Piriformis Syndrome: Overview and Evidence Summary

Condition Overview

Piriformis syndrome refers to irritation or compression of the sciatic nerve as it passes beneath, through, or occasionally above the piriformis muscle in the deep gluteal region. Although historically controversial, the condition is recognised today as part of the broader category of Deep Gluteal Syndrome—a term that reflects the complex interplay of muscular, neural, and biomechanical factors that can reproduce sciatic-like symptoms without lumbar spine involvement.

The piriformis muscle itself is a small but powerful external rotator of the hip. It sits deep in the buttock, originating from the anterior sacrum and attaching to the greater trochanter. When functioning well, it stabilises the hip during walking, running, and single-leg stance. But when overloaded, irritated, or placed under abnormal tension, the piriformis can clamp down on the sciatic nerve, creating buttock pain, radiating leg discomfort, tingling, or a feeling of “tightness” deep in the hip.

Piriformis syndrome can develop gradually due to repetitive hip rotation, prolonged sitting, altered gait mechanics, or gluteal weakness. It may also appear acutely following trauma, such as a fall onto the buttock, a sudden increase in running volume, or a twisting injury. Athletes—especially runners, dancers, and football players—are particularly susceptible due to high demands on hip rotation and stabilisation.

A major challenge is that piriformis syndrome mimics other causes of sciatic-type symptoms, particularly lumbar disc pathology, sacroiliac dysfunction, and hamstring injuries. As a result, diagnosis relies heavily on clinical reasoning, pattern recognition, and exclusion of lumbar causes. Accurate assessment is essential, as treatment differs significantly from radiculopathy originating in the spine.

Fortunately, piriformis syndrome responds extremely well to conservative care. Targeted stretching, strengthening of the hip abductors and external rotators, mobility work, nerve gliding, and manual therapy often restore full function. Understanding the condition also helps patients avoid recurrence by improving hip control, pelvic stability, and movement patterns.

Summary of Current Evidence for Piriformis Syndrome

Evidence-Based Management Discussion

Understanding the Deep Gluteal Interface

The sciatic nerve travels beneath the piriformis in approximately 85–90% of individuals. In the remaining population, anatomical variations place the nerve through or above the muscle, predisposing some individuals to compression when the piriformis becomes tight or hypertrophied. The deep gluteal space is densely packed with structures—piriformis, obturator internus, gemelli, gluteus medius and minimus, sacrotuberous ligament—and any change in tone, posture, or movement can influence sciatic nerve mobility.

Prolonged sitting is a common trigger. The sciatic nerve experiences compression between the ischial tuberosity and deep gluteal muscles when seated, especially on hard surfaces. If the piriformis is already irritable, symptoms flare more quickly.

Clinical Presentation

Patients frequently describe:

• Deep, localised buttock pain that may radiate along the posterior thigh

• Pain that worsens with sitting longer than 20–30 minutes

• Tenderness over the piriformis muscle or greater sciatic notch

• Discomfort during hip rotation, stepping uphill, or crossing the legs

• A feeling of tightness or “fullness” in the buttock

Sciatic-like symptoms such as tingling or numbness occur when the nerve is irritated. However, unlike lumbar radiculopathy, neurological deficits (reflex loss, major weakness) are rare.

A key distinguishing feature is that lumbar flexion typically does not reproduce symptoms strongly, whereas positions such as hip flexion + adduction + internal rotation (FAIR test) often do.

Rehabilitation Strategy: Addressing Muscle, Nerve, and Biomechanics

Early Phase: Reducing Compression and Irritation

The initial goal is to calm the irritated interface:

• Avoid prolonged sitting; use cushioning or take frequent breaks.

• Modify activities that aggravate symptoms, such as deep lunges or hill running.

• Introduce gentle piriformis stretching, performed without forcing end range.

Heat may help reduce muscle spasm in the early stages, while walking and light mobility maintain circulation and neural glide.

Middle Phase: Restoring Hip Mobility and Strength

This is where most progress occurs.

1. Piriformis stretching using several angles, since the muscle changes function depending on hip position.

2. Hip external rotator and abductor strengthening, especially gluteus medius and deep rotators, to offload piriformis.

3. Hip flexor and hamstring mobility to balance movement patterns around the pelvis.

4. Neural mobilisation, which helps restore sciatic nerve excursion and reduce irritability.

Patients often discover that their hips have been functioning with impaired symmetry—one side working far harder than the other. Correcting this imbalance reduces recurrence.

Late Phase: Dynamic Control and Return to Activity

As symptoms settle, rehabilitation emphasises:

• Gait training to ensure adequate hip extension and gluteal drive

• Strengthening through full ranges (squats, hinges, lateral movements)

• Reintroducing sport-specific drills: acceleration, cutting, kicking

At this stage, any residual fear of movement should be addressed, ensuring the patient feels confident loading the hip dynamically.

Manual Therapy: Enhancing Mobility and Reducing Tension

Manual therapy is often highly effective as an adjunct, including:

• Deep gluteal myofascial release targeting piriformis, obturator internus, and gluteus medius

• Sacroiliac joint mobilisation

• Hip joint mobilisation to improve rotation and extension

• Trigger point techniques where appropriate

While manual therapy reduces symptoms, the long-term solution is always strength, mobility, and load tolerance.

Medical and Surgical Considerations

NSAIDs may provide symptom relief in acute irritation.
Botulinum toxin injections into the piriformis have shown benefit for chronic cases where muscle spasm is significant.
Surgery is extremely rare and typically reserved for unambiguous nerve entrapment that has not responded to months of structured rehabilitation.

Long-Term Outcomes and Prevention

Outcomes are generally excellent when treatment is comprehensive.
Patients who continue hip-strengthening and maintain mobility see low recurrence rates.
Prevention focuses on:

• Avoiding prolonged sitting

• Maintaining hip external rotation and abduction strength

• Ensuring balanced running mechanics

• Keeping gluteal muscles strong and responsive

References

Filler, A. et al. “Sciatica of Non-Spinal Origin: Piriformis Syndrome and Related Disorders.” Neurosurgery Clinics of North America.

Boyajian-O’Neill, L. et al. “Diagnosis and Management of Piriformis Syndrome.” Journal of the American Osteopathic Association.

Martin, H., et al. “Deep Gluteal Syndrome: Clinical and MRI Correlation.” Hip & Pelvis Review.

Hopayian, K., et al. “Clinical Features and Management of Piriformis Syndrome.” BMC Musculoskeletal Disorders.

Fishman, L. et al. “Piriformis Syndrome versus Lumbar Radiculopathy.” Archives of Physical Medicine and Rehabilitation.

Disclaimer:
The information in this article is intended for educational purposes within the context of continuing education for massage therapists, continuing education for athletic trainers, continuing education for physical therapists, continuing education for chiropractors, and continuing education for rehabilitation professionals. It is not a substitute for medical advice, diagnosis, or treatment. Although every effort has been made to ensure accuracy and reflect current understanding at the time of publication, practitioners must always work within the legal scope of their professional practice and follow all regional regulatory guidelines.

Hands-on techniques and clinical applications described in this material should only be performed by appropriately trained and licensed professionals. Individuals experiencing pain or symptoms should be referred to a qualified healthcare provider for assessment. Niel Asher Education is not responsible for any injury, loss, or damage resulting from the use or misuse of the information provided in this content.