Piriformis Syndrome – A Real Pain in the Butt!!

on March 18, 2018 by Dr. John Michie
Piriformis Syndrome in the lower back

What is Piriformis Syndrome?

Piriformis Syndrome is a neuro-muscular condition that results from irritation and/or compression of the Sciatic nerve via the thick deep gluteal/hip muscle know as the Piriformis.  The Piriformis, which aids in external rotation of the hip joint, has an intimate relationship with the sciatic nerve – the largest nerve in the body – which supplies the lower extremities with motor and sensory function.  The sciatic nerve passes underneath (80% of population) or pierces through (20%) the Piriformis muscle.

Symptoms of Piriformis Syndrome:

Piriformis syndrome typically starts with pain, tingling and/or numbness in the buttock region.  Pain can be severe and even extend down the length of the sciatic nerve (from hip through ankle/foot).  Pain can be exacerbated with running, cycling, rowing and prolonged sitting.

Causes of Piriformis Syndrome:

Piriformis Syndrome diagram down legRunners, Cyclists and Rowers are especially prone to this condition due to overuse and strenuous use of the hips and legs.  Some of the specific mechanisms of this injury are:

  • Over-active hip flexors (Iliopsoas, TFL, Rectus Femoris)
  • Weak hip abductors (Gluteus Medius/Minimus)
  • Tight hip adductors
  • Restricted Sacro-Iliac joints
  • Over –pronation of the foot/ankle

Diagnosis of Piriformis Syndrome:

  • Clinical, “hands on” examination for hip, lower back and soft tissue/muscles
  • MRI to rule out lumbar disc herniation/protrusion
  • Applied Kinesiology assessment to pin-point cause and origin of symptoms
  • Biomechanical work-up to determine kinetic chain imbalances
  • Magnetic Resonance Neurography to determine if resistant cases are due to sciatic nerve piercing Piriformis or if sciatic nerve runs underneath muscle

Management of Piriformis Syndrome:

  • Trigger Point Therapy – 2-3X/week until resolution, release
  • Chiropractic adjustments @ feet, knees, hips and pelvis/Sacro-iliacs/lumbar spine to clear out restrictions and imbalances – adjust until clear and stable
  • Myofascial release @ Piriformis and associated hip muscles – this may take 3-6 sessions
  • Iontophoresis 2-3X/week until resolution, release
  • Myofascial Dry Needle Therapy – 2-6 sessions
  • Corrective Orthotics to stabilize foot/ankle/knee/hip biomechanics
  • Stretch and Foam Roller work to release tension on the Piriformis and add length to the Adductors – 3X/day
  • Kinesiotape Hip and pelvis for proper alignment and support
  • Epsom Salt Baths to release tension on Piriformis
  • Strengthen Hip Abductors, External Rotators and Extensors


This condition, if not addressed and managed properly can profoundly influence athletic function and severely limit participation.  Again, the emphasis is “living upstream” or remaining preventive with your body by listening to clues about slight nuances of imbalance, stress and/or training techniques.  This condition typically resolves with the appropriate therapy applications and the above list is not to overwhelm but to address the layers that typically need to be peeled back when “fixing” an athletic injury.
Image: Gray’s Anatomy