Since 1928 Piriformis Syndrome has been described as a source of buttock and leg pain, often confused with sciatic type leg pain of lumbar origin. The sciatic nerve and the piriformis muscle lie very close to each other in the buttock and the pain has been attributed to nerve irritation or compression, without much convincing evidence. Not universally recognised as a diagnosis, piriformis syndrome is regularly diagnosed and treated by physiotherapists.

The piriformis muscle is flat and small, lying in the centre of the buttock, taking its origin from the sacral area and inserting on to the top of the greater trochanter of the thigh, the bony prominence easily felt on the side of the leg below the hip. It either turns the leg outwards or moves the thigh away from the body, depending on the position of the hip. The sciatic nerve and the piriformis muscle vary in their structure and position in the buttock. Typically the muscle lies behind the nerve but in some cases the piriformis is divided into two parts with the sciatic nerve passing between them.

Piriformis syndrome has no clear cause of onset and may occur with sacro-iliac and lumbar spinal syndromes. Direct damage to the buttock could cause scar tissue around the muscles and the nerve, while continual pressure over time could also alter the nerve’s function. Other factors could be an increased lumbar curve, strong activity and hip replacement, with some cases imitating back pain problems such as sciatic pain. Diagnosis and treatment of piriformis syndrome is performed by physiotherapists on clinical findings due to the lack of diagnostic and imaging investigations.

Little consideration is given to piriformis syndrome as a reason for back and leg pain but it can imitate sciatic leg pain, presenting as back pain with nerve root compression due to disc prolapse or joint enlargement. Due to the insertion of the piriformis tendon into the greater trochanter this syndrome can have a connection with trochanteric bursitis. Clinical examination by the Physio shows an acutely painful trigger point in the mid buttock, some loss of hip lateral rotation, pain and loss of strength in the hip abductors and lateral rotators and a feeling of sitting on a golf ball.

There are numerous treatments for piriformis syndrome but none are scientifically valid, particularly as accurate diagnosis is not clear. Physiotherapists concentrate on finding physical signs such as a tight piriformis, tight hip external rotators and adductors, weakness of the hip abductors, stiffness of the sacro-iliac joint and lumbar spine problems. The patient may walk with the hip externally rotated, have an apparent leg shortening and a shortened stride.

There may be tightness in the hip and piriformis muscles and in these cases the physiotherapist will start a programme of muscle stretches after warming up the hip muscles. Piriformis stretches are taught in lying, the hip positioned in 90 degrees, stretching the thigh over the other leg and pulling it with the other hand. The patient will need to follow a home exercise programme of muscle stretches, up to every few hours in cases of an acute nature. Stretching the piriformis may not be appropriate if the muscle is loose or stretched, in which case muscle strengthening and stretching of the opposing stiff areas is used.

Local manipulation is a common treatment directly over the most painful point in the buttock, which can be very tender indeed. Transverse or longitudinal mobilisations over the muscle is the technique used, maintaining the pressure steadily for up to 10 minutes initially. Treatment of the back and sacro-iliac joints is important to address any dysfunction which might contribute. Modifying posture and activity, muscle injections, mobilisations and stretching are commonly successful in reducing symptoms. In resistant cases surgery to the muscle or the tendon at the greater trochanter may be contemplated.

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