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Piriformis Syndrome vs. Sciatica – What’s The Difference?

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Few things are more frustrating than wasting time on treatments that don’t work. 

Piriformis syndrome and sciatica can present with similar symptoms, however, their underlying causes are different and therefore respond to different treatments.  

Let’s dive into the differences and what you can do next to start feeling better. 

Disclaimer: This content is for educational purposes and is not medical advice. Read the full disclaimer.

What is piriformis syndrome?

Let’s take a quick step back to understand how the piriformis muscle can irritate the sciatic nerve. 

The sciatic nerve is the longest nerve in the body and originates from multiple nerve roots in the lumbar spine (lower back), forming the left and a right sciatic nerve. 

Anatomy varies but the sciatic nerve generally exits around the piriformis muscle (at the back of the hip) and runs down the back of the thigh, splitting off into smaller nerves behind the knee. These branches then continue to the foot.

illustration of piriformis syndrome
image source: depositphotos.com

The piriformis muscle runs from the sacrum to the back of the hip and helps to stabilize as well as externally rotate the hip. 

Piriformis syndrome occurs when the sciatic nerve becomes irritated or compressed by the piriformis muscle.

There is some controversy about whether or not piriformis syndrome actually exists on its own, or if it’s part of a larger picture. 

Depending on who you ask, piriformis syndrome is either common or uncommon and is estimated to be the culprit in around 5% of sciatica cases. 

Piriformis syndrome symptoms

Pain, numbness, or tingling can start in the back of the hip and radiate down the back of the leg. Lower back pain may also be present as the body attempts to compensate. 

You may feel tenderness over the piriformis muscle, especially if you’ve tried to use a foam roller

Typical piriformis syndrome symptoms can be felt with almost any motion requiring stabilization or movement of the hip, such as running, lunging, single leg balance, stair climbing, or even sitting due to compression. 

This area can also become irritated from sitting with crossed legs or items in the back pocket, such as a wallet. 

Causes of piriformis syndrome

  • Piriformis muscle spasm
  • Hip muscle weakness/imbalance
  • Sacroiliac joint dysfunction
  • Overtraining, especially on uneven surfaces
  • Work that places you in an awkward or asymmetrical position for extended amounts of time
  • Radiating pain from the lumbar spine/part of a more significant issue
  • Trauma/bruising
  • Previous hip injuries or surgeries
  • Anatomical variations

Piriformis syndrome vs. sciatica

People are quick to call almost any pain down the back of the leg “sciatica” without further teasing out the details. 

The confusing part is that piriformis syndrome can cause sciatica-like pain, however, not all sciatic symptoms are a result of piriformis syndrome.

The term sciatica is not a diagnosis but rather a description of a symptom (irritation of the sciatic nerve), and used by itself is rather vague. 

Many sciatica cases originate from the spine, such as with a disc bulge, causing inflammation of the lower spinal nerves (lumbar radiculopathy). This is sometimes referred to as a pinched nerve. 

cartoon image of the spine and sciatica
image source: depositphotos.com

Common sciatica symptoms

  • Moderate to severe pain in the lower back, back of the hip/buttock, and down the back of the leg
  • Sensation changes such as numbness, tingling, pins, and needles, or prickly sensations
  • Muscle weakness
  • Pain and symptoms can be anywhere along the distribution of the sciatic nerve

As you can see, the symptoms of both are very similar with both causing leg pain, numbness, or tingling. 

How can you tell them apart?

One of the significant differences found in an evaluation is how the pain is reproduced. 

For example, piriformis syndrome is more likely to be reproduced with various tests moving the hip joint. In contrast, a true sciatica (e.g. from a disc herniation) will likely be aggravated by spinal movements and nerve tension tests. 

It’s important to have an evaluation by a doctor and physical therapist.

Causes of sciatica

  • Lumbar herniated disc (slipped disc)
  • Impingement at the lumbar nerve root
  • Muscular spasm
  • SI joint issues
  • Piriformis syndrome
  • Sciatic nerve compression
  • Pregnancy
  • Spinal stenosis
  • Degenerative disc disease
  • Spondylolisthesis
  • Arthritis
  • Limited hip mobility 
  • Trauma
  • Malignancies or infections

Conditions such as vascular disease or peripheral neuropathy can mimic sciatic symptoms but are very different conditions. 

Hamstring strains can also be mistaken for sciatic nerve pain, but a proper evaluation will tell them apart.

It’s also possible for multiple conditions to coexist, making diagnosis and treatment a little more challenging. 

Don’t miss this article outlining plenty of tips on what to avoid when you have sciatica.

patient being evaluated at physical therapy
image source: depositphotos.com

Conservative treatment

Because the origins of these two conditions are different, treatment options for each will also look different. 

Pigeon pose or figure 4 stretch are common stretches that are blindly recommended for sciatic pain. Unfortunately, it’s not as simple as recommending one stretch and calling it a day. 

It’s essential to be evaluated by your doctor and physical therapist to start on a program specific to your needs. 

Conservative treatment may include:

  • A comprehensive evaluation with possible imaging (X-ray, MRI, or CT scans)
  • Specific strengthening and mobility/flexibility exercises (which will vary depending on the underlying causes)
  • Activity modification and avoiding aggravating factors while rehabbing
  • May include prescription or over the counter pain medication/anti-inflammatories

If you’ve never had physical therapy before learn what to know before you go here.

Wrapping up

Several issues can cause or mimic sciatica pain, so it’s crucial to get evaluated to determine what to do next. 

Don’t spend weeks trying to “stretch out” your piriformis with no improvement.

Tracking your symptoms and problem solving with your providers can help get you on the right treatment plan to start seeing results. 

REFERENCES

Davis D, Maini K, Vasudevan A. Sciatica. [Updated 2020 Nov 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507908/

Kean Chen C, Nizar AJ. Prevalence of piriformis syndrome in chronic low back pain patients. A clinical diagnosis with modified FAIR test. Pain Pract. 2013 Apr;13(4):276-81. doi: 10.1111/j.1533-2500.2012.00585.x. Epub 2012 Aug 2. PMID: 22863240.Hopayian K, Song F, Riera R, Sambandan S. The clinical features of the piriformis syndrome: a systematic review. Eur Spine J. 2010;19(12):2095-2109. doi:10.1007/s00586-010-1504-9

Thiyagarajan, Senthilkumar. (2017). Pseudo Sciatica-It’s the Condition we really Treat Better than Medicine. Journal of Novel Physiotherapies. Volume 7. 10.4172/2165-7025.1000327. 

Visser LH, Nijssen PG, Tijssen CC, van Middendorp JJ, Schieving J. Sciatica-like symptoms and the sacroiliac joint: clinical features and differential diagnosis. Eur Spine J. 2013;22(7):1657-1664. doi:10.1007/s00586-013-2660-5

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