The primary mode of presentation of piriformis syndrome is a persistent pain in the buttocks that may radiate to the hip, the posterior part of the thigh and the proximal part of the lower leg [1]. This may be associated with prolonged low back pain and sensory deficits in the form of numbness and paresthesia over the affected regions [2] [3]. Pain may also be present in the coccyx, groin or the distal parts of the leg [4]. The patient may have difficulty in walking and may present with a limp [5].

The pain may be aggravated by activity or during sitting, squatting or standing. A certain number of patients may exhibit pain with bowel movements or during sexual intercourse [6]. The pain might only be relieved by lying down or by bending the knee while walking. Some patients are unable to find pain relief in any position. However, walking does seem to provide them the maximum degree of relief.

This condition may be recognized by the short and externally rotated limb seen in a supine patient. This external rotation, also called splayfoot or a positive piriformis sign, is due to contraction of the piriformis muscle [7]. On examination, point tenderness is often found at the sciatic notch where the sciatic nerve passes under the piriformis. Certain maneuvers that may stretch the piriformis muscle and compress the sciatic nerve further may be performed to elicit the pain. These include FABER (flexion, abduction, external rotation), FAIR (flexion, adduction, internal rotation), Freiburg and the Pace maneuvers [8] [9].

Some patients may present with leg swelling and sexual dysfunction. Motor deficits, in the form of muscle weakness and decreased/ absent reflexes, are usually not seen in piriformis syndrome. This is in contrast to the other causes of low back pain.

• Pain

  The pain may be aggravated by activity or during sitting, squatting or standing. A certain number of patients may exhibit pain with bowel movements or during sexual intercourse. [symptoma.com]

  “If it's just gluteal pain then it's just that: that pain in the butt where you don't know if it's coming from the back through a referral mechanism or it's the proximal extent of radicular pain. The buttock is a nebulous area,” he explained. [mdedge.com]

  Department of Anesthesiology and Pain Medicine Naval Medical Center San Diego San Diego USA [link.springer.com]

  The second most common pelvic pain-generator I see in clinic is an iliosacral upslip. [erikdalton.com]

  Failure to identify the cause of pain in a timely manner can increase pain perception, and affect mental control, patient hope and consequently quality of life. [ncbi.nlm.nih.gov]

• Weakness

  It usually presents with sciatic pain and hypoaesthesia and a limp caused by weakness of the gluteus maximus muscle. Peroneal nerve innervated muscles and hamstrings are also usually affected. [ncbi.nlm.nih.gov]

  "If those hip muscles are weak and you continue to add mileage, it can become an overuse issue." [active.com]

  From a running technique perspective, one of the common biomechanical clues that a runner is weak through their glutes and/or core is the classic “hip drop” or Trendelenburg sign. [kinetic-revolution.com]

  Weak Gluts and Piriformis Syndrome Hi there all you runners!! [precision-chiropractic.co.uk]

  Other causes of leg pain, numbness, tingling, burning, and weakness include peripheral neuropathy, vascular disease, and piriformis syndrome. [rothmaninstitute.com]

• Inflammation

  If muscle injury or inflammation is present then increased signal within the piriformis muscle may be seen on T2 MRI. An accessory piriformis muscle may be identified. [radiopaedia.org]

  […] the inflammation and pain, and improve your function By Dr. [fitness.mercola.com]

  As the muscular and connective tissues create excess tension on the hip joint, bursitis (inflammation of the fluid-filled sac in and around the joint) and tendonitis (inflammation of the tendon) may also manifest. [beyogi.com]

  Drobnic et.al also reported similar findings. 200mg curcumin reduced lower limb pain and markers of inflammation and pain in the muscle were also reduced. [turmericforhealth.com]

  Anti-inflammatory medications, such as ibuprofen and naproxen, are commonly used to treat the pain and inflammation caused by the irritation on the nerve. [courtside.ca]

• Falling

  If you have piriformis syndrome, call your healthcare provider if you experience any of the following: Frequent trips or falls because of pain or numbness. [my.clevelandclinic.org]

  While piriformis syndrome may occur for no apparent reason or develop after regular physical activity, it is sometimes caused by a traumatic injury, such as a car accident or a fall. [arpaincareclinics.com]

  If you had a recent fall or recall straining a muscle during sports, be sure to share that information with your doctor. It doesn’t matter if you’re unsure that’s what triggered your symptoms. Your doctor will also do a physical exam. [healthline.com]

  About Poor Balance / Risk of Falling Did you know that one out of three adults aged 65 and older fall each year? Among older adults, falls are the leading cause of both fatal and nonfatal injuries. [avenuestherapyclinic.com]

  Abduction of the flexed thigh is important in the action of walking because it shifts the body weight to the opposite side of the foot being lifted, which prevents falling. [en.wikipedia.org]

• Fever

  NSAIDs help decrease swelling and pain or fever. This medicine is available with or without a doctor's order. NSAIDs can cause stomach bleeding or kidney problems in certain people. [drugs.com]

  Additionally, symptoms such as severe back pain that occur after an accident or trauma, or back pain with fever or unexplained weight loss also warrant prompt medical evaluation. [spine-health.com]

• Back Pain

  Cyclobenzaprine and back pain: a meta-analysis. Arch Intern Med. 2001;161:1613-1620. Schnitzer RJ, Gray WL, Paster RZ, Kamin M. Efficacy of tramadol in treatment of chronic low back pain. J Rheumatol. 2000;27:772-778. [posterng.netkey.at]

  This may be associated with prolonged low back pain and sensory deficits in the form of numbness and paresthesia over the affected regions. Pain may also be present in the coccyx, groin or the distal parts of the leg. [symptoma.com]

  We discuss details of this imaging technique and its importance in the frames of refractory low back pain. We also describe the treatment given to the case. [scielo.br]

  See Lumbar Epidural Steroid Injections for Low Back Pain and Sciatica [spine-health.com]

  Non-specific low back pain. The Lancet, 389(10070), 736-747. Manninen, P., Riihimakif, H., and Heliovaaraj, M. (1995). Incidence and risk factors of low-back pain in middle-aged farmers. Occupational Medicine, 45(3), 141-146. [li01.tci-thaijo.org]

• Muscle Spasm

  The piriformis muscle is a small muscle located in the buttocks. It connects the lower spine to each femur bone and assists with hip and leg movement. Piriformis syndrome is a condition in which the piriformis muscle spasms, causing pain. [twincitiespainclinic.com]

  Walking can also help relieve muscle tension throughout the body and prevent spasms from getting worse. [medicalnewstoday.com]

  Injuring or irritating the piriformis muscle can cause muscle spasms. The muscle may also swell or tighten from the spasms. This puts pressure on the nerve beneath it, causing pain. Overuse can cause swelling or injure the muscle. [medlineplus.gov]

  Like low back muscle spasm causing pain, the piriformis muscle syndrome may develop increased muscle tone as well. Unlike other back muscles, however, the piriformis muscle crosses the sciatic nerve. [necksolutions.com]

  Beneath the muscle is the sciatic nerve. This nerve runs from your lower spine down the back of your leg to your foot. Injuring or irritating the piriformis muscle can cause muscle spasms.The muscle may also swell or tighten from the spasms. [mountsinai.org]

• Buttock Pain

  Chapter First Online: 28 March 2017 Abstract Piriformis syndrome (PS) is an entrapment neuropathy of the sciatic nerve by the piriformis muscle, causing non-diskogenic sciatica, buttock pain, gluteal tenderness, and possible radiation to the ipsilateral [link.springer.com]

  It is an important cause of buttock pain that may often be accompanied by sciatica. The pain is usually increased by muscular contraction, palpation or prolonged sitting. [ncbi.nlm.nih.gov]

  Piriformis syndrome is a condition in which the piriformis muscle, located deep in the buttock, spasms and causes buttock pain. [spine-health.com]

  Overview Piriformis syndrome is a condition in which the piriformis muscle, located in the buttock region, spasms and causes buttock pain. [cedars-sinai.org]

  Most patients describe symptoms of acute tenderness in the buttock and sciatica -like pain down the back of the thigh, calf and foot. [cedars-sinai.edu]

• Low Back Pain

  This is in contrast to the other causes of low back pain. The diagnosis of piriformis syndrome is one of exclusion and is primarily made on clinical grounds. [symptoma.com]

  Cyclobenzaprine and back pain: a meta-analysis. Arch Intern Med. 2001;161:1613-1620. Schnitzer RJ, Gray WL, Paster RZ, Kamin M. Efficacy of tramadol in treatment of chronic low back pain. J Rheumatol. 2000;27:772-778. [posterng.netkey.at]

  We discuss details of this imaging technique and its importance in the frames of refractory low back pain. We also describe the treatment given to the case. [scielo.br]

  Non-specific low back pain. The Lancet, 389(10070), 736-747. Manninen, P., Riihimakif, H., and Heliovaaraj, M. (1995). Incidence and risk factors of low-back pain in middle-aged farmers. Occupational Medicine, 45(3), 141-146. [li01.tci-thaijo.org]

  See Lumbar Epidural Steroid Injections for Low Back Pain and Sciatica [spine-health.com]

• Leg Pain

  Low Back Pain • Buttock Soreness • Radiating Leg & Thigh Pain • Pain When Sitting • Tightness, Burning, Feeling of a Knot • Sciatica • Gluteal Pain If you have low back, buttock tingling, burning, or numbness extending down to your feet, most will tell [miraclestretch.com]

  Although this injury does not mimic sciatic leg pain, the ‘sheared’ hip remains very painful until a successful manual therapy correction is made. Figure 8 is the first step in correcting the client’s upslipped left ilium. [erikdalton.com]

  Hip internal rotation with flexion while the patient is supine (lying on their back) will reproduce buttocks and leg pain if piriformis syndrome is present. [neckandback.com]

  Other causes of leg pain, numbness, tingling, burning, and weakness include peripheral neuropathy, vascular disease, and piriformis syndrome. [rothmaninstitute.com]

  Typically there is painful flexion, adduction, and internal rotation. Palpation over the sacral notch and gluteal region can often produce the buttock and leg pain. [mdedge.com]

• Sciatica

  Piriformis syndrome: a cause of nondiscogenic sciatica. Curr Sports Med Rep. 2015;14(1):41–4. CrossRef PubMed Google Scholar Cassidy L, Walters A, Bubb K, et al. [link.springer.com]

  @article{Mizuguchi1976DivisionOT, title={Division of the pyriformis muscle for the treatment of sciatica. [semanticscholar.org]

  It is logical that the pyriformis muscle can play an important role in the production of sciatica associated with intraspinal lesions. [jamanetwork.com]

  Since the nerve runs close and sometimes through the piriformis, dysfunction of the piriformis can actually cause sciatica. [active.com]

  Complications Although most people recover fully from sciatica, often without treatment, sciatica can potentially cause permanent nerve damage. [mayoclinic.org]

• Irritability

  "If you have weakness of the piriformis and glute muscles, that increased internal rotation of the hip can lead to issues and irritate the piriformis." [active.com]

  The symptoms of sciatica come from irritation of the sciatic nerve. It's still a mystery why the piriformis muscle sometimes starts to irritate the sciatic nerve. [courtside.ca]

  Nerve irritation in the herniated disk occurs at the root (sciatic radiculitis). In piriformis syndrome, the irritation extends to the full thickness of the nerve (sciatic neuritis). [emedicine.medscape.com]

  It is caused by the piriformis muscle compressing or irritating the SCIATIC NERVE due to trauma, hypertrophy, inflammation or anatomic variations. [fpnotebook.com]

  Your Sciatic nerve becomes irritated When your piriformis gets overused or irritated, it affects the sciatic nerve and causes the pain that you feel. [lowbackpainprogram.com]

• Tingling

  Other causes of leg pain, numbness, tingling, burning, and weakness include peripheral neuropathy, vascular disease, and piriformis syndrome. [rothmaninstitute.com]

  These symptoms can be accompanied by numbness and tingling, because with this syndrome, your piriformis muscle in the center of your buttock impinges the sciatic nerve. [livestrong.com]

  Often, the piriformis muscle aggravates or constricts the sciatic nerve and causes tingling, numbness and pain down the back of the leg to the foot. [mercy.com]

  The piriformis muscle irritates or compresses the sciatic nerve and causes pain, tingling and numbness in buttocks. It is treated with non-steroidal anti-inflammatory drugs and/or muscle relaxants. [imedpub.com]

• Confusion

  Furthermore, it be confused with sciatica or lower back pain, & on some occasions, it is... [londonpainclinic.com]

  Piriformis syndrome is often confused with other conditions, especially lumbar spine conditions. Attaining a proper diagnosis of piriformis syndrome is important when considering treatment for low back and leg pain. [spine-health.com]

  ABSTRACT Pyramidal syndrome is a pathology included within nerve compressive syndromes where the protagonists are compressed the sciatic nerve by the piriformis muscle, provides clinically similar to sciatica symptoms, which can be confused with a radicular [medigraphic.com]

  This clinical condition is relatively less known and underestimated because it is confused with other clinical pathological conditions. [ijri.org]

  Identifying Piriformis Syndrome Symptoms Piriformis syndrome can be tricky to diagnose because it can be easily confused for a herniated disc, sciatica, a proximal hamstring strain (also known as high hamstring tendinitis), or a lower back issue. [runnersworld.com]

• Paresthesia

  This may be associated with prolonged low back pain and sensory deficits in the form of numbness and paresthesia over the affected regions. Pain may also be present in the coccyx, groin or the distal parts of the leg. [symptoma.com]

  Current evidence leans toward higher doses and short-term improvement in pain and paresthesia. Vitamins B are common oral medications to treat peripheral neuropathy and neuropathic pain. [jrpp.net]

  […] to establish an operational definition of the disorder have been made, but none are definitive. 3 Signs and Symptoms: as stated by Boyajian-O'Neill L et al Symptoms: 2 ▫ Pain with sitting, standing, or lying longer than 15 to 20 minutes ▫ Pain and/or paresthesia [morphopedics.wikidot.com]

  Clinically, PS presents itself with pain (and paresthesias) in the buttocks, hips, and lower limbs. Electrophysiological testing and nerve blocks play important roles when the diagnosis is uncertain. [link.springer.com]

  Patients with sciatic nerve entrapment often have previous history of trauma and symptoms of sit pain, radicular pain of the lower back or hip and paresthesias of the affected leg [ 4, 16 ]. [ncbi.nlm.nih.gov]

The diagnosis of piriformis syndrome is one of exclusion and is primarily made on clinical grounds. Imaging techniques, such as computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography (USG) and electromyography (EMG), are used to rule out other conditions presenting in a similar manner [10]. The differential diagnosis of piriformis syndrome includes spinal canal stenosis, lumbar muscle strain, herniated nucleus pulposus (HNP) and facet arthropathy [6].

A potentially useful modality for diagnosing piriformis syndrome is magnetic resonance neurography (MRN). This yet-investigational test can demonstrate the sciatic nerve irritation caused by the stretched piriformis muscle. Via its efficacy to show a split nerve/ muscle, this test may serve as a guide to effective therapy in the form of surgery or injections.

Image-guided injections may also be useful to make a diagnosis. These can be accomplished by MRI or 3D imaging techniques. Other modalities such as ultrasound, EMG, fluoroscopic guided or blind injections are usually not preferred owing to their lack of reliability and potential side-effects.

Piriformis syndrome: implications of anatomical variations, diagnostic techniques, and treatment options. Surg Radiol Anat. 2012;34:479–86. CrossRef PubMed Google Scholar Filler AG, Haynes J, Jordan SE, et al. [link.springer.com]

@article{Mizuguchi1976DivisionOT, title={Division of the pyriformis muscle for the treatment of sciatica. [semanticscholar.org]

Sciatic nerve anatomical variants on MRI and their relationship to piriformis syndrome. 61 Bartret AL...Lutz AM 29713768 2018 27 Ultrasound-guided Dry Needling Treatment of Myofascial Trigger Points for Piriformis Syndrome Management: A Case Series. 61 [malacards.org]

After failure of conservative treatment, surgical treatment is indicated. [scielo.br]

The prognosis is for complete recovery after symptomatic treatment with nonsteroidal antiinflammatory medication and physical therapy. [ncbi.nlm.nih.gov]

Prognosis The prognosis for most individuals with piriformis syndrome is good. Once symptoms of the disorder are addressed, individuals can usually resume their normal activities. [childneurologyfoundation.org]

Treatment of acute piriformis syndrome usually has a good prognosis; the prognosis declines as the disease becomes chronic. [medicinenet.com]

Treatment and prognosis physiotherapy with stretching (especially if a spasm is thought to be the cause) administration of non-steroidal anti-inflammatory agents injection of local anesthetic and steroid injection of botulinum toxin to atrophy the piriformis [radiopaedia.org]

Prognosis With prompt diagnosis and treatment, the prognosis is quite good. However, the condition may become recurrent or chronic; a poor outcome may be more likely if the diagnosis and treatment are delayed. [health.harvard.edu]

Secondary piriformis syndrome (pelvic outlet syndrome) - This classification would encompass all other etiologies of piriformis syndrome, with the exclusion of lumbar spinal pathology. [emedicine.medscape.com]

Historically, trauma is the most common etiology related to DGS. [practicalneurology.com]

Palavras-Chave: Síndrome do músculo piriforme; Diagnóstico; Imagem por ressonância magnética; Endoscopia Introduction In 1928, Yeoman was the first to describe the piriformis muscle as an etiological factor in sciatic pain and low back pain.1 Between [scielo.br]

Etiology early sciatic nerve division and passage through the muscle belly or above it narrowed sciatic foramen accessory piriformis muscle muscle hypertrophy lumbar lordosis ganglion or cyst any mass lesion spasm athletes cerebral palsy bursitis and [radiopaedia.org]

Imaging Given the multiple etiologies of piriformis syndrome, the findings on imaging studies are variable. [radsource.us]

Epidemiology and etiology of secondary piriformis syndrome: A single-institution retrospective study. Journal of Clinical Neuroscience, 59, 209-212. Shah, S. I. H., Zahra, G., and Muneer, S. (2014). [li01.tci-thaijo.org]

[…] sciatic nerve, unspecified lower limb G57.01 - Lesion of sciatic nerve, right lower limb G57.02 - Lesion of sciatic nerve, left lower limb M62.838 Other muscle spasm Piriformis Syndrome ICD-9 355.0 (lesion of sciatic nerve) Piriformis Syndrome Etiology / Epidemiology [eorif.com]

Adler RS 29727344 2019 17 Ultrasound appears to be a reliable technique for the diagnosis of piriformis syndrome. 61 Zhang W...Ding H 30663080 2019 18 Piriformis syndrome - a diagnosis comes into its own. 61 Fishman LM...Hosseini M 30623985 2019 19 Epidemiology [malacards.org]

Further research into the epidemiology and treatment options for piriformis syndrome is warranted. The authors wish to acknowledge Alan Branigan, MS and Drs Aaron Howell and Mike Bunch for their assistance with the figures in this manuscript. [practicalneurology.com]

Of these, epidemiological studies suggest that between 5-36% have lower back pain that is attributable to piriformis syndrome. [nevadapain.com]

[…] experienced during passive internal rotation of the hip—and Pace sign—recreation of sciatic-like symptoms with flexion, abduction, and internal rotation of the hip-FAIR test—are the clinical hallmarks.1,3 Incidence is 0.3 to 6% of all sciatic-like syndromes.2 Pathophysiology [n.neurology.org]

Signs and Symptoms Symptoms of sciatic nerve compression in the deep gluteal region are best defined as a mechanical anatomic variant rather than a pathophysiologic disease process (eg, primary neuropathy). [practicalneurology.com]

It is interesting to note that a description of the syndrome is found in most medical texts, yet the criteria for diagnosing piriformis syndrome and pathophysiology still remains a controversial issue (3,4). [blog.nasm.org]

The weakness, atrophy and relief of the sciatic nerve compression are all result of the botox, which essentially reverses the underlying pathophysiology of PS. 1 In a 10 year cohort study it was reported reported that patients who received the botox injection [morphopedics.wikidot.com]

Full size image Pathophysiology and etiology There are two components contributing to the clinical presentation, namely, somatic and neuropathic. [link.springer.com]

PREVENTION Most causes of piriformis syndrome are preventable and frequently are related to activities of daily living. [journals.lww.com]

Learn how to treat and prevent this lower-back and buttock pain that is common among runners and triathletes. Photo: Shutterstock.com Learn how to treat and prevent this lower-back and buttock pain that is common among runners and triathletes. [triathlete.com]

Preventing Piriformis Syndrome To prevent recurrence of piriformis syndrome, you need to reduce the piriformis muscle’s vulnerability. One of the best ways to do so is to strength train. [runnersworld.com]

1. Tonley JC, Yun SM, et al. Treatment of an individual with piriformis syndrome focusing on hip muscle strengthening and movement reeducation: a case report. J Orthop Sports Phys Ther 2010;40(2):103-111.
2. Foster MR. Piriformis syndrome. Orthopedics. 2002;25:821-825.
3. Retzlaff EW, Berry AH, Haight AS, Parente PA, Lichty HA, Turner DM, et al. The piriformis muscle syndrome. J Am Osteopath Assoc. 1974;73:799-807.
4. Cramp F, Bottrell O, et al. Non–surgical management of piriformis syndrome: A systematic review. Phys Ther Rev 2007; 12:66-72.
5. Hughes SS, Goldstein MN, Hicks DG, Pellegrini VD. Extrapelvic compression of the sciatic nerve. An unusual cause of pain about the hip: report of five cases. J Bone Joint Surg Am. 1992;74:1553-1559.
6. Kirschner JS, Foye PM, Cole JL. Piriformis syndrome, diagnosis and treatment. Muscle Nerve Jul 2009; 40(1):10-18.
7. Lori A, Boyajian-O’ Neill, et al. Diagnosis and management of piriformis syndrome:an osteopathic approach. J Am Osteopath Assoc Nov 2008; 108(11):657-664.
8. Chaitow L. Soft Tissue Manipulation: A Practitioner's Guide to the Diagnosis and Treatment of Soft-Tissue Dysfunction and Reflex Activity. 3rd ed. Rochester, Vt: Healing Arts Press;1988.
9. Magee DJ. Orthopedic Physical Assessment. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1997.
10. DiGiovanna EL, Schiowitz S, Dowling DJ, eds. An Osteopathic Approach to Diagnosis and Treatment. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins;2005 .