A pain in the BUTTocks! Piriformis Syndrome is just that, both literally and figuratively.
It is one of the conditions that falls under the umbrella of sciatica. As we previously discussed sciatica is the name we give to conditions where the sciatic nerve is affected. In piriformis syndrome, sciatica is caused by the compression of the sciatic nerve by the piriformis muscle in spasm.
The piriformis muscle is a small, flat, triangular shaped muscle that originates in the sacrum and runs backwards and upwards to attach on the hip bone. The sciatic nerve runs from the sacrum and commonly passes under the piriformis muscle before it runs down the posterior thigh and into the leg. It is important to note that there are some variations where the sciatic nerve may run through or over the piriformis muscle or a combination (where the muscle has split).
The main cause for the syndrome is spasm of the piriformis muscle. Other causes may be:
- Muscle tightness;
- Muscle and fascial adhesions;
- Repetitive overuse activities;
- Previous gluteal trauma;
- Post-traumatic scarring;
- Anatomical abnormalities.
The pressure of the muscle on the sciatic nerve causes irritation which then leads to swelling, inflammation and may even lead to compression of the nerve.
- Pain in the buttock and/or going down the leg;
- Numbness, tingling or burning sensation down the leg, or a combination of these;
- Difficulty walking or leg feeling heavy;
- Difficulty performing certain activities such as extended periods of sitting, going up stairs or doing squats.
Piriformis syndrome diagnosis is made through a clinical examination through a process of elimination. There is no single or special test to get a diagnosis, but assessment commonly includes palpation of the piriformis muscle as well as SLR.. Imaging procedures such as an MRI may be useful in showing the condition of the nerve, muscles and surrounding structures but it is an expensive and impractical tool for the diagnosis of piriformis syndrome.
Most treatments will start with interventions to decrease pain and inflammation, NSAIDS are commonly used. Physiotherapy is often sufficient to treat this condition. Most of the interventions are conservative such as:
- Soft tissue release
- Muscle stretches, followed by muscle strengthening;
- Dry needling
- FAIR manoeuvre, etc.
Should these interventions not work, then some patients may opt for corticosteroids, nerve blocks. Only in some extreme cases, management may require surgical intervention.
As we see, the diagnosis and treatment of piriformis syndrome is very similar to that we described with Sciatica. So why is it important to know and differentiate between them?
First of all, understanding that sciatica is a symptom or a group of symptoms, ensures we look for a source of the issue, and therefor allows for effective treatment. Sometimes, releasing the piriformis muscle also helps in a process of elimination when trying to identify the source of the sciatica.
Secondly, it is important to remember that these conditions are not mutually exclusive. One may have sciatica because of piriformis syndrome and a disc herniation, or another condition. When we treat these conditions, we need to make sure we do not lose the big picture of the body as a whole.
Lastly, once we understand the difference between these we can use them to effectively assess, diagnose and treat these conditions. Where X-rays and CT scans may be beneficial to identify some sciatica causes, it may not be useful in the assessment of piriformis syndrome. Therefore a lot of attention should be taken to the clinical examination to get the right clues.
Yes, Piriformis Syndrome is a pain in the BUTTocks, but it doesn’t have to be yours.