What to Know About Piriformis Syndrome

You may know it as a tingling feeling or a burning sensation running down the back of one of your legs. Piriformis syndrome, which is more common among runners and cyclists but can occur in anyone, can range from mild discomfort to severe pain.

Scott A. Barbuto, MD, a Columbia specialist in rehabilitation and regenerative medicine, explains the signs and symptoms of piriformis syndrome, as well as the most effective ways to get relief.

What is piriformis syndrome?

The piriformis is a small muscle deep in the buttock that helps with the rotation of your hips.

Piriformis syndrome occurs when this muscle compresses the sciatic nerve, which causes pain to radiate down the leg. The pain can worsen with prolonged sitting, climbing stairs, or squatting.

Could you explain the relationship between the piriformis muscle and sciatic nerve?

The sciatic nerve is the largest nerve in the body. It starts at the base of the spine, and in most people, it runs from the pelvis underneath the piriformis muscle and down each leg. It is the proximity of the piriformis muscle and the sciatic nerve that leads to complications.

Furthermore, in some people, the sciatic nerve passes through the piriformis muscle or even above it. These individuals are more likely to have from piriformis syndrome. 

What are the symptoms of piriformis syndrome? How do you confirm a diagnosis?

Piriformis syndrome can present as a deep pain in the buttocks. In some patients, a tingling, numbness, or burning sensation radiates down the back of the leg.

Piriformis syndrome is usually diagnosed when these symptoms are present and an MRI of the lumbar spine (the vertebrae of the lower back) excludes the possibility of a pinched nerve. Sometimes, we use an ultrasound to “see” the muscle pressing the nerve to confirm the diagnosis.

Let’s say I have symptoms of piriformis syndrome. When should I call my doctor?

You should seek treatment when one or more of these is true:

• The pain does not improve within a week
• The pain gets worse
• You develop other symptoms, such as bowel/bladder incontinence or muscle weakness
• You have difficulty doing normal activities such as sitting on a toilet seat, climbing stairs, cycling, or running
• Your pain develops after a physical trauma or a fall 

Can you recommend ways to ease mild to moderate discomfort from piriformis syndrome?

Of course. Here are a few examples of what I typically recommend to patients with piriformis syndrome:

• Limit prolonged sitting. This is really important. People underestimate how much pressure a chair can exert on the back of our legs. One solution is to use a standing desk. Another is to get up and walk around every 30 minutes or so. It turns out this behavior is great for overall health, too.

• Limit repetitive motions that aggravate symptoms. If you are a runner or a cyclist, I would take a break from that activity. Consider trying other forms of cardio exercise, such as swimming, rowing, or using an elliptical machine. The idea is to stay active while you temporarily offload the piriformis muscle. If stairs are a problem for you, use a ramp or elevator. But don’t give up on stairs forever; they are excellent for maintaining lower body strength and cardio fitness.

• Stretch the piriformis muscle, as well as your glutes. Stretching is important because as the piriformis muscle becomes more supple, it infringes less forcefully on the sciatic nerve. A more supple piriformis muscle also increases the hip’s range of motion.

• Strengthen your hips and core. Two important principles in rehabilitation and regenerative medicine are balance and alignment. Trouble often arises when the bones and muscles in and around our joints are unbalanced or out of alignment. Strengthening the involved muscles can help optimize a joint’s movement. In the case of piriformis syndrome, I often recommend a series of strengthening exercises. These might include glute bridges, bird dogs, lunges, and planks. I also recommend working with a physical therapist, who can demonstrate each exercise (and others) with your limitations in mind.

• Manual manipulation of the piriformis muscle. In addition to helping with strengthening and stretching exercises, a physical therapist can provide a myofascial release and other manual techniques to address pain.

• Consider NSAIDs or muscle relaxants. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen can help with pain and inflammation. A muscle relaxant drug such as cyclobenzaprine might be warranted, but it and others require a prescription. Ask your doctor what’s best for you.

In general, how do you feel about online physical therapy instruction videos?

I usually do not recommend online videos. I prefer the patient see a professional (usually a physical therapist) in person to learn how to do each exercise correctly. Then, after proper and sufficient instruction, they can certainly do the exercises on their own.

For severe discomfort associated with piriformis syndrome, what are a patient’s options?

For severe discomfort that does not respond to what I already mentioned, a doctor can try trigger point injections or Botox injections. Failing that, surgery can decompress the sciatic nerve. The surgery is called a piriformis release or sciatic nerve decompression surgery. It is usually performed by an orthopedic surgeon, but sometimes it is performed by a neurosurgeon. 

Scott A. Barbuto, MD, is an assistant professor of rehabilitation and regenerative medicine at the Vagelos College of Physicians and Surgeons.