by Sarah Voelkel Feierstein PT, DPT, OCS, CMPT

Piriformis syndrome is a commonly overlooked diagnosis for hip and buttock pain. In the article, Diagnosis and Management of Piriformis Syndrome: An Osteopathic Approach, the researchers reviewed the literature to present a summary of this diagnosis as well as a variety of treatment options.

This diagnosis is a neuromuscular condition which is caused by peripheral neuritis of the sciatic nerve due to an abnormal condition of the piriformis muscle. It is characterized by hip and buttock pain, parasthesia, hyperasthesia, and muscle weakness. This syndrome occurs most frequently in women ages 40-60. Incidence ranges widely from an estimated 5% to 36% among patients with low back pain.

The sciatic nerve exits inferior to the piriformis in the majority of the population. It is estimated that in 22% of the population, the sciatic nerve pierces the muscle, splits the muscle, or both as it travels posteriorly down the leg. When this anatomical variation is present, it is known as primary piriformis syndrome.

Secondary piriformis syndrome occurs as the result of a micro or microtrauma, local ischemia, or mass ischemia. The most common cause is a direct trauma to the buttocks region, leading to inflammation of soft tissue and/or muscle spasm which results in nerve compression. Microtrauma may result from overuse of the muscle such as in long distance walking or running.

The most common symptoms patients present with include increased pain while sitting longer than 20 minutes and tenderness over the piriformis muscle. Patients might also complain of difficulty walking and pain while sitting cross-legged. The symptoms may appear gradually or suddenly and are associated with spasm of the muscle or compression of the sciatic nerve.

As clinicians, we also look for certain objective measures to support the diagnosis including tenderness to palpation of the piriformis, palpable mass in the muscle belly, weakness, limited hip internal rotation of affected side, and a shorter leg on the affected side. A spasming piriformis muscle causes ipsilateral hip external rotation, anterior sacral torsion toward ipsilateral side, and compensatory lumbar rotation in the direction of the spasming side. Additional osteopathic tests include the Pace sign, Lasegue sign, Freidberg sign, Beatty test, and FAIR test (flexion, adduction, internal rotation). Differential diagnoses include lumbosacral radiculopathy, degenerative disc disease, compression fractures, and spinal stenosis. The obturator internus muscle has also been suggested as a contributing source of sciatic neuritis in patients with piriformis syndrome.

Physical therapy is a great option to treat patients with piriformis syndrome. A trained physical therapist will focus on treatment techniques specific to this diagnosis which focus on decreasing and eliminating the spasm in the piriformis by way of strain-counterstrain and facilitated positional release. Spinal, pelvic, and hip manipulations might also be warranted to address associated lumbo-pelvic dysfunctions. Strengthening of the hip adductor muscles has been shown to be beneficial for this syndrome as well as a stretching sequence which is tailored to each patients’ needs. The staff at Physical Therapy First are board-certified manual trained therapists with experience providing these techniques. Further diagnostic tests and imaging include EMG studies, and MRI or CT scan to rule out lumbar disc pathologies. Other treatment includes pharmacologic treatment (NSAIDs, muscle relaxers, local steroid injection, and prolotherapy), and in severe cases, surgery.


Boyajian-O’Neil, L., McClain, R., Coleman, M., Thomas, P (2008). Diagnosis and Management of Piriformis Syndrome: An Osteopathic Approach. Journal of the American Osteopathic Association: Volume 8, No 11.