What Is Piriformis Syndrome?

Piriformis syndrome is a painful condition that happens when the piriformis muscle compresses or irritates the sciatic nerve, causing inflammation. It can cause pain and numbness in the buttocks area and down the back of the leg, on one side of your body or on both.

The piriformis is a flat, narrow muscle that runs from the lower spine through the butt to the top of the thighs. The sciatic nerve usually runs underneath the piriformis. It’s the longest and largest nerve in the body, and it travels from the spinal cord through the buttocks and down the back of each leg to the feet.

But piriformis syndrome isn’t the same as sciatica. In sciatica, the symptoms usually affect the lower back and can travel down through the buttocks and leg, whereas in piriformis syndrome, the pain is typically centered in the buttocks and may extend down the back of the leg.

There are two types of piriformis syndrome, primary and secondary.

Symptoms can occur in the buttocks, hips, or upper legs. It can feel like:

• Pain in the buttocks, often radiating down the back of the leg
• Burning, numbness, or a tingling sensation along the sciatic nerve path
• Pain that worsens with prolonged sitting, walking, running, and stair climbing

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• Pain when getting out of bed

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Causes of piriformis syndrome can include:

• Injury or trauma: A fall or direct injury to the buttocks can damage the piriformis muscle or irritate the sciatic nerve.
• Not stretching or warming up: Warming up before exercise helps to supply your muscles with blood and oxygen so they’re ready for activity.
• Tight muscles from lack of physical activity
• Lifting something heavy without good form
• Prolonged sitting: Sitting for extended periods, especially with poor posture, or sitting with a thick wallet in a back pocket directly behind the piriformis muscle can contribute to piriformis syndrome.
• Overexercise: Repetitive motions and activities like ultramarathons can lead to piriformis syndrome.
• Anatomical variations: In primary piriformis syndrome, a person may have anatomical variations where the sciatic nerve passes through the piriformis muscle instead of underneath it, making it more prone to irritation. Abnormal spine alignment (such as scoliosis) and leg-length discrepancy (where legs are different lengths) can also cause piriformis syndrome.

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Diagnosing piriformis syndrome is based on symptoms and a physical exam. The healthcare provider will likely ask you questions about your medical history, symptoms, and activity level.

Common Diagnostic Procedures

There isn’t any one test to confirm a diagnosis of piriformis syndrome, but there are tests that may be used to pinpoint what is causing the pain, including:

• MRI or CT scan
• Electromyography (EMG)
• Ultrasound

Treatment for piriformis syndrome often starts with noninvasive methods and may include a combination of physical therapy, medication, and lifestyle changes.

Medication Options

Medications, given as pills or injections, are used to relieve pain from piriformis syndrome.

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Over-the-counter pain relievers like ibuprofen or naproxen can help reduce inflammation and pain in the shorter term.
• Muscle Relaxants Medications like cyclobenzaprine can help relieve muscle spasms and tension.
• Corticosteroid Injections For more severe cases, a healthcare provider may recommend corticosteroid injections directly into the piriformis muscle to reduce inflammation.

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• Anesthetic Injections Local anesthetics such as lidocaine or bupivacaine may also be injected into the piriformis muscle for pain relief.

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• Botulinum Toxin Injections Similarly, botulinum toxin injections into the piriformis muscle can relieve pain. Research suggests that the median time spent pain-free after a botulinum toxin injection was about one month, which is significantly longer than the time spent pain-free after corticosteroid or anesthetic injections.

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Physical Therapy

While drugs or injections are sometimes necessary to manage symptoms, the mainstay of treatment for piriformis syndrome is physical therapy (PT), exercise, and stretching. Specific treatments may include the following:

• Adjustments in gait (the way a person walks)
• Improved mobility of sacroiliac joints, the points where the spine and pelvis connect
• Stretching to relieve tight piriformis muscles and those surrounding the hip
• Strengthening of the hip abductors (muscles that move the hips outward from the body)
• Soft tissue mobilization and myofascial release to help reduce muscle pain

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Surgery

Complementary Therapies

Several complementary therapies can provide relief from symptoms, including:

• Massage therapy: Targeted massage techniques can help relieve muscle tightness and alleviate pain.

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• Dry needling: In dry needling, a needle is inserted into a trigger point (a tight band or knot in a muscle fiber) to relieve tightness. There are case reports of piriformis syndrome symptoms improving after 10 days of treatment with ultrasound-guided dry-needling.

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• Acupuncture: There is evidence that acupuncture can be an effective treatment for piriformis syndrome, though more research is needed to determine the safest and most effective acupuncture methods.

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• Ice or heat: Cold packs or a heating pad may improve pain — you can try both to see what works best for your symptoms.

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While it may not always be preventable, certain lifestyle changes can help reduce the risk of developing piriformis syndrome.

• Exercise regularly. Physical activity and twice-weekly resistance training can keep your muscles strong and healthy.
• Practice good posture. When sitting, make sure your spine is supported and your feet either touch the floor or rest on a footrest.
• Practice safe lifting. Lift things properly by bending your knees and squatting, making sure to keep your back straight. Don’t twist while lifting.
• Avoid prolonged sitting. Take regular breaks to stand or walk if you sit for long periods, especially if you have a desk job or drive for hours at a time.
• Avoid activities that trigger piriformis syndrome. If certain activities trigger piriformis syndrome — for example, running or biking — find another way to exercise, at least for a few days.
• Stretch. Perform regular stretching exercises, especially after exercise, to maintain flexibility and reduce muscle tightness in the hips and buttocks. For example, lie on your back, then pull one knee toward your chest. Hold for 30 seconds, then change legs. Another way to stretch without lying down is to stand, hinge at your hips and let your head and hands fall toward the floor.

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For most people with piriformis syndrome, the prognosis is very good. Typically, symptoms improve within a few weeks with conservative treatments like physical therapy, lifestyle changes, and over-the-counter pain medications.

While piriformis syndrome isn’t a medical emergency, you should contact your healthcare provider if you experience any of the following symptoms:

• Frequent trips or falls due to pain or numbness
• Pain that continues longer than a few weeks after you make lifestyle changes
• Problems controlling your bladder or bowels (urinary or fecal incontinence)
• Sudden weakness or numbness in your back or leg
• Sudden, severe pain in your lower back or leg
• Trouble picking your foot off the floor

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Piriformis syndrome may be related to or occur alongside other conditions, including:

• Sciatica A common condition in which the sciatic nerve is irritated, it often mimics the symptoms of piriformis syndrome but in a larger area that can include the low back, buttocks, and legs.
• Herniated Disc When bulging or ruptured discs in the spine press on the nerves, the result can be pain that radiates down the leg.
• Hip Arthritis Inflammation in the hip joint may contribute to muscle tightness or misalignment that exacerbates piriformis syndrome.

• Piriformis syndrome occurs when the piriformis muscle compresses the sciatic nerve, leading to pain, numbness, and tingling in the buttocks and legs.
• It can be caused by muscle overuse, trauma, anatomical variations, or prolonged sitting.
• Treatment options include physical therapy, medication, and as a last resort, surgery. Most cases improve with conservative care.
• Early diagnosis, treatment, and lifestyle changes can help prevent the condition from becoming chronic.