eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions

Piriformis Syndrome: Differential Diagnoses & Workup

Author: Milton J Klein, DO, MBA, Consulting Physiatrist, Heritage Valley Health System-Sewickley Hospital, Allegheny General Hospital, and Ohio Valley General Hospital.
Contributor Information and Disclosures

Updated: Sep 14, 2009

Differential Diagnoses

Achilles Tendon Injuries and Tendonitis
Lumbar Facet Arthropathy
Lumbar Spondylolysis and Spondylolisthesis
Lumbosacral Radiculopathy
Myofascial Pain
Trochanteric Bursitis

Other Problems to Be Considered

Degenerative lumbar disk disease 
Buttock pain
Ischial tuberosity bursitis
Sciatica

Workup

Laboratory Studies

  • Laboratory studies generally are not indicated in the diagnosis of piriformis syndrome.

Imaging Studies

  • Diagnostic imaging of the lumbar spine is mandatory to exclude associated diskogenic and/or osteoarthritic contributing pathology.
  • Reports in the literature on the piriformis muscle describe imaging by nuclear diagnostic studies and magnetic resonance imaging (MRI) of the pelvis,8 but these tests are neither practical nor reliable approaches to the diagnosis of piriformis syndrome. The history and clinical diagnostic examination provide the greatest and most specific diagnostic yield for the disorder.
  • Magnetic resonance neurography is a newer, sensitive imaging technique that increases nerve conspicuity by suppressing the signal from adjacent soft tissue, including fat, bone, and muscle.9 The nerve itself contains minimal fat, and its signal is unsuppressed. According to Filler and colleagues, MR neurography demonstrated piriformis muscle asymmetry and sciatic nerve hyperintensity at the sciatic notch with 93% specificity.10 The investigators also found that the technique had a sensitivity of 64% with regard to distinguishing patients with piriformis syndrome from persons who, despite having similar symptoms, did not have the condition (p<0.01).
  • Diagnostic ultrasonographic imaging of the piriformis muscle for the assessment of muscle morphology has demonstrated a significant correlation of piriformis muscle morphology abnormality, especially in patients with lumbosacral/buttock pain and pain ascending stairs, referred pain to the posterior thigh on the symptomatic side, and reproduction of pain with needling of the piriformis muscle.

Other Tests

  • The results of electrodiagnostic testing for piriformis syndrome usually are normal. Reports of positional H-reflex abnormalities can be found in the literature11 ; however, such findings have not been widely accepted or reproduced.

More on Piriformis Syndrome

Overview: Piriformis Syndrome
Differential Diagnoses & Workup: Piriformis Syndrome
Treatment & Medication: Piriformis Syndrome
Follow-up: Piriformis Syndrome
Multimedia: Piriformis Syndrome
References
Further Reading
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References

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Further Reading

Related eMedicine topics:
 Botulinum Toxin in Pain Management
Chronic Pain Syndrome
Chronic Pelvic Pain
Injection, Piriformis
Nerve Entrapment Syndromes
Nerve Entrapment Syndromes of the Lower Extremity
Piriformis Syndrome [Sports Medicine]

Clinical guidelines:
Pain (chronic). Work Loss Data Institute - Public For Profit Organization. 2003 (revised 2008 May 19). 475 pages. NGC:006564

The initial management of chronic pelvic pain. Royal College of Obstetricians and Gynaecologists - Medical Specialty Society. 2005 Apr. 12 pages. NGC:004471

Clinical trials:
Effectiveness of Oral Prednisone in Improving Physical Functioning and Decreasing Pain in People With Sciatica

Ultrasound Description of the Sciatic Nerve

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Keywords

piriformis syndrome, sciatica, sciatic nerve, piriformis, sciatic, sciatic nerve pain, piriformis muscle, sciatic pain, sciatica treatment, sciatica exercises, nerve compression, sciatic nerve treatment, piriformis sciatica, pyriformis, pyriformis syndrome, hip socket neuropathy, pseudosciatica, wallet sciatica, deep gluteal syndrome

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Contributor Information and Disclosures

Author

Milton J Klein, DO, MBA, Consulting Physiatrist, Heritage Valley Health System-Sewickley Hospital, Allegheny General 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, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Rajesh R Yadav, MD, Assistant Professor, Section of Physical Medicine and Rehabilitation, MD Anderson Cancer Center, University of Texas 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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael T Andary, MD, MS, Residency Program Director, Professor, 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, and Association of Academic Physiatrists
Disclosure: allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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