What piriformis syndrome is
The piriformis muscle lies deep in the buttock, beneath gluteus maximus, and runs from the sacrum to the greater trochanter of the femur. Right next to it – and in some people partly through the muscle itself – runs the sciatic nerve. Piriformis syndrome assumes that an overloaded or irritated muscle irritates the nerve and causes buttock pain, sometimes running down the back of the thigh.
To be honest, this diagnosis is disputed. There is no test that confirms it unambiguously, and in practice it is made much more often than research would suggest. Many people with this “diagnosis” actually have sciatica caused by irritation of a nerve root in the lumbar spine – and then work focused only on the buttock changes little.
How we tell it apart from sciatica and hip pain
We start the assessment with the spine, not the buttock. We check sensation, strength and reflexes, carry out nerve tension tests, and see whether movements of the lumbar spine change the symptoms in the leg. If they do, the source most likely lies higher up. Next we assess the hip joint and the sacroiliac joint, because pain in this area often comes from them – more on this on the pages about hip pain and sacroiliac joint pain.
Only when these causes do not explain the symptoms, and the familiar pain is reproduced by pressure deep in the buttock and by tests that load this area, do we consider a problem within the deep gluteal muscles. Buttock and calf pain that comes on with walking and goes away when you stop can have a vascular cause or result from narrowing of the spinal canal – in that case we refer you to a doctor.
Treatment – what helps
If the assessment points to the buttock area, we start by reducing the irritation. We use soft tissue manual therapy, nerve mobilisation techniques and, where needed, dry needling. Just as important is changing whatever keeps the problem going – long periods of sitting on a hard surface or a sharply increased mileage.
The basis of further work is gradual strengthening of the gluteal muscles and hip rotators, and pelvic control in single-leg movements. Stretching and foam rolling on their own usually bring only short-lived relief, so we treat them as an add-on rather than the main treatment. Improvement comes gradually – the first changes usually after a few weeks of regular work.
In runners and cyclists we also check how training volume has changed over recent weeks and how the hip works when you stand on one leg. This is often where the answer lies to the question of why the problem appeared at all.
When to come in and what to expect
It is worth coming in when buttock pain lasts longer than two to three weeks, makes sitting difficult, or comes back with running or cycling. At the first visit we establish where the symptoms really come from. If it turns out that it is not the piriformis but the spine or the hip, we say so plainly and change the plan straight away. If you have already been given this diagnosis and have been stretching your buttock for months with no improvement, bring your previous test results and a description of your treatment to the visit – this helps narrow down the cause faster. You can arrange an appointment via the Contact page.