Piriformis syndrome

Piriformis syndrome is another cause of buttock and leg pain.

The name arises from the piriformis muscle, a small structure that passes from the sacrum, [or tailbone, the large wedge-shaped bone that forms the base of the spine], deep in the buttock to its attachment on the side of the hipbone. It is a small muscle compared to other muscles around the hip and thigh, aiding in external rotation (turning out) of the thigh bone (femur).

The sciatic nerve passes close by the piriformis, and sometimes through the fibres of the muscle.

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This is what is called an entrapment neuropathy. It is postulated that when the muscle becomes tight, it may press on the sciatic nerve which lies close by. Pain along the course of the sciatic nerve is called sciatica. The piriformis muscle and its tendon have an intimate relationship to the sciatic nerve - the largest nerve in the body - which supplies the legs with motor and sensory function. It drives many of the leg muscles, and brings sensation and other information back to the Central Nervous System. (For example hot and cold, position sense, vibration sense.)


Medically, it is acknowledged that about a quarter of surgeries for sciatica fail and lead to FBS, Failed Back Syndrome.

In the United States alone, each year 1.5 million people have lumbar MRI scans to look for the cause of the buttock and leg pain called 'sciatica'.

More than 1.2 million (over 80%) of those scans fail to find the cause in the spine.

But three hundred thousand of the scans are sufficiently positive that the patient has lumbar spine surgery. Of the 300,000 surgeries, as many as 25% fail to relieve the pain - in many cases this is because the diagnosis of a spinal cause for the sciatica was incorrect. Was it an irritation of the sciatic nerve by the piriformis muscle?


Physical findings include tenderness of the buttock region, increased pain with adduction, internal rotation and flexion of the affected thigh, weakened abduction of the flexed thigh and frequently sacroiliac joint derangement and/or an associated iliotibial band syndrome. Sacro-iliac joint tests are often positive. Electrodiagnostic tests may be positive if the thigh is placed in a position which places the piriformis under extreme stretch (flexed, adducted and internally rotated).

Sometimes referred to as "deep buttock pain," other causes of this type of pain include spine problems (including herniated discs, spinal stenosis, etc.), pinched and irritated nerves, and tendonitis. The diagnosis of this syndrome is often given when all of these diagnoses are eliminated as possible causes of pain. Other signs of of this syndrome include examination maneuvers that attempt to isolate the function of this muscle, and the finding of pain directly over the tendon of the piriformis muscle, which then radiates down the leg.

Maigne's syndrome

A high lumbar facet syndrome can irritate the superior cluneal nerves which supply part of the buttock, and the groin, and can easily lead one to suspect a piriformis syndrome.

Exclusion diagnosis

In medicine it is freely acknowledged that no one really knows exactly what causes piriformis syndrome, or if it really exists. Some physicians believe that it is the name given to hip/buttock pain that cannot be otherwise diagnosed. However, others believe that piriformis syndrome is a very real cause of pain and disability.

Medical Treatment

Unfortunately, the treatment of piriformis syndrome is quite general, and it is acknowledged by orthopedists that it is often a difficult problem to recover from. Some treatment medical suggestions are:

* Physical Therapy - Emphasis on stretching and strengthening the hip rotator muscles

* Rest - Avoid the activities that cause symptoms for at least a few weeks

* Anti-Inflammatory Medication - To decrease inflammation around the tendon

* Deep Massage - Advocated by some physicians

On some occasions, when these treatment fail, patients have surgery to release, or loosen, the piriformis muscle tendon. This surgery is not a small procedure, and generally considered the last resort if a lengthy period of conservative treatment does not solve the problem.

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Chiropractors treat the piriformis syndrome with confidence. Treatment is based on findings of a fixated sacrum (based on motion palpation and the Derefield test) and active trigger points in the piriformis muscle.

A true short leg may be a part of the problem, in which case a heel lift may be employed.

Some chiropractors consider that carrying of a wallet in the back pocket may be part of the problem.

Manipulation of the sacral portion of the sacroiliac joint anatomy and  stretching of the piriformis muscles, cross-friction of the muscle and possibly needling, and rehabilitative exercises.

Piriformis syndrome

Piriformis syndrome is a medium sized muscle in the buttock that can cause a gnawing pain down the leg called sciatica.

Note the proximity of the sacro-iliac joint to the piriformis muscle which has its origin on the anterior surface of the sacrum and passing to the hip bone. They have a profound effect on each other.

Motion palpation inevitably reveals a FIXATION of the Sacro-iliac joint. Releasing this fixation is what gives chiropractic the edge in treating the piriformis syndrome.

Because the piriformis muscle forms part of the pelvic floor, it is often associated with groin and pubic bone pain, especially in pregnancy. Read more about pubic bone pain …

See the piriformis? It's striped...

Useful links

› Piriformis syndrome

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Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I have left alone. After seven treatments his pain and stiffness is 50 percent better, and he is happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti-inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He is doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost pain-free. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he is well pleased; sixty-five percent better after three treatments.

5. Mr T is a wise man; he has taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily stroll has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift; he has a short leg.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. X-rays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65-year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88-year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done. 

10. Mr X is a 71-year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a few months ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It is a non-complicated upper cervical facet syndrome, and she is doing well.

12. Mr D is a 38-year old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he could not sleep on that shoulder.

13. Mr D, a 71-year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors should not be treating the elderly most medical sites state but that is so much bunkum.

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