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]

  but there was an initial drop in pain score Not a significant drop in pain score, but there was a decrease of more than 2 points Statistical analysis Age, BMI, pain level, duration of pain, sex, presence of buttock pain and back pain, pain meds, radiculopathy [ncbi.nlm.nih.gov]

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

• Inflammation

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

  The most common causes of this syndrome include trauma, inflammation, and degenerative changes. [clinicalimagingscience.org]

  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]

• 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]

  […] caused by: Microtrauma to muscles of the buttocks that results in inflammation or muscle spasms from frequent and repetitive motions such as walking, running, dancing, over-stretching or other exercises Sudden injury to the muscle by accidents such as a falls [bonsecours.com]

• Asymptomatic

  Nine months after the surgery, the patient was asymptomatic. [scielo.br]

  Exercise 2) After much progress has been made and the patient is relatively asymptomatic, this may be carefully tried. Stand on a 6" platform or step near a rail. The injured leg should be the high side, the uninjured dangles. [drpribut.com]

  Reliability of ultrasound shear-wave elastography in assessing low back musculature elasticity in asymptomatic individuals. J Electromyogr Kinesiol 2018;39:49-57. 38. Park GY, Kwon DR, Kwon DG. [ijri.org]

  […] of the patients.[12] FAIR[edit | edit source] Painful flexion-adduction-internal rotation[16] [17] Beatty’s Manoeuver[edit | edit source] An active test that involves elevation of the flexed leg on the painful side, while the patient is lying on the asymptomatic [physio-pedia.com]

  Beatty’s maneuver 1,35 is an active test that involves elevation of the flexed leg on the painful side while the patient lies on the asymptomatic side. [link.springer.com]

• Surgical Procedure

  This material is intended to give the patient an overview of surgical procedures and treatments and is not intended to replace the advice and guidance of a physician. [neurosurgicalassociatespc.com]

  For chronic piriformis pain, a non-surgical nerve block procedure is recommended to provide patients with significant, and often complete, relief from pain. [nevadapain.com]

  Additionally, all three of our surgical procedures using this technique were performed as outpatient procedures with long-term pain relief without prolonged hospital stay and increased morbidity as seen in the traditional open surgical technique. [cnjournal.biomedcentral.com]

  However, at times surgical intervention may be necessary to clean and shave down the torn areas of the meniscus. Physical therapy is very important in the full recovery after this surgical procedure. [avenuestherapyclinic.com]

  FBSS patients were included, that is, persistent lumbar pain or early recurrence before three months after surgical herniated disc procedure (group I / n=16), of both genders, without cognitive deficit, seen by the Pain Clinic, Base Hospital / FAMERP. [scielo.br]

• Prolapse

  Cureus 10(5): e2606. doi:10.7759/cureus.2606 Abstract Piriformis syndrome (PS) involves the piriformis muscle and adjacent sciatic nerve, producing features similar to true sciatica of lumbar spine origin, for example, lumbar disc prolapse, thereby confusing [cureus.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]

  What Is Failed Back Surgery Syndrome? If you still have pain or if your pain has gotten worse following back surgery, you may have failed back surgery syndrome. [southeasttexasspine.com]

  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]

  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]

  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]

• Buttock Pain

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

  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]

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

  Piriformis syndrome symptoms Most people with piriformis syndrome experience low back pain or buttock pain, numbness or a tingling sensation. [aurorahealthcare.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]

  Piriformis syndrome occurs when the piriformis muscle, located deep in the buttock region, spasms and causes buttock pain. The muscle spasms can also irritate the nearby sciatic nerve. [spine-health.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]

• 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]

  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]

  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]

  Prevalence of Piriformis Syndrome in Chronic Low Back Pain Patients. A Clinical Diagnosis with Modified FAIR Test. Pain Pract [Internet]. 2013 Apr 1;13(4):276–81. [pji.ub.ac.id]

• Arthritis

  It will also include a review of conditions that may be in the patient’s family, such as arthritis. [spine-health.com]

  The relation of arthritis of the sacroiliac joint to sciatica. Lancet. 1928;2:1119–22. CrossRef Google Scholar Copyright information © Springer International Publishing Switzerland 2017 Authors and Affiliations M. [link.springer.com]

  Imaging studies such as MRI may be useful in ruling out other causes of sciatic nerve compression such as lumbar spine degenerative disc disease, spondylolisthesis, spinal stenosis, or arthritis of the spine. [novaorthospine.com]

  Imaging studies such as MRI may be useful in ruling out other causes of sciatic nerve compression such as degenerative disc disease, spondylolisthesis, spinal stenosis or arthritis of the spine. [seacoastorthopedics.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]

  Piriformis syndrome and sciatica are not the same Piriformis syndrome and sciatica are two different health conditions, but they're often mistaken for one another. This is because piriformis syndrome can cause sciatica-like symptoms. [anthonyechomd.com]

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

• Irritability

  The muscle spasms can also irritate the nearby sciatic nerve. [spine-health.com]

  "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. [proactiverehab.com]

  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]

• Tingling

  The piriformis muscle can also irritate the nearby sciatic nerve and cause pain, numbness and tingling along the back of the leg and into the foot (similar to sciatic pain). [spine-health.com]

  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]

  The piriformis muscle also can irritate the nearby sciatic nerve and cause pain, numbness and tingling along the back of the leg and into the foot (similar to sciatic pain). [cedars-sinai.org]

• Radiculopathy

  Lumbar radiculopathy is a condition in which lumbar spinal nerve roots are affected due to various pathologies. The diagnosis is made clinically by the symptoms and physical examination findings. [clinicaltrials.gov]

  Differential includes a lumbosacral radiculopathy, sacroiliac joint dysfunction, or hamstring injury. Treatment options include NSAIDs, muscle relaxants, physical therapy, botulinum toxin and steroid injection. [n.neurology.org]

  […] similar presentation to lumbar disc herniation, stenosis, radiculopathy, and neurogenic pain, piriformis syndrome is often difficult to diagnose. [practicalneurology.com]

  You treat their disease and the radiculopathy goes away. And they really don't have any disk disease,” he explained. [mdedge.com]

  Due to this innervation, a lower lumbar radiculopathy may cause secondary irritation of the piriformis muscle, which may complicate diagnosis and hinder patient progress. [emedicine.medscape.com]

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]

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]

What Is the Prognosis for Piriformis Syndrome? The prognosis for piriformis syndrome varies, often depending on when it is diagnosed. Since it is a condition that is often overlooked and misdiagnosed, delayed diagnosis is common. [emedicinehealth.com]

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]

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

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]

MRI may reveal hypertrophy/atrophy, fibrosis, and anomalous insertion of the piriformis muscle and help exclude other etiologies; NCS shows increased H reflex latency with FAIR-test, while EMG shows signs of denervation in the pattern of the posterior [n.neurology.org]

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]

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]

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]

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 .