What is Piriformis Syndrome?
Piriformis syndrome is a medical condition where the sciatic nerve, which is located near the hip, gets trapped by the piriformis muscle, found near the bottom of your spine. There could be various reasons why this happens, but the symptoms are pretty standard. People with piriformis syndrome often feel pain in their rear and might also experience sharp, burning, or aching pain down the back of their leg, similar to what is experienced with sciatica. It’s also common to feel numbness in this area or tingling sensations along the path where the sciatic nerve runs.
The sciatic nerve and the piriformis muscle, which helps rotate your hip, are close neighbors. So, if the piriformis muscle gets irritated or inflamed, it can also bother the sciatic nerve, causing discomfort that feels a lot like sciatica. Diagnosing piriformis syndrome can be tricky and depends on consulting your medical history and figuring out the specific symptoms you have. There are other conditions, like stenosis of the lumbar canal (narrowing of the spinal canal in your lower back), disc inflammation, or issues in the pelvic area that can cause similar discomfort.
What Causes Piriformis Syndrome?
Sciatic nerve entrapment, or piriformis syndrome, can happen in two different areas near the hip bone – in the front of a muscle called the piriformis, or behind a complex of muscles including the gemelli and obturator internus, situated near the rear part of the hip bone. This condition can be triggered either by constant inappropriate body movements or an abrupt intense hip rotation. There could also be physical abnormalities that lead to the nerve being squeezed. This includes a split piriformis muscle, a tumor directly affecting the region, unique flow paths of the sciatic nerve, a tumor directly invading this area, or a bloated artery in the lower part of the buttock, pushing on the nerve.
Piriformis syndrome can be caused by a few things:
* A brutal impact to the hip or behind area
* An enlarged piriformis muscle, commonly witnessed in athletes during stages of higher weightlifting activities or pre-competition training)
* Sitting for extended periods (like taxi drivers, office employees, or cyclists)
* Physical anomalies:
* Split piriformis muscle
* Variations in the sciatic nerve’s route around the piriformis muscle
* In over 80% of people, the sciatic nerve runs beneath and exits through the lower part of the piriformis muscle or tendon
Early separation of the sciatic nerve into the tibial and common peroneal parts (these are branches of the nerve) can make individuals more susceptible to piriformis syndrome. These branches traverse through, above, and beneath the piriformis muscle.
Risk Factors and Frequency for Piriformis Syndrome
Piriformis syndrome is a condition that causes low back pain and/or sciatica. It accounts for 0.3% to 6% of these types of pain. With about 40 million new cases of low back pain and sciatica every year, approximately 2.4 million of these could be due to piriformis syndrome. It mostly occurs in middle-aged people. The ratio of males to females who get piriformis syndrome is 1:6, meaning that it’s more common in women.
Signs and Symptoms of Piriformis Syndrome
Piriformis syndrome is a condition causing chronic pain in the buttock and hip area. People with this condition often find it painful to get out of bed or sit for extended periods. The pain, often located in the buttocks, becomes worse with hip movements. Some people may also experience symptoms similar to sciatica, making it tricky to identify the pain’s exact source, whether it’s due to piriformis syndrome or spinal stenosis.
The pain can spread to the back of the thigh and even to the lower leg. People may also feel soreness around the sciatic notch, which is the dip between the hip and the buttock. The tips of the fingers pressing into this area can often identify this tenderness.
Healthcare professionals can reproduce these symptoms using the FAIR test (flexion, adduction, and internal rotation). During this test, the patient lies flat on their back whilst the healthcare worker asks them to flex their hip and move it towards the body’s midline. Simultaneously, the healthcare worker rotates the patient’s lower leg to put tension on the piriformis muscle whilst also pressing on the muscle belly extending from the base of the spine (sacrum) to the bony part at the top of the thigh bone (greater trochanter of the femur).
- Chronic pain in the buttock and hip area
- Pain when getting out of bed
- Inability to sit for a prolonged time
- Pain in the buttocks that is worsened by hip movements
- Possibly, pain spreading to the back of the thigh or lower leg
- Tenderness around the sciatic notch
- FAIR test may reproduce the symptoms
Testing for Piriformis Syndrome
If you’re experiencing deep buttock pain, you might be under suspicion for a condition known as piriformis syndrome. Doctors often make this diagnosis based on their observations during a physical examination, rather than relying solely on lab tests or imaging.
During your check-up, your doctor might attempt certain stretching exercises to see if these actions prompt the pain related to piriformis syndrome. These stretches might include the Freiberg, which is a forceful internal rotation of your extended upper leg, the Pace, which involves resisting the sideways and outward rotation of your upper leg, and the Beatty, where, laying on your side, you hold your bent knee slightly off the table which may produce deep buttock pain. Lastly, the FAIR manoeuvre involves the bending, pulling together, and inward rotation of your upper leg.
Your doctor might need to ensure your pain isn’t due to other conditions, such as joint issues in your back (facet arthropathy), a slipped disc in your spine (herniated nucleus pulposus), a strained back muscle, or spinal stenosis, which is a narrowing of the spaces in your spine.
To rule out these conditions, your doctor might use imaging techniques like ultrasound, MRI scans or CT scans. They might also use an electromyography (EMG) – a procedure to assess the health of your muscles and the nerve cells that control them. These techniques are mostly used to exclude other possible conditions rather than to confirm piriformis syndrome.
A type of MRI scan known as a magnetic resonance neurography could help identify irritation in your sciatic nerve, which passes just below the piriformis muscle near a spot called the sciatic notch. However, this technique is experimental, not widely available, and may not be covered by private insurance.
Treatment Options for Piriformis Syndrome
Treatment for this condition often involves a short period of rest, typically less than two days, along with the use of medicines that can help to relax your muscles and reduce pain and inflammation. Physical therapy might also be part of the treatment. This could involve stretching exercises, improving your range of motion, and deep-tissue massages.
For some people, an injection around the affected muscle may help to lessen inflammation and pain. There are also reports suggesting that an injection of a specific type of medicine, called botulinum toxin, could provide some relief. However, this relief usually doesn’t last long, and so the injections may need to be repeated.
If all other treatments haven’t worked, then surgery might be an option. This is generally reserved for situations where the nerve is being pinched or there are scars or adhesions around the nerve that need to be removed. But keep in mind, surgery doesn’t always guarantee a cure. After surgery, some patients might still experience pain. It’s best to discuss all of your treatment options, the pros and cons, with your healthcare provider before deciding on the next step for you.
What else can Piriformis Syndrome be?
When trying to diagnose certain medical conditions, doctors will consider a variety of other physical problems that could be causing the symptoms. These include:
- Hamstring injury
- Injuries to the discs in the lower back and tailbone area (lumbosacral disc injuries)
- Pain syndrome related to the discs in the lower back and tailbone area (lumbosacral discogenic pain syndrome)
- Disorder related to the joints connecting the spinal bones in the lower back and tailbone region (lumbosacral facet syndrome)
- A condition where nerves in the lower back and tailbone area are compressed or irritated (lumbosacral radiculopathy)
- Sprain in the lower back and tailbone spine (lumbosacral spine sprain)
- Condition where one of the spinal bones slips out of position (lumbosacral spondylolisthesis)
- Stress fracture in the lower back and tailbone area (lumbosacral spondylolysis)
- Injury or dysfunction in the joint that connects the hip bone to the spine (sacroiliac joint injury/dysfunction)
- Swelling or bulging of the artery that supplies blood to the buttocks (inferior gluteal artery aneurysm or pseudoaneurysm)
- Cancerous or non-cancerous growths (malignancy/tumors)
- Abnormal tangles of blood vessels (arteriovenous malformations)
What to expect with Piriformis Syndrome
Patients who have piriformis syndrome, which is a type of muscle irritation, often feel better after receiving a localized trigger-point injection. This is when medication is delivered directly into an area of tight muscles. If this is paired with rehabilitation exercises, then the chances of experiencing the condition again are relatively low.
It’s worth noting, though, that the recovery time for individuals who have surgery to remove adhesions and scars might be a bit longer. It could be a few months before they can return to their normal routines fully.
Possible Complications When Diagnosed with Piriformis Syndrome
Complications that can arise from surgery include:
- Damage to nerves, with the sciatic nerve being the most commonly affected
- Infection
- Bleeding
Recovery from Piriformis Syndrome
If you are diagnosed with piriformis syndrome, it’s recommended that you start a program of physical therapy. Research has shown that both hands-on therapy (like massage) and stretching exercises can be helpful in managing this condition.
