Piriformis syndrome is associated with the compression of the sciatic nerve around the ischial tuberosity. The symptoms are likely to have a normal pattern though there are many factors that may lead to its development. The patients tend to complain of their discomfort in the buttock or gluteal region, and it may extend down the back of the leg in sharp, burning, or pain that are similar to sciatica. The numbness of the buttock and pain in the sciatic nerve course is also often reported. One of the muscles that lie nearest to the sciatic nerve is the piriformis muscle that is an external rotator of the hip. When this muscle becomes inflamed or irritated, the nerve may be squeezed or irritated causing pain that is like sciatica. Diagnosis is also difficult and depends on the history and clinical presentations of the patient. A number of other conditions can have similar symptoms and should be included in the differential, these include lumbar spinal stenosis, disc pathology, or pelvic issues.
Epidemiology
Piriformis syndrome is estimated to account between 0.3 to 6% of the total cases of low back pain and sciatica. With an estimated 40 million cases of low back pain and sciatica each year, approximately 2.4 million of these are attributed to piriformis syndrome. The condition occurs most commonly in people in the middle age and females are said to be at a higher risk of it being six times more than males.
Anatomy
Pathophysiology
Piriformis is a flat muscle that is oblique shaped and forms a pyramid. It occurs due to the anterior part of the sacral vertebrae (S2S4), the apical part of the greater sciatic foramen and the sacrotuberous ligament. Since its inception, it crosses the greater sciatic notch and gets attached to the greater trochanter of the femur. Its activity is determined by the position of the hips, in the extension of the hips it acts mainly as an external rotator whereas in the flexion the activity of the hip acts as an adductor. Branches of L5, S1 and S2 nerve roots innervate the muscle. Since sciatic nerve is nearby to the piriformis muscle, the inflammation, excessive use, or any form of irritation of this muscle can easily impact the nerve. Scientific nerve entrapment could be done either in front of the piriformis muscle or behind the gemelli/ obturator internus complex, around the ischial tuberosity. The piriformis may be stressed either by chronic poor skeletal position or by acute trauma, especially, a sharp, violent internal hip rotation.
Etiology
The entrapment of the sciatica nerve can be in front or behind the piriformis muscle or even at the base of ischial tuberosity behind the gemelli-obturator internus complex. The piriformis may be strained by improper body mechanics during the course of time or an acute trauma, e.g. abrupt forcefulness of turning the hip internally. Some anatomical differences can also predispose the individuals to nerve compression. These are a bifid piriformis muscle, differences in the sciatic nerve course, mass effect due to a tumor or vascular causes like inferior gluteal artery aneurysm which cause pressure on the nerve.
Genetics
Prognostic Factors
The local trigger-point injections of piriformis syndrome provide many patients with relief. With such injections, coupled with specific rehabilitation exercises, then the chances of a recurrence are minimized. In patients that need surgical procedures to break adhesions or scar tissue, it may take several months before the patient gets back to normal activity.
Clinical History
Age group
The age of adults who mostly exhibit the piriformis syndrome is in the middle age (usually between 30-50 years). It is rare in case of children and younger adults and has greater prevalence with respect to prolonged sitting, repetitive movements of the lower limbs, or injury to the hip and buttock area. It is reported that women are more often affected as compared to their men.
Physical Examination
Age group
Associated comorbidity
Lumbar spine disorders such as disc herniation or spinal stenosis
Sacroiliac joint dysfunction
Leg length discrepancy or pelvic malalignment
Arthritis of the hip or spine
Prior trauma to the pelvis or buttock region
Associated activity
Acuity of presentation
Acute onset: The symptoms could appear at once after trauma or a fall or the sharp internal rotation of the hip. Patients will complain of sharp buttock pains which spread down the leg but sometimes it happens immediately after the triggering episode.
Subacute or chronic symptom development: Piriformis syndrome is often related to chronic sitting, repetitive motion or improper posture. The pain accumulates in the course of weeks to months, being referred to as dull, aching, or burning in the gluteal area, with occasional radiation along the sciatic nerve pathway.
Recurrent episodes: In a few cases, patients have repeated exacerbations particularly when the exacerbating factors like overuse, long distance driving or demanding physical activities are repeated.
Differential Diagnoses
Malignancy/tumors
Arteriovenous malformations
Inferior gluteal artery aneurysm or pseudoaneurysm
Lumbosacral spondylolisthesis
Lumbosacral spondylolysis
Lumbosacral radiculopathy
Lumbosacral facet syndrome
Lumbosacral discogenic pain syndrome
Lumbosacral disc injuries
Lumbosacral spine sprain
Sacroiliac joint injury/dysfunction
Hamstring injury
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
Management of piriformis syndrome typically begins with conservative measures. Short periods of rest, generally limited to no more than 48 hours, may provide initial relief. Medications such as muscle relaxants and nonsteroidal anti-inflammatory drugs (NSAIDs) are often used alongside physical therapy, which focuses on piriformis stretching, range-of-motion exercises, and deep-tissue massage techniques. In some cases, corticosteroid injections around the piriformis muscle can help reduce inflammation and alleviate pain.
There are anecdotal reports that botulinum toxin injections may also provide symptomatic relief. However, the benefit tends to be temporary, requiring repeated treatments for sustained effect.
Surgical intervention is reserved for patients who do not respond to conservative therapy, including structured exercise programs. The goal of surgery is to decompress the sciatic nerve, either by releasing adhesions, removing scar tissue, or addressing impingement. Outcomes following surgery are variable, and some individuals may continue to experience persistent pain despite intervention.
Lidocaine (Xylocaine, Zingo):
Lidocaine alleviates neuron membranes by inhibiting ionic permeability, and hence conduction of nerve impulses. After the parenteral route of administration, it is well absorbed where it goes through hepatic metabolism and the unchanged metabolites are also excreted through the kidneys. Its half-life is between 2 and 1. 5 hours. Lidocaine easily penetrates the bloodbrain as well as placental barrier and can be used to perform regional and local anesthesia.
Bupivacaine (Marcaine, Posi Mir, Sensorcaine):
Bupivacaine is also an inhibitory nerve conductor that inhibits ionic fluxes. It is completely absorbed on parenteral routes and is metabolized in the liver and excreted through renal route with the same metabolites. It has a half-life of about 3-4 hours with the highest plasma levels attained 30-40 minutes. Similar to lidocaine, it bypasses the bloodbrain and placental barriers and has been used in regional and local anesthesia.
Focus on pain and inflammation control with short rest (≤48 hours), NSAIDs, muscle relaxants, and ice or heat therapy while avoiding aggravating activities.
Subacute Phase
Emphasis on rehabilitation through piriformis stretching, range-of-motion exercises, deep-tissue massage, and gradual return to activity. Corticosteroid or local anesthetic injections may be added if symptoms persist.
Chronic/Refractory Phase
For resistant cases, options include botulinum toxin injections for temporary relief or surgery to decompress the sciatic nerve, release adhesions, or remove scar tissue. Post-surgical rehab is essential, though outcomes may vary.
Piriformis syndrome is associated with the compression of the sciatic nerve around the ischial tuberosity. The symptoms are likely to have a normal pattern though there are many factors that may lead to its development. The patients tend to complain of their discomfort in the buttock or gluteal region, and it may extend down the back of the leg in sharp, burning, or pain that are similar to sciatica. The numbness of the buttock and pain in the sciatic nerve course is also often reported. One of the muscles that lie nearest to the sciatic nerve is the piriformis muscle that is an external rotator of the hip. When this muscle becomes inflamed or irritated, the nerve may be squeezed or irritated causing pain that is like sciatica. Diagnosis is also difficult and depends on the history and clinical presentations of the patient. A number of other conditions can have similar symptoms and should be included in the differential, these include lumbar spinal stenosis, disc pathology, or pelvic issues.
Piriformis syndrome is estimated to account between 0.3 to 6% of the total cases of low back pain and sciatica. With an estimated 40 million cases of low back pain and sciatica each year, approximately 2.4 million of these are attributed to piriformis syndrome. The condition occurs most commonly in people in the middle age and females are said to be at a higher risk of it being six times more than males.
Piriformis is a flat muscle that is oblique shaped and forms a pyramid. It occurs due to the anterior part of the sacral vertebrae (S2S4), the apical part of the greater sciatic foramen and the sacrotuberous ligament. Since its inception, it crosses the greater sciatic notch and gets attached to the greater trochanter of the femur. Its activity is determined by the position of the hips, in the extension of the hips it acts mainly as an external rotator whereas in the flexion the activity of the hip acts as an adductor. Branches of L5, S1 and S2 nerve roots innervate the muscle. Since sciatic nerve is nearby to the piriformis muscle, the inflammation, excessive use, or any form of irritation of this muscle can easily impact the nerve. Scientific nerve entrapment could be done either in front of the piriformis muscle or behind the gemelli/ obturator internus complex, around the ischial tuberosity. The piriformis may be stressed either by chronic poor skeletal position or by acute trauma, especially, a sharp, violent internal hip rotation.
The entrapment of the sciatica nerve can be in front or behind the piriformis muscle or even at the base of ischial tuberosity behind the gemelli-obturator internus complex. The piriformis may be strained by improper body mechanics during the course of time or an acute trauma, e.g. abrupt forcefulness of turning the hip internally. Some anatomical differences can also predispose the individuals to nerve compression. These are a bifid piriformis muscle, differences in the sciatic nerve course, mass effect due to a tumor or vascular causes like inferior gluteal artery aneurysm which cause pressure on the nerve.
The local trigger-point injections of piriformis syndrome provide many patients with relief. With such injections, coupled with specific rehabilitation exercises, then the chances of a recurrence are minimized. In patients that need surgical procedures to break adhesions or scar tissue, it may take several months before the patient gets back to normal activity.
Age group
The age of adults who mostly exhibit the piriformis syndrome is in the middle age (usually between 30-50 years). It is rare in case of children and younger adults and has greater prevalence with respect to prolonged sitting, repetitive movements of the lower limbs, or injury to the hip and buttock area. It is reported that women are more often affected as compared to their men.
Lumbar spine disorders such as disc herniation or spinal stenosis
Sacroiliac joint dysfunction
Leg length discrepancy or pelvic malalignment
Arthritis of the hip or spine
Prior trauma to the pelvis or buttock region
Acute onset: The symptoms could appear at once after trauma or a fall or the sharp internal rotation of the hip. Patients will complain of sharp buttock pains which spread down the leg but sometimes it happens immediately after the triggering episode.
Subacute or chronic symptom development: Piriformis syndrome is often related to chronic sitting, repetitive motion or improper posture. The pain accumulates in the course of weeks to months, being referred to as dull, aching, or burning in the gluteal area, with occasional radiation along the sciatic nerve pathway.
Recurrent episodes: In a few cases, patients have repeated exacerbations particularly when the exacerbating factors like overuse, long distance driving or demanding physical activities are repeated.
Malignancy/tumors
Arteriovenous malformations
Inferior gluteal artery aneurysm or pseudoaneurysm
Lumbosacral spondylolisthesis
Lumbosacral spondylolysis
Lumbosacral radiculopathy
Lumbosacral facet syndrome
Lumbosacral discogenic pain syndrome
Lumbosacral disc injuries
Lumbosacral spine sprain
Sacroiliac joint injury/dysfunction
Hamstring injury
Management of piriformis syndrome typically begins with conservative measures. Short periods of rest, generally limited to no more than 48 hours, may provide initial relief. Medications such as muscle relaxants and nonsteroidal anti-inflammatory drugs (NSAIDs) are often used alongside physical therapy, which focuses on piriformis stretching, range-of-motion exercises, and deep-tissue massage techniques. In some cases, corticosteroid injections around the piriformis muscle can help reduce inflammation and alleviate pain.
There are anecdotal reports that botulinum toxin injections may also provide symptomatic relief. However, the benefit tends to be temporary, requiring repeated treatments for sustained effect.
Surgical intervention is reserved for patients who do not respond to conservative therapy, including structured exercise programs. The goal of surgery is to decompress the sciatic nerve, either by releasing adhesions, removing scar tissue, or addressing impingement. Outcomes following surgery are variable, and some individuals may continue to experience persistent pain despite intervention.
Anesthesiology
Lidocaine (Xylocaine, Zingo):
Lidocaine alleviates neuron membranes by inhibiting ionic permeability, and hence conduction of nerve impulses. After the parenteral route of administration, it is well absorbed where it goes through hepatic metabolism and the unchanged metabolites are also excreted through the kidneys. Its half-life is between 2 and 1. 5 hours. Lidocaine easily penetrates the bloodbrain as well as placental barrier and can be used to perform regional and local anesthesia.
Bupivacaine (Marcaine, Posi Mir, Sensorcaine):
Bupivacaine is also an inhibitory nerve conductor that inhibits ionic fluxes. It is completely absorbed on parenteral routes and is metabolized in the liver and excreted through renal route with the same metabolites. It has a half-life of about 3-4 hours with the highest plasma levels attained 30-40 minutes. Similar to lidocaine, it bypasses the bloodbrain and placental barriers and has been used in regional and local anesthesia.
Acute Phase
Focus on pain and inflammation control with short rest (≤48 hours), NSAIDs, muscle relaxants, and ice or heat therapy while avoiding aggravating activities.
Subacute Phase
Emphasis on rehabilitation through piriformis stretching, range-of-motion exercises, deep-tissue massage, and gradual return to activity. Corticosteroid or local anesthetic injections may be added if symptoms persist.
Chronic/Refractory Phase
For resistant cases, options include botulinum toxin injections for temporary relief or surgery to decompress the sciatic nerve, release adhesions, or remove scar tissue. Post-surgical rehab is essential, though outcomes may vary.
Piriformis syndrome is associated with the compression of the sciatic nerve around the ischial tuberosity. The symptoms are likely to have a normal pattern though there are many factors that may lead to its development. The patients tend to complain of their discomfort in the buttock or gluteal region, and it may extend down the back of the leg in sharp, burning, or pain that are similar to sciatica. The numbness of the buttock and pain in the sciatic nerve course is also often reported. One of the muscles that lie nearest to the sciatic nerve is the piriformis muscle that is an external rotator of the hip. When this muscle becomes inflamed or irritated, the nerve may be squeezed or irritated causing pain that is like sciatica. Diagnosis is also difficult and depends on the history and clinical presentations of the patient. A number of other conditions can have similar symptoms and should be included in the differential, these include lumbar spinal stenosis, disc pathology, or pelvic issues.
Piriformis syndrome is estimated to account between 0.3 to 6% of the total cases of low back pain and sciatica. With an estimated 40 million cases of low back pain and sciatica each year, approximately 2.4 million of these are attributed to piriformis syndrome. The condition occurs most commonly in people in the middle age and females are said to be at a higher risk of it being six times more than males.
Piriformis is a flat muscle that is oblique shaped and forms a pyramid. It occurs due to the anterior part of the sacral vertebrae (S2S4), the apical part of the greater sciatic foramen and the sacrotuberous ligament. Since its inception, it crosses the greater sciatic notch and gets attached to the greater trochanter of the femur. Its activity is determined by the position of the hips, in the extension of the hips it acts mainly as an external rotator whereas in the flexion the activity of the hip acts as an adductor. Branches of L5, S1 and S2 nerve roots innervate the muscle. Since sciatic nerve is nearby to the piriformis muscle, the inflammation, excessive use, or any form of irritation of this muscle can easily impact the nerve. Scientific nerve entrapment could be done either in front of the piriformis muscle or behind the gemelli/ obturator internus complex, around the ischial tuberosity. The piriformis may be stressed either by chronic poor skeletal position or by acute trauma, especially, a sharp, violent internal hip rotation.
The entrapment of the sciatica nerve can be in front or behind the piriformis muscle or even at the base of ischial tuberosity behind the gemelli-obturator internus complex. The piriformis may be strained by improper body mechanics during the course of time or an acute trauma, e.g. abrupt forcefulness of turning the hip internally. Some anatomical differences can also predispose the individuals to nerve compression. These are a bifid piriformis muscle, differences in the sciatic nerve course, mass effect due to a tumor or vascular causes like inferior gluteal artery aneurysm which cause pressure on the nerve.
The local trigger-point injections of piriformis syndrome provide many patients with relief. With such injections, coupled with specific rehabilitation exercises, then the chances of a recurrence are minimized. In patients that need surgical procedures to break adhesions or scar tissue, it may take several months before the patient gets back to normal activity.
Age group
The age of adults who mostly exhibit the piriformis syndrome is in the middle age (usually between 30-50 years). It is rare in case of children and younger adults and has greater prevalence with respect to prolonged sitting, repetitive movements of the lower limbs, or injury to the hip and buttock area. It is reported that women are more often affected as compared to their men.
Lumbar spine disorders such as disc herniation or spinal stenosis
Sacroiliac joint dysfunction
Leg length discrepancy or pelvic malalignment
Arthritis of the hip or spine
Prior trauma to the pelvis or buttock region
Acute onset: The symptoms could appear at once after trauma or a fall or the sharp internal rotation of the hip. Patients will complain of sharp buttock pains which spread down the leg but sometimes it happens immediately after the triggering episode.
Subacute or chronic symptom development: Piriformis syndrome is often related to chronic sitting, repetitive motion or improper posture. The pain accumulates in the course of weeks to months, being referred to as dull, aching, or burning in the gluteal area, with occasional radiation along the sciatic nerve pathway.
Recurrent episodes: In a few cases, patients have repeated exacerbations particularly when the exacerbating factors like overuse, long distance driving or demanding physical activities are repeated.
Malignancy/tumors
Arteriovenous malformations
Inferior gluteal artery aneurysm or pseudoaneurysm
Lumbosacral spondylolisthesis
Lumbosacral spondylolysis
Lumbosacral radiculopathy
Lumbosacral facet syndrome
Lumbosacral discogenic pain syndrome
Lumbosacral disc injuries
Lumbosacral spine sprain
Sacroiliac joint injury/dysfunction
Hamstring injury
Management of piriformis syndrome typically begins with conservative measures. Short periods of rest, generally limited to no more than 48 hours, may provide initial relief. Medications such as muscle relaxants and nonsteroidal anti-inflammatory drugs (NSAIDs) are often used alongside physical therapy, which focuses on piriformis stretching, range-of-motion exercises, and deep-tissue massage techniques. In some cases, corticosteroid injections around the piriformis muscle can help reduce inflammation and alleviate pain.
There are anecdotal reports that botulinum toxin injections may also provide symptomatic relief. However, the benefit tends to be temporary, requiring repeated treatments for sustained effect.
Surgical intervention is reserved for patients who do not respond to conservative therapy, including structured exercise programs. The goal of surgery is to decompress the sciatic nerve, either by releasing adhesions, removing scar tissue, or addressing impingement. Outcomes following surgery are variable, and some individuals may continue to experience persistent pain despite intervention.
Anesthesiology
Lidocaine (Xylocaine, Zingo):
Lidocaine alleviates neuron membranes by inhibiting ionic permeability, and hence conduction of nerve impulses. After the parenteral route of administration, it is well absorbed where it goes through hepatic metabolism and the unchanged metabolites are also excreted through the kidneys. Its half-life is between 2 and 1. 5 hours. Lidocaine easily penetrates the bloodbrain as well as placental barrier and can be used to perform regional and local anesthesia.
Bupivacaine (Marcaine, Posi Mir, Sensorcaine):
Bupivacaine is also an inhibitory nerve conductor that inhibits ionic fluxes. It is completely absorbed on parenteral routes and is metabolized in the liver and excreted through renal route with the same metabolites. It has a half-life of about 3-4 hours with the highest plasma levels attained 30-40 minutes. Similar to lidocaine, it bypasses the bloodbrain and placental barriers and has been used in regional and local anesthesia.
Acute Phase
Focus on pain and inflammation control with short rest (≤48 hours), NSAIDs, muscle relaxants, and ice or heat therapy while avoiding aggravating activities.
Subacute Phase
Emphasis on rehabilitation through piriformis stretching, range-of-motion exercises, deep-tissue massage, and gradual return to activity. Corticosteroid or local anesthetic injections may be added if symptoms persist.
Chronic/Refractory Phase
For resistant cases, options include botulinum toxin injections for temporary relief or surgery to decompress the sciatic nerve, release adhesions, or remove scar tissue. Post-surgical rehab is essential, though outcomes may vary.
Both our subscription plans include Free CME/CPD AMA PRA Category 1 credits.
Digital Certificate PDF
On course completion, you will receive a full-sized presentation quality digital certificate.
medtigo Simulation
A dynamic medical simulation platform designed to train healthcare professionals and students to effectively run code situations through an immersive hands-on experience in a live, interactive 3D environment.
medtigo Points
medtigo points is our unique point redemption system created to award users for interacting on our site. These points can be redeemed for special discounts on the medtigo marketplace as well as towards the membership cost itself.
Community Forum post/reply = 5 points
*Redemption of points can occur only through the medtigo marketplace, courses, or simulation system. Money will not be credited to your bank account. 10 points = $1.
All Your Certificates in One Place
When you have your licenses, certificates and CMEs in one place, it's easier to track your career growth. You can easily share these with hospitals as well, using your medtigo app.
