Piriformis syndrome can masquerade as sciatic pain or a herniated disc.
Diagnostic dilemma

Piriformis syndrome: A frequently misdiagnosed pain in the buttocks

Muscular disorder is often mistaken for sciatica or a herniated disc, leaving patients with unresolved pain.

It’s been called pseudosciatica, wallet sciatica, and deep gluteal syndrome.

Runners, dancers and patients who sit for hours most often present with symptoms, which can include pain, tingling or numbness in the backside and down the leg. The disorder—piriformis syndrome—happens when the piriformis muscle in the buttocks irritates the sciatic nerve.

While relatively common among marathon runners and other athletes, only about 200,000 cases are diagnosed each year. Osteopathic researchers say piriformis syndrome is often overlooked in clinical settings because it can masquerade as other conditions with similar symptoms.

“Effective treatment requires identification of the true musculoskeletal culprit,” says Clifford Stark, DO, medical director at Sports Medicine at Chelsea in New York City. “On an MRI, I may see a herniated or bulging disc but the physical exam tells me the disc isn’t causing the problem.”

According to Dr. Stark, the condition is often misdiagnosed as sciatica or a herniated disc, rather than piriformis syndrome. Underdiagnosis may stem from patients simply living with the pain rather than seeking out medical care.

The piriformis plays a crucial role

The piriformis muscle—the flat, band-like muscle located in the buttocks near the top of the hip joint and next to the sciatic nerve—stabilizes the hip area and is critical to lower body movement.

“It’s an important muscle for biomechanics and function,” says Dr. Stark. “It plays a crucial role in gait and balance.”

The sciatic nerve—where shooting leg or back pains often originate—passes alongside or through the piriformis muscle, before it continues down the back of the leg and eventually branches off into smaller nerves that end in the feet. A healthy piriformis can protect and improve sciatic function, while compression or spasm of the muscle can cause excruciating pain when it compresses and irritates the nearby sciatic nerve.

“The piriformis muscle allows us to walk and maintain balance,” says Dr. Stark. “For one of the most central, connected muscles in our body, it receives limited attention—leading to a lack of the maintenance care that can prevent extensive pain.”

Diagnosing and treating the culprit

Treatments for piriformis syndrome include stretching, manipulation, anti-inflammatory drugs, and in rare cases, surgery.

While there is no definitive test for piriformis syndrome, diagnosis involves a discussion of the patient’s symptoms and daily activities. To identify the source of the disorder, an osteopathic physician should manipulate the body to elicit pain in the region, which can help determine if it’s a contracted or tender piriformis muscle, a herniated disc or other issue.

“Many patients present with disc herniation, but that does not preclude piriformis syndrome,” says Dr. Stark. “Tests such as an ultrasound or MRI may be required to rule out other causes of sciatic nerve compression, such as a herniated disc, but in most cases the initial treatment is the same.”

A physician can suggest a program of exercises and stretches to conduct under the care of a physical therapist to help reduce sciatic nerve compression. Additionally, osteopathic manipulative treatment can be used to help relieve pain and increase range of motion. Rest, ice, and heat may also help alleviate symptoms.

Some health care providers may recommend anti-inflammatory medications, muscle relaxants, or injections with a corticosteroid or anesthetic, though Dr. Stark recommends against this approach as the first line of care.

Surgery is a last resort.

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