Piriformis syndrome is sciatic nerve entrapment at the level of the ischial tuberosity (The sit bones). The medical publication STATPEARLS at the National Institutes of Health describes the symptoms as: “report(ed) pain in the gluteal region that is characterized as shooting, burning, or aching down the back of the leg. In addition, numbness in the buttocks and tingling sensations along the distribution of the sciatic nerve is not uncommon.” (1)

“My chiropractor did not think I had sciatica, he thought maybe piriformis syndrome?”

Here is the email: “Are you able to successfully treat sciatica type symptoms? I have NOT had an MRI and have only seen a chiropractor. He thought it could be sciatica or piriformis syndrome. I am sore on the outside of the buttocks, down the back and outside of the leg to the foot with some lower back pain but not always. It is triggered mainly when standing or walking and has progressively gotten worse.”

  • Piriformis Syndrome is caused by the compression of the sciatic nerve by the piriformis muscle.
  • Piriformis Syndrome mimics sciatica by causing in some people, numbness in the buttocks, hip, knee and into the feet and the pain travels down the sciatic nerve into the feet.
  • Piriformis Syndrome pain can be made worse by running, walking, standing or sitting for long periods of time.

So in this patient, treatment of piriformis syndrome can alleviate the sciatica like symptoms.

Pseudo Sciatica – gluteus minimus trigger points

What else can be causing “sciatica-like symptoms,” or Pseudo “fake” sciatica? A group of researchers published this paper in October 2020 (4).

“Not all sciatica-like manifestations are of lumbar spine origin. Some of them are caused at points along the extra-spinal course of the sciatic nerve, making diagnosis difficult for the treating physician and delaying adequate treatment. While evaluating a patient with sciatica, straightforward diagnostic conclusions are impossible without first excluding sciatica mimics. Examples of benign extra-spinal sciatica are piriformis syndrome, walletosis, quadratus lumborum myofascial pain syndrome (a muscle problem) . . .”

A 2014 paper (5) points out that a trigger point or a “muscle knot,” of the gluteus minimus muscle (upper butt muscle) can be the cause of pseudo sciatica.

“Sciatica has classically been associated with irritation of the sciatic nerve by the vertebral disc and consequent inflammation. Some authors suggest that active trigger points in the gluteus minimus muscle can refer pain in similar way to sciatica.”

A 2016 paper agrees:

“Pseudo-sciatica is a diagnostic term sometimes used to describe sciatic nerve symptoms which are not caused by the typical spinal sources. . . Trigger points can form in the muscles of the hip and lower back and refer pain down the leg. Trigger points are ‘knots’ in the muscle which become inflamed and highly irritable. They are more often found in weak muscles or muscles that have been ‘overloaded’ and have fatigued .”(6)

Treatment options

Generally doctors will follow an anti-inflammatory path with NSAIDs and possibly steroid anti-inflammatories. When these are not responsive, other options, like those below will be explored including surgery.

A February 2021 paper (2) describes current treatment options:

“Clinicians should consider medical management and conservative management in the initial treatment plan for piriformis syndrome. There are many options within the conservative management and the literature shows much promise regarding these. Physical therapy, steroid injections, botulinum toxin injections, and dry needling are all potentially effective therapies with few adverse effects.”

An October 2024 study (3) aimed to explore the immediate effect of hip exercises-inducing motor unit recruitment on postural balance in piriformis muscle syndrome patients.

  • twelve patients with piriformis muscle syndrome participated in a single session of hip exercises-inducing motor unit recruitment, consisting of two exercises, bilateral bridging to target hip extensors and side lying clams to target hip abductors and external rotators.

The researchers found: “A single session of hip exercises-inducing motor unit recruitment immediately improved static postural balance (unipedal posture with eyes closed) in patients with piriformis muscle syndrome. Given that this protocol is simple and easy to implement, it is recommended that patients with piriformis muscle syndrome consider incorporating these exercises into their daily physical activity.”

An August 2021 paper (4) examined outcomes in patients treated with Platelet-Rich Plasma (PRP) for piriformis syndrome. Six hundred patients were divided into PRP and control groups. One session of PRP and one session of saline.

  • The researchers found: “Ultrasound-guided PRP injection provided greater improvements in both pain and functional status in patients with piriformis syndrome, starting in the early period after treatment. A repeat injection might be needed for a long-term effect.”

A November 2024 case study (5) showed radial extracorporeal shockwave therapy piriformis syndrome improved the clinical symptoms, piriformis hardness, and cross-sectional area of the sciatic nerve in a single patient.

Dry Needling

An August 2023 paper (6) examined dry needling therapy and exercise programs on pain, neuropathic pain, physical function, and disability in patients with Piriformis  syndrome.

  • Forty-four Piriformis syndrome patients were divided into two groups, a group treated with (5) ultrasound guidance dry needling three times, once per week and those who had an exercise program for three weeks.

Conclusion: Both treatment showed beneficial results in reducing pain and disability, and increasing the functional status of the patients with Piriformis muscle syndrome. at three months of follow-up. . .Dry needling treatment under ultrasound guidance should be kept in mind as a minimally invasive treatment modality.

Hydro-dissection

Hydro-dissesction is the injection of fluid to separate soft tissue. A February 2022 study found: (7)  “Hydro-dissection by ultrasound-guided injection of a very low concentration of local anesthetic is effective and has a lower risk of adverse effects, thus making it more convenient for the treatment of piriformis syndrome than conventional treatments, such as local anesthetics, steroids, and botulinum toxin injection.”

Platelet Rich Plasma Injections for Piriformis Syndrome

PRP  injections are made from your blood. The treatment concentrates blood platelets for the growth and healing factors within. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors

An recent paper (8) describes outcomes with one PRP injection in 30 patients with piriformis syndrome. The researchers found: “Ultrasound-guided PRP injection provided greater improvements in both pain and functional status in patients with piriformis syndrome, starting in the early period after treatment. A repeat injection might be needed for a long-term effect.”

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References

1 Hicks BL, Lam JC, Varacallo M. Piriformis Syndrome. InStatPearls [Internet] 2023 Aug 4. StatPearls Publishing.
2 Vij N, Kiernan H, Bisht R, Singleton I, Cornett EM, Kaye AD, Imani F, Varrassi G, Pourbahri M, Viswanath O, Urits I. Surgical and Non-surgical Treatment Options for Piriformis Syndrome: A Literature Review. Anesthesiology and Pain Medicine. 2021 Feb 28;11(1).
3 Öztürk GT, Erden E, Erden E, Ulašlı AM. Effects of ultrasound-guided platelet rich plasma injection in patients with piriformis syndrome. Journal of Back and Musculoskeletal Rehabilitation. 2021(Preprint):1-7.
4 Nakanishi S, Tsutsumi M, Kawanishi K, Wada M, Kudo S. Effects of Radial Extracorporeal Shockwave Therapy on Piriformis Syndrome: A Single-Case Experimental Design. Cureus. 2024 Jun 7;16(6).
5 Guner D, Ozcete ZA. Evaluation of the efficacy of ultrasound-guided dry needling therapy and exercise in piriformis muscle syndrome. Cureus. 2023 Aug 20;15(8).
6 Chaari, F., Jardak, M., Bouchaala, F., Harrabi, M.A., Rebai, H. and Sahli, S., 2024. Immediate effect of hip exercises-inducing motor unit recruitment on static and dynamic postural balance in patients with piriformis muscle syndrome. Journal of Bodywork and Movement Therapy
7 Kaga M, Ueda T. Effectiveness of hydro-dissection of the piriformis muscle plus low-dose local anesthetic injection for piriformis syndrome: A report of 2 cases. The American Journal of Case Reports. 2022;23:e935346-1.