The patient is placed in supine. The involved leg is positioned with the
hip and knee flexed and foot is placed on the table lateral to the opposite
knee. The examiner passively moves the involved hip and knee into
adduction. The patient reports discomfort across the buttock.

• FAIR test (flexion adduction internal rotation): The patient is placed in

supine. The involved leg is positioned with the hip flexed and internally
rotated. Knee also flexed and foot is placed on the opposite knee. The
examiner passively moves the involved hip into more flexion.

• The patient is asked to lie on the unaffected side, the knee of the painful
limb is flexed to 900, catching the foot behind the calf of the healthy leg,
the knee of the affected limb is gradually brought down till it touches the
top of the examination table. There is a sudden increase of symptoms of
sciatica.

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Treatment
Drug therapy
• NSAIDs
• Muscle relaxants
• Duloxetine

Electrophysical agent
• IFT
• UST (Wilson, P. R. (2015). Pain Medicine: An Interdisciplinary Case-Based Approach Eds.
Hayek SM, Shah BJ, Desai MJ & Chelimsky TC New York, Oxford University Press; 2015;
pp. 429; ISBN 978-0-19-993148-4.)
• LASER (Brukner, P. (2012). Brukner & Khan's clinical sports medicine. North Ryde:
McGraw-Hill. 4th ed. Page -506).

Exercise
• Myofascial release
• DTF (Either manually or with vibrators or Thera gun)
• Stretching
• Core stability exercise program (Brukner, P. (2012). Brukner & Khan's clinical
sports medicine. North Ryde: McGraw-Hill. 4th ed. Page -505).
• Strengthening exercises for Gluteus maximus and Medius muscles.
(Kisner, C., Colby, L. A., & Borstad, J. (2017). Therapeutic exercise: foundations and
techniques. Fa Davis. 7th ed., page no. 720)

Figure: Myofascial release of piriformis muscle

Others
• Acupuncture
• Dry needling
• Local corticosteroid injection
• Botulinum toxin injections (BTX, Botox)
(Hayek SM, Shah BJ, Desai MJ, Chelimsky TC (16 April 2015). Pain Medicine: An
Interdisciplinary Case-Based Approach. Oxford University Press. p. 240. ISBN 978-0-19-
939081-6.)

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Advice
• Rest - Stop causing activities
• Self-stretching: To stretch the piriformis, place the leg of the side
want to stretch across the other knee, then pull that knee toward the
chest. Hold each stretch for at least 10 seconds.
• Sleep with pillow placing between two legs
• Tennis ball massage

Figure: Self Stretching of piriformis muscle

Figure: Sleep with pillow placing between two legs

Figure: Tennis ball massage

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