A Guide to Physical Therapy for Piriformis Syndrome
Piriformis syndrome (PS) — also called deep gluteal syndrome, wallet neuritis, and extra-spinal sciatica — is a literal pain in the butt.1 This neuromuscular disorder can affect your ability to perform many everyday activities such as walking down the hallway, sitting at your desk, standing by the mailbox to gossip with your neighbor, or even getting a good night's rest.
Piriformis syndrome accounts for less than 1% of low back pain and hip pain complaints.2 However, with 40 million American complaining of low back pain each year, that's still a staggering 2 million people. PS is six times more likely to affect women due to anatomical differences in the hips.
Physical therapy is recommended as one of the most cost-effective treatments for piriformis syndrome.3 In this guide, we will discuss symptoms, causes, diagnosis, treatment, and prevention tips.
- Understanding Piriformis Syndrome
- Symptoms of Piriformis Syndrome
- What are the Most Common Causes of Piriformis Syndrome?
- Diagnosing Piriformis Syndrome
- What to Expect from Physical Therapy for Piriformis Syndrome
- Physical Therapy FAQs
- What If Conservative Treatment Doesn't Work?
- Preventing Piriformis Syndrome
- Is It Time to Seek Treatment?
The piriformis muscle is a small muscle that runs diagonally across the buttocks. This band-like muscle is located behind the hip joint. It starts at the sacrum (lowest part of the spine) and attaches to the top of the femur (thighbone). This muscle is responsible for rotating the thigh outward (external rotation), extension, and abduction (bringing the thigh sideways away from the body).
The sciatic nerve is the largest in the body that originates in the low back and extends into and down the back of the leg. It branches into the gluteal region (including the piriformis muscle), hip, leg, and foot on each side.
Piriformis syndrome refers to sciatic nerve compression or irritation due to abnormal interaction with the piriformis muscle itself (see causes below). Depending on genetic factors, the sciatic nerve can run alongside, below, or through the piriformis muscle belly.
The symptoms associated with piriformis syndrome can vary daily and range from mild to severe. The most common symptom is buttock pain or a dull ache that radiates down the back of the leg (thigh pain). This pain is often described as sharp, shooting, or burning.
Other piriformis syndrome symptoms include:4
- Pain with sitting or lying on the affected side
- Tenderness to the touch in the buttocks region
- Painful bowel movements
- Difficulty walking, squatting, and/or standing
- Walking with a limp (due to pain or a functional leg length discrepancy)
- Numbness or tingling in the buttock, hip, or back of the thigh (along the sciatic nerve pathway)
- Swelling of the legs
- Sexual dysfunction and pain in the genitals (dyspareunia)
- Gluteal muscle spasm(s)
Warning: If you are experiencing a sudden change in your symptoms, particularly numbness in the saddle area, seek medical care immediately.
Piriformis syndrome typically correlates to certain primary factors, such as anatomical anomalies predisposing development. However, identifying secondary factors that correlate to piriformis syndrome is most helpful in diagnosing and treating the condition. The most common secondary factors are:3
- Muscle imbalance or weakness of the hip stabilizers (weak agonist muscles, such as the gluteal muscles)
- Direct trauma to the piriformis muscle or surrounding tissues (such as a fall or direct blow)
- Overuse of the gluteals, most common with long-distance walking or running
- Prolonged sitting or standing
- Prolonged postures that place excessive strain on the low back and hips
- Tightness of the piriformis muscle
- A larger Q angle (the angle between your hip and knee) — genetically, women have a larger Q angle
- The hip excessively adducts (the knee moves toward the center of the body) with changes in standing, running or walking mechanics
- Local tissue changes that put pressure on the sciatic nerve, such as an abscess, hematoma (bruise), neuroma, inflammation, etc.
The most important aspect of diagnosing patients with piriformis syndrome is taking a thorough health history and completing an in-depth physical exam. Your CityPT physical therapist will assess your range of motion, strength, flexibility, movement mechanics, posture, and more. Plus, they'll perform special tests to rule out other potential causes of hip pain, low back pain, and other sacroiliac pathologies.
Additionally, electromyography (EMG) and nerve conduction velocity (NCV) tests can be used to help identify PS and determine where the sciatic nerve irritation or damage is occurring. However, these tests are not always accurate and should only be used in conjunction with a thorough clinical exam.
In general, imaging is not useful in diagnosing patients with piriformis syndrome. However, if other causes of hip and back pain are suspected and need to be ruled out, tests like an MRI, CT scan, or X-ray can be ordered by your physician.
The main goal of physical therapy for piriformis syndrome is to decrease pain and improve function. Your CityPT physical therapist will work with you to develop a personalized treatment program that helps you sustainably recover. Some viable options include:3
- Manual therapy techniques: Including soft tissue mobilization, dry needling, and joint mobilization to help reduce muscle spasms and sciatic pain. Lumbar spine treatments (of the low back) can also help secondarily.
- Exercise rehabilitation: Functional exercises aimed at improving flexibility, range of motion, strength, endurance, and control of the hip and pelvis. Examples include targeting the abdominals, hip extensors, flexors, and rotators.
- Modalities: Such as electrical stimulation, ice/heat therapy, and laser therapy to help relieve pain and inflammation.
- Lifestyle modification: Addressing risk factors like obesity and sedentary behavior.
- Biomechanical and ergonomic training: To reduce unnecessary strain on the hip and sciatic nerve with your daily activities and postures.
- Education: Learning about your condition, how to stretch and strengthen the affected muscles, and what activities/positions to modify.
Let's review a few of the most commonly asked questions we receive about piriformis syndrome.
What is the best treatment for piriformis syndrome?
A personalized program designed with your physical therapist will yield the best results. It will ensure you factor in your unique deficits, goals, and preferences.
Is massage good for piriformis syndrome?
Yes, but only when initiated by a medical professional. Once the exact cause of your pain is determined, they can show you self-massage techniques to try. With this knowledge, you can avoid aggravating the area further.
What is the best sleeping position for piriformis syndrome?
A sleep position that reduces the direct pressure on your low back and buttocks is best. Typically, this means lying on your back with the knees supported. Your mattress quality can play a role in this too. Talk to your CityPT clinician for tips on maximizing your sleep habits to promote healing.
What are the best exercises for piriformis syndrome?
There is not one perfect exercise. A mix of options that functionally challenge your lower body is best. For example, this might include hip abduction exercises, core exercises, and balancing.
What exercises should I avoid with piriformis syndrome?
Initially, you will want to minimize your time in any aggravating position. However, you don't need to stress over altogether avoiding any movement or posture. Instead, focus on moving the body in ways that feel good and practice moderation with prolonged static positions.
Although rare, conservative treatment like physical therapy is sometimes not enough to provide long-lasting relief. If this is the case, your physician may recommend you treat piriformis syndrome with an injection or prescribed medication, such as muscle relaxants. In severe cases, orthopedic surgery may be considered to remove irritating tissues, such as an abscess, or to release tight connective tissue.
The best way to reduce your risk of developing piriformis syndrome, and other chronic pain conditions, include:
- Maintaining a healthy weight
- Regular exercise, including a core and hip muscle strengthening program that targets hip abduction and extension
- Lower body range of motion exercises and stretching the muscles around your hips and pelvis, including the piriformis muscle and gluteus maximus
- Modifying activities/positions that put unnecessary strain on these structures
- Practicing healthy lifestyle habits to reduce overall body inflammation, such as getting enough sleep, eating nutrient-dense meals, adequate stress management, and addressing any mental health concerns with professional support
- Discuss personalized options with a round (or two) of physical therapy
If you're struggling with piriformis syndrome or other hip and low back pain, don't wait to seek professional help. The sooner you start working with a physical therapist, the sooner you can return to your favorite activities and enjoy your life pain-free.
At CityPT, our team of expert physical therapists will work with you to develop a personalized physical therapy treatment plan to help you find long-lasting relief.
This guide is intended for informational purposes only. We are not providing legal or medical advice and this guide does not create a provider-patient relationship. Do not rely upon this guide (or any guide) for medical information. Always seek the help of a qualified medical professional who has assessed you and understands your condition.
Hicks BL, Lam JC, Varacallo M. Piriformis Syndrome. [Updated 2022 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK448172/ ↩
Cramp F, Bottrell O, Campbell H, et al. Non-surgical management of piriformis syndrome: a systematic review. 2007. In: Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. https://www.ncbi.nlm.nih.gov/books/NBK74304/ ↩ ↩2 ↩3
Hopayian K, Song F, Riera R, Sambandan S. The clinical features of the piriformis syndrome: a systematic review. Eur Spine J. 2010 Dec;19(12):2095-109. doi: 10.1007/s00586-010-1504-9. Epub 2010 Jul 3. PMID: 20596735; PMCID: PMC2997212. https://pubmed.ncbi.nlm.nih.gov/20596735/ ↩