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Physical Medicine and Rehabilitation for Piriformis Syndrome Clinical Presentation

  • Author: Milton J Klein, DO, MBA; Chief Editor: Consuelo T Lorenzo, MD  more...
Updated: May 16, 2016


Piriformis syndrome often is not recognized as a cause of low back pain (LBP) and associated sciatica. This clinical syndrome is due to a compression of the sciatic nerve by the piriformis muscle; it is identical in clinical presentation to LBP with associated L5, S1 radiculopathy due to diskogenic and/or lower lumbar facet arthropathy with foraminal narrowing. (The image below demonstrates the origins of both conditions.) Not uncommonly, patients demonstrate both of these clinical entities simultaneously. This diagnostic dilemma highlights the need for patients with LBP and associated radicular pain to undergo a complete history and physical examination, including a digital rectal examination.

Nerve irritation in the herniated disk occurs at tNerve irritation in the herniated disk occurs at the root (sciatic radiculitis). In piriformis syndrome, the irritation extends to the full thickness of the nerve (sciatic neuritis).

Many cases of refractory trochanteric bursitis are observed to have an underlying occult piriformis syndrome due to the insertion of the piriformis muscle on the greater trochanter of the hip. If a patient's trochanteric bursitis and piriformis syndrome are treated inadequately, both conditions remain resistant to medical management.



Examination findings may include the following:

  • Piriformis muscle spasm often is detected by careful, deep palpation.
  • A digital rectal examination may reveal a tenderness on the lateral pelvic wall that reproduces symptoms.
  • The reproduction of sciatica-type pain with weakness results from resisted abduction/external rotation (Pace test).
  • The Freiberg test is another diagnostic sign that elicits pain upon forced internal rotation of the extended thigh.[9]
  • The Beatty maneuver reproduces buttock pain by selectively contracting the piriformis muscle.[10] The patient lies on the uninvolved side and abducts the involved thigh upward; this activates the ipsilateral piriformis muscle, which is a hip external rotator and, when the hip is flexed, an abductor.
  • A painful point may be present at the lateral margin of the sacrum.
  • Shortening of the involved lower extremity may be seen.
  • The patient may have difficulty sitting due to an intolerance of weight bearing on the buttock.
  • The patient may have the tendency to demonstrate a splayed foot on the involved side when in the supine position.
  • Piriformis syndrome alone is rarely the cause of a focal neuromuscular impairment; either a sciatic mononeuropathy or an L5-S1 radiculopathy can mimic both of these conditions, obscuring diagnosis of piriformis syndrome.
  • A Morton foot may predispose the patient to developing piriformis syndrome. The prominent second metatarsal head destabilizes the foot during the push-off phase of the gait cycle, causing foot pronation and internal rotation of the lower limb. As a compensatory mechanism, the piriformis muscle (external hip rotator) reactively contracts repetitively during each push-off phase of the gait cycle , leading to piriformis syndrome.


Approximately 50% of patients with piriformis syndrome have a history of trauma, with either a direct buttock contusion or a hip/lower back torsional injury. The remaining 50% of cases are of spontaneous onset, so the treating physician must have a high index of suspicion for the problem, lest it be overlooked.

Contributor Information and Disclosures

Milton J Klein, DO, MBA Consulting Physiatrist, Heritage Valley Health System-Sewickley Hospital and Ohio Valley General Hospital

Milton J Klein, DO, MBA is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Medical Acupuncture, American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, American Pain Society, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, Association of Academic Physiatrists

Disclosure: Received honoraria from Allergan for speaking and teaching.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Additional Contributors

Rajesh R Yadav, MD Associate Professor, Section of Physical Medicine and Rehabilitation, MD Anderson Cancer Center, University of Texas Medical School at Houston

Rajesh R Yadav, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

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Nerve irritation in the herniated disk occurs at the root (sciatic radiculitis). In piriformis syndrome, the irritation extends to the full thickness of the nerve (sciatic neuritis).
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