Where is the piriformis muscle?
The piriformis is a small muscle located deep in the buttock (under the gluteus maximus). The piriformis starts at the lower spine and connects to the upper surface of each femur (thighbone). The piriformis functions to assist in rotating the hip, leg, and foot outward.
Piriformis syndrome, first described in 1928, arises when an over tight or irritated piriformis muscle compresses the sciatic nerve. (1) This pressure causes neurologic disruption, local inflammation and radicular complaints. (2) Researchers estimate that piriformis syndrome contributes to up to one third of all back pain. (3,4)
The sciatic nerve has a variable relationship to the piriformis muscle. In the majority of the population, the sciatic nerve travels just under the muscle. Approximately one fourth of the population is anatomically predisposed to piriformis syndrome because their sciatic nerve passes through the muscle, splits the muscle or both. (5,6)
Like many other lower extremity biomechanical problems, the presence of a Morton foot (longer second toe) is thought to be a predisposing factor. (7)
Signs and Symptoms of piriformis syndrome:
Symptoms of piriformis syndrome may begin abruptly as the result of a traumatic event, or may develop slowly in response to repeated irritation. Piriformis muscle irritation and tightness can result from a strain, a fall onto the buttocks, or catching oneself from a “near fall”. In other instances, the process may begin following repetitive microtrauma, like long distance walking, stair climbing or from chronic compression, like sitting on the edge of a hard surface or a wallet. (8,9)
Presenting complaints for piriformis syndrome include pain, paresthesia or numbness beginning in the gluteal region and radiating along the course of the sciatic nerve. Additional symptoms may develop from local trigger point referral into the proximal thigh, sacroiliac and hip regions. (9) Symptoms are often provoked by holding any one position for longer than 15-20 minutes- particularly prolonged sitting or standing. Shifting positions may provide some short term relief. Patients may report increasing discomfort when walking, running, stair climbing, riding in a car or arising from a seated position. Activities that involve hip internal rotation, like sitting cross-legged, may make the symptoms worse. Patients with piriformis syndrome sometimes exhibit a modified gait. (10)
Other associated issues:
During your visit, we may assess the tensor fascia lata, obturator externus, adductor and gluteal muscles for tension- particularly in chronic cases. Motion palpation and orthopedic testing may reveal sacroiliac joint dysfunction and compensatory restrictions in the spine and lower extremity. (11)
Is x-ray or advanced imaging needed?
Radiographic imaging of a suspected soft tissue disorder is of limited benefit. (21) Advanced imaging may be an appropriate modality to rule out other sources of radicular complaints if there is a failed trial of care or red flags during history or examination. (17)
- The foundations of treatment for piriformis syndrome include stretching, myofascial release and correction of underlying biomechanical dysfunction.
- Patients may need to temporarily limit provocative activities, including hill and stair climbing, walking on uneven surfaces, intense downhill running or twisting and throwing objects backward (i.e. firewood).
- Patients should avoid sitting on one foot and take frequent breaks from prolonged standing, sitting and car rides. Stretching of the piriformis muscle is crucial and may be performed with seated, prone or quadruped maneuvers. (26)
- Manual manipulation may be necessary to correct lumbar, sacroiliac and lower extremity joint dysfunction. (28,29)
- Some studies have shown benefit from heat, ice and ultrasound, particularly when applied prior to manual treatments. (30)
- NSAIDs may provide benefit in the early stages of management.
- Strengthening exercises should be directed at the abductor, adductor and gluteal muscles.
- Patients with a loss of the longitudinal arch of the foot would benefit from arch supports or orthotics.
- Medical co-management with muscle relaxants, steroids, trigger point injections or Botox may be considered for non-responding cases. (17,31)
At Creekside Chiropractic & Performance Center, we are highly trained to treat each of these conditions. We are the only inter-disciplinary clinic in Sheboygan county that provides chiropractic, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves. Voted Best Chiropractor in Sheboygan by the Sheboygan Press.
Evidence Based-Patient Centered-Outcome Focused
1. Yeoman W. The relation of arthritis of the sacroiliac joint to sciatica. Lancet. 1928;ii:1119-22.
2. Williams PL, Warwick R. Gray's Anatomy. 36th ed. Philadelphia, Pa: WB Saunders Co; 1980.
3. Papadopoulos EC, Khan SN. Piriformis syndrome and low back pain: a new classification and review of the literature. Orthop Clin North Am. 2004;35:65-71.
4. Pace JB, Nagle D. Piriformis syndrome. West J Med. 1976;124:435-439.
5. Beason LE, Anson B.J. The relation of the sciatic nerve and its subdivisions to the piriformis muscle. Anat Record. 1937;70:1-5.
6. Pecina M. Contribution to the etiological explanation of the piriformis syndrome. Acta Anat (Basel). 1979;105:181-187.
7. http://physioplus.blogspot.com/2008/09/piriformis-syndrome.html, retrieved 10/13
8. Foster MR. Piriformis syndrome. Orthopedics. 2002;25:821-825
9. Travell J, Simons D. Myofascial Pain and Dysfunction, Vol 2. Williams and Wilkins 1992. pp 186-214
10. Magee DJ. Orthopedic Physical Assessment. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1997.
11. 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
12. TePoorten BA. The piriformis muscle. J Am Osteopath Assoc. 1969;69:150-160
13. Meknas K, Christensen A, Johansen O. The internal obturator muscle may cause sciatic pain. Pain. 2003;104:375-380.
16. DiGiovanna EL, Schiowitz S, Dowling DJ, eds. An Osteopathic Approach to Diagnosis and Treatment. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins;2005
17. Boyajian-O'Neill, LA.; McClain, RL.; Coleman, MK.; Thomas, PP. (Nov 2008). "Diagnosis and management of piriformis syndrome: an osteopathic approach.". J Am Osteopath Assoc 108 (11): 657–64.
18. Magee DJ. Orthopedic Physical Assessment. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1997.
19. Beatty RA. The piriformis muscle syndrome: a simple diagnostic maneuver. Neurosurgery. 1994;34:512-514.
20. Fishman LM, Dombi GW, Michaelsen C, Ringel S, Rozbruch J, Rosner B, et al. Piriformis syndrome: diagnosis, treatment, and outcome—a 10-year study [review]. Arch Phys Med Rehabil. 2002;83:295-301.
21. Benson ER, Schutzer SF. Posttraumatic piriformis syndrome: diagnosis and results of operative treatment. J Bone Joint Surg Am. 1999;81:941-949.
23. Fishman LM, Schaefer MP. The piriformis syndrome is underdiagnosed. Muscle Nerve. 2003;28:646-649.
25. Grant JH. Leg length inequality in piriformis syndrome. J Am Osteopath Assoc. 1987;87:456
26. Prather H. Sacroiliac joint pain: practical management. Clin J Sport Med. 2003;13:252-255.
28. DiGiovanna EL, Schiowitz S, Dowling DJ, eds. An Osteopathic Approach to Diagnosis and Treatment. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins;2005
29. Mayranda N, Fortin J, et al. Diagnosis and Management of Posttraumatic Piriformis Syndrome: A Case Study Journal of Manipulative and Physiological Therapeutics Volume 29, Issue 6, July–August 2006, Pages 486–491
30. Steiner C, Staubs C, Ganon M, Buhlinger C. Piriformis syndrome: pathogenesis, diagnosis, and treatment. J Am Osteopath Assoc. 1987;87:318-323.
31. van Tulder MW, Scholten RJ, Koes BW, Deyo RA. Nonsteroidal anti-inflammatory drugs for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine. 2000;25:2501-2513.
32. Iwanaga J. et al. The Majority of Piriformis Muscles are Innervated by the Superior Gluteal Nerve. Clin Anat. 2018 Nov 8. doi: 10.1002/ca.23311. [Epub ahead of print] 33. Zhang W et al. Ultrasound Appears to be a Reliable Technique for the Diagnosis of Piriformis Syndrome Muscle Nerve. 2019 Jan 20. doi: 10.1002/mus.26418. [Epub ahead of print]