Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Piriformis Syndrome Clinical Presentation

  • Author: Shishir Shah, DO; Chief Editor: Sherwin SW Ho, MD  more...
 
Updated: Aug 19, 2015
 

History

Patients with piriformis syndrome have the following symptomatic history:

  • Chronic pain in the buttocks
    • This pain may radiate to the lower leg and worsens with walking or squatting.
    • This pain may imitate LBP.
  • Pain with bowel movements
  • Pain in the labia majora in women; pain in the scrotum in men
  • Dyspareunia in women
  • Pain when getting up from bed
  • Pain exacerbated by hip adduction and internal rotation
  • Intolerance to sitting
Next

Physical

Piriformis syndrome is a diagnosis of exclusion.

  • At physical examination, the most important factor that differentiates sciatic pain from piriformis syndrome is the absence of neurologic deficit in piriformis syndrome.
  • Herniation or disc compression results in intraneural derangement of the nerve root structure, whereas piriformis syndrome causes a qualitative epineural irritation.
  • In piriformis syndrome, the only true-positive sign is tenderness over the gluteal region.
    • The pain can be reproduced with maximum elongation of the piriformis muscle in flexion, adduction, and internal rotation of the hip.
    • Weakness can be observed with resisted external rotation and abduction of the hip.
  • Several authors describe the use of the following signs in diagnosing piriformis syndrome:
    • Lasegue sign: Pain is present in the vicinity of the greater sciatic notch during extension of the knee with the hip flexed to 90 º, tenderness to palpation of the greater sciatic notch is noted.
    • Pace sign: Pain and weakness are present on resisted abduction-external rotation of the thigh.
    • Freiberg sign: Pain occurs with passive internal rotation of the extended thigh when the patient is supine.
  • Robinson, who first described the syndrome, stated that piriformis syndrome had 6 cardinal features:
    • Positive Lasegue sign
    • Sausage-shaped mass over the piriformis muscle
    • Gluteal atrophy in chronic cases
    • Trauma to the region
    • Pain in the sacroiliac joint region, gluteal muscles, or greater sciatic notch
    • Pain exacerbated by lifting and relieved by traction on the affected extremity
  • Beatty reproduced the pain of piriformis syndrome in the following way[3] :
    • The patient lies with the painful side up and the involved leg flexed.
    • The knee of the affected side rests on the table. Pain in the buttocks is reproduced when the patient lifts the leg and knee slightly above the table.
  • Other authors conclude that pain can be reproduced in the lateral pelvic wall by means of rectal or pelvic examination.
Previous
Next

Causes

See the list below:

  • Trauma to the buttocks or gluteal region is the most common cause of piriformis syndrome.
  • Skiers, truck drivers, tennis players, and long-distance bikers are at high risk.
  • In Morton foot, the prominent head of the second metatarsal causes foot instability and a reactive contraction of the external rotators of the hip during gait.
  • Spinal stenosis can lead to bilateral piriformis tenderness.
  • Anatomic variations of the divisions of the sciatic nerve above, below, and through the belly of the piriformis muscle may be causative factors.[4]
Previous
 
 
Contributor Information and Disclosures
Author

Shishir Shah, DO Consulting Staff, Comprehensive Woundcare, Banner Baywood Hospital

Shishir Shah, DO is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, American Osteopathic Association

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas W Wang, MD Consulting Staff, Department of Occupational Medicine, Kaiser-Permanente

Thomas W Wang, MD is a member of the following medical societies: American Academy of Family Physicians

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.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Joseph P Garry, MD, FACSM, FAAFP Associate Professor, Department of Family Medicine and Community Health, University of Minnesota Medical School

Joseph P Garry, MD, FACSM, FAAFP is a member of the following medical societies: American Academy of Family Physicians, American Medical Society for Sports Medicine, Minnesota Medical Association, American College of Sports Medicine

Disclosure: Nothing to disclose.

References
  1. Jawish RM, Assoum HA, Khamis CF. Anatomical, clinical and electrical observations in piriformis syndrome. J Orthop Surg Res. 2010 Jan 21. 5:3. [Medline]. [Full Text].

  2. Benson ER, Schutzer SF. Posttraumatic piriformis syndrome: diagnosis and results of operative treatment. J Bone Joint Surg Am. 1999 Jul. 81(7):941-9. [Medline].

  3. Beatty RA. The piriformis muscle syndrome: a simple diagnostic maneuver. Neurosurgery. 1994 Mar. 34(3):512-4; discussion 514. [Medline].

  4. Robinson ES, Lindley EM, Gonzalez P, Estes S, Cooley R, Burger EL, et al. Piriformis syndrome versus radiculopathy following lumbar artificial disc replacement. Spine (Phila Pa 1976). 2011 Feb 15. 36(4):E282-7. [Medline].

  5. Boyajian-O'Neill LA, McClain RL, Coleman MK, Thomas PP. Diagnosis and management of piriformis syndrome: an osteopathic approach. J Am Osteopath Assoc. 2008 Nov. 108(11):657-64. [Medline]. [Full Text].

  6. Fowler IM, Tucker AA, Weimerskirch BP, Moran TJ, Mendez RJ. A randomized comparison of the efficacy of 2 techniques for piriformis muscle injection: ultrasound-guided versus nerve stimulator with fluoroscopic guidance. Reg Anesth Pain Med. 2014 Mar-Apr. 39(2):126-32. [Medline].

  7. Blunk JA, Nowotny M, Scharf J, Benrath J. MRI verification of ultrasound-guided infiltrations of local anesthetics into the piriformis muscle. Pain Med. 2013 Oct. 14(10):1593-9. [Medline].

  8. Ozisik PA, Toru M, Denk CC, Taskiran OO, Gundogmus B. CT-guided piriformis muscle injection for the treatment of piriformis syndrome. Turk Neurosurg. 2014. 24(4):471-7. [Medline].

  9. Misirlioglu TO, Akgun K, Palamar D, Erden MG, Erbilir T. Piriformis syndrome: comparison of the effectiveness of local anesthetic and corticosteroid injections: a double-blinded, randomized controlled study. Pain Physician. 2015 Mar-Apr. 18 (2):163-71. [Medline].

  10. Naja Z, Al-Tannir M, El-Rajab M, et al. The effectiveness of clonidine-bupivacaine repeated nerve stimulator-guided injection in piriformis syndrome. Clin J Pain. 2009 Mar-Apr. 25(3):199-205. [Medline].

  11. Filler AG. Piriformis and related entrapment syndromes: diagnosis & management. Neurosurg Clin N Am. 2008 Oct. 19(4):609-22, vii. [Medline].

  12. Greenman PE. Piriformis syndrome. Principles in Manual Medicine. 2nd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1996. 467-74.

  13. Jankiewicz JJ, Hennrikus WL, Houkom JA. The appearance of the piriformis muscle syndrome in computed tomography and magnetic resonance imaging. A case report and review of the literature. Clin Orthop Relat Res. 1991 Jan. 262:205-9. [Medline].

  14. Julsrud ME. Piriformis syndrome. J Am Podiatr Med Assoc. 1989 Mar. 79(3):128-31. [Medline].

  15. Medical Economics. Physicians' Desk Reference. Montvale, NJ: Thompson Medical Economics; 1999.

  16. Merlo IM, Poloni TE, Alfonsi E, Messina AL, Ceroni M. Sciatic pain in a young sportsman. Lancet. 1997 Mar 22. 349(9055):846. [Medline].

  17. Naja Z, Al-Tannir M, El-Rajab M, et al. The effectiveness of clonidine-bupivacaine repeated nerve stimulator-guided injection in piriformis syndrome. Clin J Pain. 2009 Mar-Apr. 25(3):199-205. [Medline].

  18. Ozaki S, Hamabe T, Muro T. Piriformis syndrome resulting from an anomalous relationship between the sciatic nerve and piriformis muscle. Orthopedics. 1999 Aug. 22(8):771-2. [Medline].

  19. Pace JB, Nagle D. Piriformis syndrome. West J Med. 1976. 24:435-9.

  20. Papadopoulos SM, McGillicuddy JE, Albers JW. Unusual cause of 'piriformis muscle syndrome'. Arch Neurol. 1990 Oct. 47(10):1144-6. [Medline].

  21. Parziale JR, Hudgins TH, Fishman LM. The piriformis syndrome. Am J Orthop. 1996 Dec. 25(12):819-23. [Medline].

  22. Pecina HI, Boric I, Smoljanovic T, Duvancic D, Pecina M. Surgical evaluation of magnetic resonance imaging findings in piriformis muscle syndrome. Skeletal Radiol. 2008 Nov. 37(11):1019-23. [Medline].

  23. Silver JK, Leadbetter WB. Piriformis syndrome: assessment of current practice and literature review. Orthopedics. 1998 Oct. 21(10):1133-5. [Medline].

  24. Steiner C, Staubs C, Ganon M, Buhlinger C. Piriformis syndrome: pathogenesis, diagnosis, and treatment. J Am Osteopath Assoc. 1987 Apr. 87(4):318-23. [Medline].

  25. Tibor LM, Sekiya JK. Differential diagnosis of pain around the hip joint. Arthroscopy. 2008 Dec. 24(12):1407-21. [Medline].

Previous
Next
 
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).
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.