How many people do you know who tell of back pain that has no cure? Or sciatica or leg pain than doctors cannot find the cause for. They tell you that the MRI scan was normal, back injections of steroids do not help and no medication has relieved their pain. There are tens of thousands of people with back pain and sciatica who never get the right diagnosis despite having several MRI scans and seeing numerous physicians. There is a high probability that these individuals suffer from a condition called piriformis syndrome. Unfortunately piriformis syndrome is frequently misdiagnosed as sciatica.
The piriformis muscle is a triangular shaped muscle that is in the middle of the buttocks. The base of the triangle attaches to the side of the sacrum (tailbone) and the tip attaches to the top of the femur (the major bone in the hip and leg.) An excellent piriformis diagram is found on the Institute for Nerve Medicine website. Injury or sprain to the piriformis muscle causes spasm, which in and of itself is painful. This can cause back pain and buttocks pain. Prolonged sitting will make the pain worse. Walking, climbing stairs or bending can be difficult and painful. The sciatic nerve comes out of the spine, exiting just below the piriformis muscle. In approximately 15% of individuals, the sciatic nerve pierces through the lower border of the piriformis muscle. It is these individuals who are predisposed to developing sciatica with injury to the piriformis muscle. Even without this, a strained, inflamed piriformis muscle will cause irritation to the sciatic nerve thereby causing sciatica.
There is no specific test, MRI or EMG findings in piriformis syndrome. It is a diagnosis made on the basis of getting the patient’s history, unique set of symptoms and detailed physical exam. Ordering an MRI of the back and getting an EMG will only help to exclude other causes of back pain and sciatica. Remember, just because you may have a “bulging disc” or “herniated disc” does not mean that this is causing your back pain or sciatica. Thirty percent of the general population have disc herniation on their MRI scans that are causing no symptoms. Therefore disc herniation does not equal back pain or sciatica Once the diagnosis is made, treatment should be started as soon as possible. The first is to educate the patient about the condition and identify activities that they are doing that irritate the piriformis muscle. Avoiding these activities and holding off on sports activities will help to stop straining the hip muscles. A set of stretching exercises for the back and hip muscles should be done twice daily to relieve the spasm, which will reduce the pain. Muscle Ventures has an excellent diagram and explanation of the piriformis stretch, even with a video. With this stretching, an anti-inflammatory medication, such as ibuprofen or naproxen, can be taken to lessen the pain and treat the inflammation in the muscle, tendon and sciatic nerve. Physical therapy can have a part in treating piriformis syndrome. It takes a therapist familiar with the condition to effectively provide relief. This in combination with deep neuromuscular therapy in the buttocks region will also help. Injections into the piriformis muscle are rarely performed due to its close relationship to the sciatic nerve and risk of injury to the nerve. Surgery has been tried but it is a major procedure and the effectiveness of this remains in question.
In summary, piriformis syndrome is a condition of strain and injury to the muscle. The sciatic nerve runs immediately below or just exits through the lower piriformis muscle. When injury occurs to the piriformis muscle, the sciatic nerve becomes irritated. This causes lower back and buttocks pain with sciatica. Diagnostic tests can only help in excluding other causes of back and leg pain. Therapy for piriformis syndrome consists of daily stretching, antiinflammatory medication and physical therapy. Affected individuals should avoid activities that aggravate their back pain and sciatica. Healing time can be weeks to months.