Your Sciatica is Coming From Your Hip! Piriformis Syndrome

 
Your Sciatica is Coming From Your Hip! Piriformis Syndrome

Sciatica is a common condition that causes pain radiating down the leg, often caused by nerve compression in the lower back. However, not all sciatica pain originates from the spine. In some cases, the culprit is a small muscle located deep in the buttock called the piriformis.

In this post, we'll explore the relationship between the piriformis muscle and sciatica pain and how understanding this connection can lead to better treatment and relief.


The Piriformis Muscle

The piriformis is a small, flat, and pear-shaped muscle located deep in the buttock. It lies in the centre of the buttock and directly below the large gluteus maximus muscle, which provides shape and form to the buttock and hip. The piriformis muscle originates near/just below the lower spine, on the front side of the tailbone (sacrum), and inserts into the top of the thighbone (femur). 

The piriformis is a type of external rotator muscle. It helps rotate the hip in an outward direction, which allows the thigh and knee to rotate or move away from the body, such as when stepping to the side from a standing position or getting out of a car. A healthy piriformis muscle is critical to the stability of the hip joint. Its attachment to the top part of the thighbone helps maintain balance while walking by shifting the body's weight to the opposite side.


What is Sciatica?

Sciatica refers to nerve pain caused by damage or irritation to the sciatic nerve. In addition to pain, it may involve sensations like tingling or numbness in the lower back or buttocks, which can spread down the leg. More severe symptoms are also possible. The sciatic nerve is the body’s largest and thickest nerve, measuring up to 2 centimetres in width (roughly the width of a $2 coin!). Contrary to its name, it's not a single nerve but a bundle of nerves formed from five nerve roots extending from the spinal cord. 

There are two sciatic nerves, one on each side of the body. Each one runs from the hip and buttock down the leg until just below the knee, where it branches into smaller nerves that reach the lower leg, foot, and toes. Sciatica can cause varying degrees of pain along any path where the nerve travels, affecting areas like the lower back, hips, buttocks, and legs. Depending on which nerve(s) are involved, symptoms may extend as far down as the feet and toes. 

Sciatica symptoms often include pain described as a burning or electric shock sensation, which radiates down the leg and may worsen with movements like coughing, sneezing, or bending. Many people also experience tingling, or "pins and needles" (paraesthesia), numbness in the affected areas due to disrupted nerve signals, and in more severe cases, muscle weakness.

In rare and serious instances, sciatica can cause urinary or faecal incontinence, signalling significant nerve damage. Sciatica is typically caused by conditions affecting the sciatic nerve or the spinal nerves that contribute to it, such as herniated discs, degenerative disc disease, spinal stenosis, spondylolisthesis, osteoarthritis, injuries, pregnancy, tumours, cauda equina syndrome OR piriformis syndrome.

Although sciatica may sound like a disc injury, it is not the same. A key distinction between sciatica and herniated discs is that sciatica typically takes less time to treat, whereas herniated discs often require more intensive orthopaedic care. A herniated disc is a permanent condition that, if left untreated, can severely impact your quality of life and lead to more serious complications. Without proper diagnosis from a specialist, it can be easy to confuse the two conditions. In some cases, an MRI may be needed to identify the affected areas and ensure an accurate diagnosis. Additionally, a herniated disc can cause sciatica, but the reverse is not true!

What’s the Connection?

Piriformis syndrome, the topic of our post today, is a condition where the sciatic nerve is compressed and irritated. It is a challenging diagnosis to make at times, due to the confusion of disc injuries and other sources of nerve pain. PS is typically associated with buttock or low back pain and accounts for 0.3% to 6% of sciatica cases. The piriformis muscle, which changes function depending on hip position, sometimes compresses the sciatic nerve, especially when anatomical variations are present. 

Trauma to the gluteal area, leading to hematomas and scarring, is a common cause of PS, and it may also develop from piriformis muscle overuse or hypertrophy. Functional entrapment of the sciatic nerve has been demonstrated through EMG studies, and conservative treatments, such as physical therapy, have been effective in resolving symptoms, even in athletes. Despite limited sports-related case studies, it is likely that PS occurs more frequently in athletics due to the patho-mechanics involved.

There are two types of piriformis syndrome – Primary & Secondary. Primary Piriformis Syndrome occurs due to anatomical variations, such as a split in the piriformis muscle or sciatic nerve. Less than 15% of cases of piriformis syndrome are attributed to these primary causes, and there is minimal evidence linking sciatic nerve anomalies directly to the condition. Secondary Piriformis Syndrome results from external factors like trauma, overuse, or ischemia. 

The most common cause, accounting for 50% of cases, is macrotrauma to the buttocks, which triggers inflammation or muscle spasms that compress the sciatic nerve. Muscle spasms can result from direct injury, surgeries, joint issues, or overuse, while microtrauma comes from repetitive activities like running or walking long distances. Piriformis syndrome may also be caused by biomechanical issues, where changes in movement lead to sciatic nerve compression and symptoms such as pain in the gluteal region and down the sciatic nerve pathway. 

Contributing factors include gluteal trauma, hypertrophy or spasm of the piriformis muscle, injections, tumors, and less common conditions like Morton’s Toe. Those at higher risk include skiers, truck drivers, tennis players, and long-distance cyclists. According to Tonley JC, piriformis syndrome may also result from the muscle being overstretched or subjected to eccentric loads due to weak gluteal muscles, leading to sciatic nerve compression or irritation.

Variations in the relationship of the sciatic nerve to the piriformis muscle shown on the diagram above:

  1. The sciatic nerve exiting the greater sciatic foramen along the inferior surface of the piriformis muscle (A)

  2. The sciatic nerve splitting as it passes through the piriformis muscle with the tibial branch passing inferiorly(B)

  3. The sciatic nerve splitting as it passes through the piriformis muscle with the tibial branch passing superiorly ©

  4. The entire sciatic nerve passing through the muscle belly (D)

  5. The sciatic nerve exiting the greater sciatic foramen along the superior surface of the piriformis muscle (E)


Diagnosis & Treatment

Piriformis syndrome is often diagnosed through a patient's history and physical exam. Common symptoms include pain after sitting for 15-20 minutes, particularly around the piriformis muscle, sacrum, and greater trochanter. Symptoms may develop suddenly or gradually, often due to muscle spasms or compression of the sciatic nerve, leading to difficulty walking and pain with internal hip rotation. Trauma, sacroiliac joint pain, or sciatic notch tenderness may also be present.

During a physical exam, tenderness, muscle spasms, and reduced internal hip rotation may be detected. Various tests, such as the Piriformis sign, Lasègue sign, Freiberg sign, and Beatty manoeuvre, help reproduce sciatic pain and confirm the diagnosis. While MRI and CT scans are primarily used to exclude other conditions like disc herniation or spinal issues, electrodiagnostic tests, including EMG, can distinguish piriformis syndrome from other nerve problems. Findings of muscle weakness and a prolonged H reflex in the affected limb often point to piriformis syndrome. Below are some videos for fantastic ways to strengthen and mobilise your hips & assist in the rehabilitation of the piriformis.

Piriformis Syndrome (PS) is commonly treated with non-invasive methods, though controlled trials are limited. Physical therapy, manipulative treatments, and lifestyle modifications are frequently used, and Ozone Therapy is also an option due to its safety and ease of use. Common physical therapy interventions include ultrasound, soft tissue mobilization, piriformis stretching, and strengthening exercises for the hip.

These exercises focus on correcting movement patterns and targeting the hip extensors, abductors, and external rotators. Stretching, particularly in the FAIR position (Flexed, Adducted, Internally Rotated), is essential for relieving nerve compression, while techniques like muscle-energy and myofascial release further alleviate symptoms.

Patients are advised to avoid prolonged sitting, take regular stretching breaks, and limit activities that might worsen their condition. Medications such as NSAIDs, muscle relaxants, and neuropathic pain relievers like gabapentin are often used alongside physical therapy. Some cases may benefit from injections, including lidocaine for diagnosis or corticosteroids and botulinum toxin to reduce muscle tension and allow for more effective physical therapy.

In severe or chronic cases, surgical decompression may be considered to reduce tension in the piriformis muscle and alleviate sciatic nerve compression. Despite the lack of extensive research, conservative treatments like stretching, strengthening exercises, and manual techniques remain the cornerstone of PS management, showing significant success in alleviating symptoms.

Understanding and Treating the Hidden Cause of Sciatica-Like Pain

Piriformis syndrome is an under-recognized cause of sciatica-like symptoms, arising from the compression of the sciatic nerve by the piriformis muscle. Despite its complex diagnosis, conservative treatments such as physical therapy, stretching, and strengthening exercises show significant effectiveness in alleviating symptoms. Early intervention is crucial to prevent the condition from becoming chronic. 

While invasive procedures like surgery are reserved for severe cases, non-invasive treatments, including targeted stretching and muscle re-education, are the mainstay approaches and often lead to successful pain management and functional improvement. Understanding the role of the piriformis muscle in hip stability and sciatic nerve compression is essential for addressing the root cause of PS and ensuring lasting recovery.

Relieve Sciatica Pain Naturally with Personalised Chiropractic Care

​​Chiropractic care provides a non-invasive solution for many, offering relief from sciatica pain by targeting its root causes and enhancing overall mobility—without relying on medications or surgery.

If sciatica pain is holding you back, Elite Health & Performance is here to support your recovery. Our team delivers personalised, evidence-based care designed to help you regain comfort and mobility. Reach out to us today to get started.

 
 
 
Mitch HillsComment