Diagnosis and Management of Piriformis Syndrome: An Osteopathic Approach

Abstract

Piriformis syndrome is a neuromuscular condition characterized by hip and buttock pain. This syndrome is often overlooked in clinical settings because its presentation may be similar to that of lumbar radiculopathy, primary sacral dysfunction, or innominate dysfunction. The ability to recognize piriformis syndrome requires an understanding of the structure and function of the piriformis muscle and its relationship to the sciatic nerve. The authors review the anatomic and clinical features of this condition, summarizing the osteopathic medical approach to diagnosis and management. A holistic approach to diagnosis requires a thorough neurologic history and physical assessment of the patient based on the pathologic characteristics of piriformis syndrome. The authors note that several nonpharmacologic therapies, including osteopathic manipulative treatment, can be used alone or in conjunction with pharmacotherapeutic options in the management of piriformis syndrome.

Full text

JAOA • Vol 108 • No 11 • November 2008 • 657
Boyajian-O’Neill
• Review Article
Piriformis syndrome is a neuromuscular condition charac-
terized by hip and buttock pain. This syndrome is often
overlooked in clinical settings because its presentation may
be similar to that of lumbar radiculopathy, primary sacral
dysfunction, or innominate dysfunction. The ability to rec-
ognize piriformis syndrome requires an understanding of the
structure and function of the piriformis muscle and its rela-
tionship to the sciatic nerve. The authors review the anatomic
and clinical features of this condition, summarizing the
osteopathic medical approach to diagnosis and manage-
ment. A holistic approach to diagnosis requires a thorough
neurologic history and physical assessment of the patient
based on the pathologic characteristics of piriformis syn-
drome. The authors note that several nonpharmacologic
therapies, including osteopathic manipulative treatment,
can be used alone or in conjunction with pharmacothera-
peutic options in the management of piriformis syndrome.
J Am Osteopath Assoc. 2008;108:657-664
P
iriformis syndrome is a peripheral neuritis of the sciatic
nerve caused by an abnormal condition of the piriformis
muscle.1It frequently goes unrecognized or is misdiagnosed
in clinical settings. Piriformis syndrome can “masquerade”
as other common somatic dysfunctions, such as intervertebral
discitis, lumbar radiculopathy, primary sacral dysfunction,
sacroiliitis, sciatica, and trochanteric bursitis.
More than 16% of all adult work disability evaluations and
examinations are performed to rate the patient’s partial or
total disability associated with chronic low back pain.2It is
estimated that at least 6% of patients who are diagnosed as
having low back pain actually have piriformis syndrome.3-5
Delay in diagnosing piriformis syndrome may lead to
pathologic conditions of the sciatic nerve, chronic somatic dys-
function, and compensatory changes resulting in pain, pares-
thesia, hyperesthesia, and muscle weakness.6The challenge for
physicians is to recognize symptoms and signs that are unique
to piriformis syndrome, enabling appropriate treatment in a
timely manner.
The purpose of the present article is to review the patho-
logic features of piriformis syndrome and the diagnostic cri-
teria and treatments available for patients with this condition.
Emphasis is placed on the application of osteopathic principles
and practice in diagnosis and treatment.
Methods
A literature search was conducted using the MEDLINE,
OSTMED, Ovid, PubMed, and SPORTDiscus databases. The
searches were conducted without limitation on article publi-
cation dates. Multiple key terms applicable to piriformis syn-
drome were used in the searches, including the following:
manipulative treatment, obturator internus muscle, osteopathic
diagnosis, piriformis, piriformis anatomy, piriformis muscle, piri-
formis syndrome, sciatica, sciatic nerve, sciatic pain, and somatic dys-
function.
Epidemiologic Considerations
Piriformis syndrome occurs most frequently during the fourth
and fifth decades of life and affects individuals of all occupa-
tions and activity levels.7-12 Reported incidence rates for piri-
formis syndrome among patients with low back pain vary
widely, from 5% to 36%.3,4,11 Piriformis syndrome is more
common in women than men, possibly because of biome-
chanics associated with the wider quadriceps femoris muscle
angle (ie, “Q angle”) in the os coxae (pelvis) of women.3
Difficulties arise in accurately determining the true preva-
lence of piriformis syndrome because it is frequently confused
with other conditions.
Anatomic Characteristics
The piriformis muscle acts as an external rotator, weak
abductor, and weak flexor of the hip, providing postural sta-
bility during ambulation and standing.4,9,13 The piriformis
muscle originates at the anterior surface of the sacrum, usually
at the levels of vertebrae S2 through S4, at or near the sacroiliac
joint capsule. The muscle attaches to the superior medial aspect
of the greater trochanter via a round tendon that, in many
individuals, is merged with the tendons of the obturator
internus and gemelli muscles (Figure 1).1,13,14 The piriformis
Diagnosis and Management of Piriformis Syndrome: An Osteopathic Approach
Lori A. Boyajian-O’Neill, DO; Rance L. McClain, DO; Michele K. Coleman, DO; and Pamela P. Thomas, PhD
From the Departments of Family Medicine (Drs Boyajian-O’Neill and McClain)
and Anatomy (Dr Thomas) at Kansas City (Mo) University of Medicine and Bio-
sciences College of Osteopathic Medicine, and St John’s Episcopal Hospital in
Far Rockaway, NY (Dr Coleman).
Address correspondence to Rance L. McClain, DO, Assistant Professor,
Department of Family Medicine, Kansas City University of Medicine and Bio-
sciences College of Osteopathic Medicine, 1750 Independence Ave, SEP 358,
Kansas City, MO 64106-1453.
E-mail: rmcclain@kcumb.edu
Submitted December 12, 2006; revision received May 2, 2007; accepted July
23, 2007.
REVIEW ARTICLE

658 • JAOA • Vol 108 • No 11 • November 2008
muscle is innervated by spinal nerves S1 and S2—and occa-
sionally also by L5.
The proper understanding of piriformis syndrome
requires knowledge of variations in the relationships between
the sciatic nerve and the piriformis muscle (Figure 2). In as
much as 96% of the population, the sciatic nerve exits the
greater sciatic foramen deep along the inferior surface of the
piriformis muscle.15-17 In as much as 22% of the population, the
sciatic nerve pierces the piriformis muscle, splits the piriformis
muscle, or both, predisposing these individuals to piriformis
syndrome. The sciatic nerve may pass completely through
the muscle belly, or the nerve may split—with one branch
(usually the fibular portion) piercing the muscle and the other
branch (usually the tibial portion) running inferiorly or supe-
riorly along the muscle.7,13-16,18,19 Rarely, the sciatic nerve exits
the greater sciatic foramen along the superior surface of the pir-
iformis muscle.15-17
Some symptoms of piriformis syndrome occur as a result
of local inflammation and congestion caused by the muscular
compression of small nerves and vessels—including the
pudendal nerve and blood vessels, which exit at the medial
inferior border of the piriformis muscle.13
Etiologic Considerations
There are two types of piriformis syndrome—primary and
secondary. Primary piriformis syndrome has an anatomic
cause, such as a split piriformis muscle, split sciatic nerve, or
an anomalous sciatic nerve path.8,9,20 Secondary piriformis
Boyajian-O’Neill
• Review Article
REVIEW ARTICLE
Figure 1. Anatomic features of the hip, including the most common
orientation of the sciatic nerve, running inferior to the piriformis
muscle.
Figure 2. Variations in the relationship of the sciatic nerve to the piriformis muscle: (A) the sciatic nerve exiting the greater sciatic foramen along
the inferior surface of the piriformis muscle; the sciatic nerve splitting as it passes through the piriformis muscle with the tibial branch passing
(B) inferiorly or (C) superiorly; (D) the entire sciatic nerve passing through the muscle belly; (E) the sciatic nerve exiting the greater sciatic foramen
along the superior surface of the piriformis muscle.
Sacrum
Os Coxae
Gluteus Minimus
Piriformis Muscle
Gemelli
Sciatic Nerve
Femur
Obturator Internus
Quadriceps Femoris
Os Coxae
AB
CDE
Piriformis Muscle
Sciatic Nerve
Greater Sciatic
Foramen
Greater Trochanter

JAOA • Vol 108 • No 11 • November 2008 • 659
of the ipsilateral leg, such as occurs during cross-legged sitting
or ambulation.1,6,8,9,11,21,23
Spasm of the piriformis muscle and sacral dysfunction
(eg, torsion) cause stress on the sacrotuberous ligament. This
stress may lead to compression of the pudendal nerves or
increased mechanical stress on the innominate bones, poten-
tially causing groin and pelvic pain.6,9,22 Compression of the
fibular branch of the sciatic nerve often causes pain or pares-
thesia in the posterior thigh.1,6,8,9,11,21,23
Through compensatory or facilitative mechanisms, piri-
formis syndrome may contribute to cervical, thoracic, and
lumbosacral pain, as well as to gastrointestinal disorders and
headache.9,22
Clinical signs of piriformis syndrome are shown below in
Figure 4. These clinical signs relate, either directly or indirectly,
to muscle spasm, resulting nerve compression, or both. Ten-
derness with palpation over the piriformis muscle, especially
over the muscle’s attachment at the greater trochanter, is
common. Patients may also experience tenderness with pal-
pation in the region of the sacroiliac joint, greater sciatic notch,
and piriformis muscle—including pain that may radiate to
the knee.1,6,8,9,11,21,23
Some patients have a palpable “sausage-shaped” mass in
the buttock caused by contraction of the piriformis muscle.6,9,24
syndrome occurs as a result of a precipitating cause, including
macrotrauma, microtrauma, ischemic mass effect, and local
ischemia.1,6,11,21,22 Among patients with piriformis syndrome,
fewer than 15% of cases have primary causes.4,11
Piriformis syndrome is most often caused by macro-
trauma to the buttocks, leading to inflammation of soft tissue,
muscle spasm, or both, with resulting nerve compres-
sion.1,8,9,11,21 Microtrauma may result from overuse of the pir-
iformis muscle, such as in long-distance walking or running or
by direct compression. An example of this kind of direct com-
pression is “wallet neuritis” (ie, repetitive trauma from sit-
ting on hard surfaces).
Clinical Diagnosis
Symptoms of piriformis syndrome are shown below in Figure 3.
The most common presenting symptom of patients with pir-
iformis syndrome is increasing pain after sitting for longer
than 15 to 20 minutes. Many patients complain of pain over the
piriformis muscle (ie, in the buttocks), especially over the
muscle’s attachments at the sacrum and medial greater
trochanter. Symptoms, which may be of sudden or gradual
onset, are usually associated with spasm of the piriformis
muscle or compression of the sciatic nerve. Patients may com-
plain of difficulty walking and of pain with internal rotation
Boyajian-O’Neill
• Review Article
REVIEW ARTICLE
Figure 3. Clinical symptoms of piriformis syndrome. Figure 4. Clinical signs of piriformis syndrome.
Symptoms
▫Pain with sitting, standing, or lying longer than 15 to
20 minutes
▫Pain and/or paresthesia radiating from sacrum
through gluteal area and down posterior aspect of
thigh, usually stopping above knee
▫Pain improves with ambulation and worsens with no
movement
▫Pain when rising from seated or squatting position
▫Change of position does not relieve pain completely
▫Contralateral sacroiliac pain
▫Difficulty walking (eg, antalgic gait, foot drop)
▫Numbness in foot
▫Weakness in ipsilateral lower extremity
▫Headache
▫Neck pain
▫Abdominal, pelvic, and inguinal pain
▫Dyspareunia in women
▫Pain with bowel movements
Signs
▫Tenderness in region of sacroiliac joint, greater sciatic
notch, and piriformis muscle
▫Tenderness over piriformis muscle
▫Palpable mass in ipsilateral buttock
▫Traction of affected limb provides moderate relief
of pain
▫Asymmetrical weakness in affected limb
▫Piriformis sign positive
▫Lasègue sign positive
▫Freiberg sign positive
▫Pace sign (flexion, adduction, and internal rotation
test result) positive
▫Beatty test result positive
▫Limited medial rotation of ipsilateral lower extremity
▫Ipsilateral short leg
▫Gluteal atrophy (chronic cases only)
▫Persistent sacral rotation toward contralateral side
with compensatory lumbar rotation

660 • JAOA • Vol 108 • No 11 • November 2008
A contracted piriformis muscle also causes ipsilateral external
hip rotation. When a patient with piriformis syndrome is
relaxed in the supine position, the ipsilateral foot is externally
rotated (Figure 5)—a feature referred to as a positive piriformis
sign.6,9,11,21 Active efforts to bring the foot to midline result in
pain.1,9,24 Many patients with piriformis syndrome also have
positive Lasègue, Freiberg, or Pace signs (observed in tests
described in the next section of the present article), and these
patients may exhibit an antalgic gait.25
Sacral plexus nerves that innervate the tensor fascia lata,
gluteus minimus, gluteus maximus, adductor magnus,
quadratus femoris, and obturator externus muscles are also
subject to irritation by the piriformis muscle. Ipsilateral muscle
weakness may occur if piriformis syndrome is caused by an
anatomic anomaly or if it is chronic in duration.1,4,6,8,9,11,13,17,21,22
Range-of-motion evaluation may reveal decreased internal
rotation of the ipsilateral hip in such cases.1
In most cases of piriformis syndrome, the sacrum is ante-
riorly rotated toward the ipsilateral side on a contralateral
oblique axis, resulting in compensatory rotation of the lower
lumbar vertebrae in the opposite direction (Figure 6).6,21 For
example, piriformis syndrome on the right side would cause
a left-on-left forward sacral torsion with L5 rotated right. Sacral
rotation often creates ipsilateral physiologic short leg.6,9,21,26
Facilitation and compensatory somatic dysfunctions may lead
to cervical, thoracic, and low back pain.6,9,21,26 TePoorten9
reported decreased range of motion at vertebrae T10 and T11,
tissue texture changes at T3 and T4, pain and decreased range
of motion of the contralateral C2, and ipsilateral occiput-atlas
lesion in patients with piriformis syndrome.
Diagnostic Tests
Several clinical tests can be used to aid in the diagnosis of pir-
iformis syndrome. These tests are useful for clarifying clin-
ical situations, though there is no single test specific to piriformis
syndrome.
As previously mentioned, tests for Lasègue, Freiberg, and
Pace signs are used in cases of piriformis syndrome. Lasègue
sign is localized pain when pressure is applied over the piri-
formis muscle and its tendon, especially when the hip is flexed
at an angle of 90 degrees and the knee is extended.25 Freiberg
sign is pain experienced during passive internal rotation of the
hip.25
Pace sign, revealed with the FAIR (flexion, adduction,
and internal rotation) test (Figure 7), involves the recreation of
sciatic symptoms.25 The FAIR test is performed with the patient
in a lateral recumbent position, with the affected side up, the
hip flexed to an angle of 60 degrees, and the knee flexed to an
angle of 60 degrees to 90 degrees. While stabilizing the hip, the
examiner internally rotates and adducts the hip by applying
downward pressure to the knee. Fishman et al27 found the
FAIR test to have sensitivity and specificity of 0.881 and 0.832,
respectively. Alternatively, the FAIR test can be performed
with the patient supine or seated, knee and hip flexed, and hip
medially rotated, while the patient resists examiner attempts
to externally rotate and abduct the hip. The FAIR test result is
positive if sciatic symptoms are recreated.3,11,17,25,27,28
The Beatty test is another diagnostic test for piriformis
syndrome.12 In this test, the patient lies on the unaffected side,
lifting and holding the superior knee approximately 4 inches
off the examination table. If sciatic symptoms are recreated, the
test result is positive.
Neurophysiologic testing can also be used in the diag-
nosis of piriformis syndrome. Electromyography (EMG) may
be beneficial in differentiating piriformis syndrome from inter-
vertebral disc herniation.1,3,8,29 Interspinal nerve impingement
will cause EMG abnormalities of muscles proximal to the pir-
Boyajian-O’Neill
• Review Article
REVIEW ARTICLE
Figure 5. Ipsilateral external rotation of the lower extremity in a
patient who is relaxed in the supine position, a positive piriformis sign.
(Photograph by Michael D. Roach.)
Sacrum
Piriformis
Muscle
Axis
Figure 6. The attachment of the piriformis muscle to the anterior
surface of the sacrum, fixing the sacrum’s oblique axis on the con-
tralateral side and causing the sacrum to rotate to the ipsilateral
side.

JAOA • Vol 108 • No 11 • November 2008 • 661
source of the sciatic neuritis observed in patients with pos-
sible piriformis syndrome. In a study35 of 6 patients who
underwent surgery for suspected piriformis syndrome, all
were observed intraoperatively to have increased obturator
internus muscle tension, hyperemia, and hypertrophy. Fur-
thermore, the obturator internus muscle was observed
impinging on the sciatic nerve during an intraoperative
Lasègue maneuver.35 Anatomically, the obturator internus is
deep to both the piriformis muscle and the sciatic nerve, and
it parallels the piriformis in its attachments.13 Because of this
proximity, similar pathway, and similar function, most treat-
ments for patients with piriformis syndrome would affect the
internal obturator muscle as well.
Treatment
Throughout the physical evaluation of patients, clinicians
should maintain a high index of suspicion for piriformis syn-
drome. Early conservative treatment is the most effective treat-
ment, as noted by Fishman et al,27 who reported that more than
79% of patients with piriformis syndrome had symptom reduc-
tion with use of nonsteroidal anti-inflammatory drugs
(NSAIDs), muscle relaxants, ice, and rest.
Stretching of the piriformis muscle and strengthening of
iformis muscle. In patients with piriformis syndrome, EMG
results will be normal for muscles proximal to the piriformis
muscle and abnormal for muscles distal to it. Electromyog-
raphy examinations that incorporate active maneuvers, such
as the FAIR test, may have greater specificity and sensitivity
than other available tests for the diagnosis of piriformis syn-
drome.30
Radiographic studies have limited application to the diag-
nosis of piriformis syndrome. Although magnetic resonance
imaging and computed tomography may reveal enlargement
of the piriformis muscle, these imaging technologies are most
useful in this setting when ruling out disc and vertebral patho-
logic conditions.8,17,31-33
Differential Diagnosis
Piriformis syndrome may mimic other conditions. Alterna-
tively, it may be a comorbid condition or considered in a dif-
ferential diagnosis. A complete neurologic history and phys-
ical assessment of the patient is essential for accurate diagnosis.
This history and physical assessment should encompass any
trauma to the buttocks and the presence of any bowel and
bladder changes.3,9 The physical assessment should also include
the following:
▫an osteopathic structural examination with special attention
to the lumbar spine, pelvis, and sacrum, as well as any leg
length disparities9,21,26
▫the diagnostic tests previously mentioned12,25,27
▫deep-tendon reflex testing and strength and sensory
testing1,3,8,29
A combination of the medical history and physical assess-
ment as well as neurologic and radiologic testing can be used
to rule out lumbosacral radiculopathies, degenerative disc
disease, compression fractures, and spinal stenosis. Radicu-
lopathies are usually accompanied by both proximal and distal
muscle weakness and atrophy. By contrast, patients with pir-
iformis syndrome typically exhibit weakness and atrophy
only in distal musculature.27,28 Sacroiliitis, other sacroiliac joint
dysfunction, and somatic dysfunction of the sacrum and
innominates should be considered as possible causes or effects
of piriformis syndrome and can be determined with a thorough
osteopathic structural examination and radiographic
testing.1,4,8,9,17,21,22
Leg length discrepancy warrants an investigation to dis-
tinguish between physiologic or anatomic causes.9,21,26 Dis-
eases of the hip, including arthritis and bursitis, as well as
fracture, should be considered in differential diagnoses. Com-
puted tomography, magnetic resonance imaging, and ultra-
sound technologies can be used to rule out referred pain from
gastrointestinal or pelvic causes, such as colon cancer,
endometriosis, and interstitial cystitis.4,6,11,25,34
The obturator internus muscle, which also acts as an
external hip rotator, has been suggested as a contributing
Boyajian-O’Neill
• Review Article
REVIEW ARTICLE
Figure 7. Coinvestigator Rance L. McClain, DO, demonstrates the
FAIR (flexion, adduction, and internal rotation) test. The FAIR test is
performed with the patient in a lateral recumbent position, with
the affected side up, the hip flexed to an angle of 60 degrees, and
the knee flexed to an angle of 60 degrees to 90 degrees. While sta-
bilizing the hip, the examiner internally rotates and adducts the hip
by applying downward pressure to the knee. (Photograph by Michael
D. Roach.)

662 • JAOA • Vol 108 • No 11 • November 2008
the abductor and adductor muscles should also be included in
patient treatment plans.34 A manual medicine approach may
combine muscle stretches, Gebauer’s spray and stretch tech-
nique, and soft tissue, myofascial, muscle energy, and thrust
techniques to address all somatic dysfunctions in the patient
with piriformis syndrome.1,4,6,9 If the patient does not respond
adequately to manual treatment, then acupuncture and trigger
point injection with lidocaine hydrochloride, steroids, or
botulinum toxin type A (BTX-A) may be considered.4,17,25,36
If all of the pharmacologic and manual medicine treat-
ments fail, the final treatment option is surgical decompres-
sion.4,8,9,16
Pharmacologic Treatment
Nonsteroidal anti-inflammatory drugs and acetaminophen
have been considered the medications of choice in the man-
agement of the many conditions that manifest as low back
pain, including piriformis syndrome.37 Patients using NSAIDs,
compared with those using placebo, reported global reduction
of symptoms after 1 week of treatment.38
Muscle relaxants are another frequently prescribed med-
ication for patients with piriformis syndrome. Patients using
muscle relaxants are nearly five times as likely to report
symptom improvement by day 14, compared with patients
given placebo.39 Common adverse effects of muscle relaxants
are dryness of mouth, drowsiness, and dizziness.
Few studies have examined the role of narcotic analgesics
in managing acute vs chronic musculoskeletal pain. How-
ever, it is clear that some patients with chronic pain do benefit
from these medications.40,41 Narcotics can be helpful in con-
trolling episodes of severe or debilitating pain, but they should
be considered a short-term treatment only. Constipation, gas-
trointestinal upset, and sedation are common adverse effects
of narcotic medications. In addition, the potential for addiction
should always be considered when initiating treatment with
medications from this drug class.
Local steroid injections can produce an anti-inflamma-
tory effect. Although evidence for the efficacy of steroids in
cases of chronic musculoskeletal pain is inconclusive, steroid
injections have proven helpful in the treatment of carefully
selected patients.42 Infection is the most common complication
of this invasive treatment.
Other potential treatments for patients with piriformis
syndrome include prolotherapy (ie, sclerotherapy, ligament
reconstructive therapy). This kind of treatment involves injec-
tion of an irritating solution at the origin or insertion of liga-
ments or tendons to strengthen the weakened or damaged
connective tissue.43 There is little published research regarding
the efficacy of this treatment option. Infection is the most
common complication of prolotherapy.
Osteopathic Manipulative Treatment
The goals of osteopathic manipulative treatment (OMT) for
patients who have piriformis syndrome are to restore normal
range of motion and decrease pain. These goals can be achieved
by decreasing piriformis spasm. Indirect osteopathic manip-
ulative techniques have been used to treat patients with piri-
formis syndrome. The two indirect OMT techniques most
commonly reported for the management of piriformis syn-
drome are counterstrain and facilitated positional release.1,26
Both techniques involve the principle of removing as much ten-
sion from the piriformis muscle as possible.
Three tender point locations can be addressed with coun-
terstrain—at the midpole sacrum, piriformis muscle, and pos-
teromedial trochanter.1To position a patient for counterstrain
treatment, the patient is generally asked to lie in a prone posi-
tion with the affected side of the body at the edge of the exam-
ination table. In performing the counterstrain technique, the
osteopathic physician brings the patient’s affected leg over
the side of the table, placing it into flexion at the hip and knee,
with abduction and external rotation at the hip (Figure 8).
Facilitated positional release can also be achieved from the
position shown in Figure 8, with compression through the
long axis of the femur from the knee toward the sciatic notch.
This additional compressive force can reduce patient treat-
ment time from 90 seconds when performing counterstrain to
3 to 5 seconds when performing facilitated positional release.1
Direct OMT techniques can be performed using either
active or passive methods. The direct OMT techniques that are
the most useful in treating patients with piriformis syndrome
include muscle energy, articulatory, Still, and high velocity/low
amplitude.1The muscle energy technique can be applied in the
management of piriformis spasm, as well as for associated
dysfunctions of the sacrum and pelvis. No absolute con-
traindications are defined for the muscle energy technique.
The patient must understand the required amount of mus-
cular force and the correct direction of this force for the tech-
nique to be effective.1
Articulatory OMT techniques are applied by advancing
and retreating from a restrictive barrier in a repetitive manner
to advance that barrier and increase the range of motion. The
presence of osteoarthritis can limit the applicability of this
technique secondary to articulatory pain.44 The Still technique,
a specialized form of articulatory treatment, is begun by placing
a joint in a relaxed position away from restrictive barriers.
Then, with an arching motion, compression is applied to the
level of dysfunction and moved toward the restrictive barrier
while the patient is passive and relaxed. No absolute con-
traindications are defined for the Still technique.45
High velocity/low amplitude technique is most often
used in cases of piriformis syndrome to correct associated
sacral and pelvic somatic dysfunctions. Extreme caution should
be exercised when using this manual technique with individ-
uals who have osteoporosis.1
Physical Therapy
Patients with piriformis syndrome may be treated with phys-
ical therapy involving a variety of motion exercises and
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JAOA • Vol 108 • No 11 • November 2008 • 663
to transport solubilized medication across the skin, and
sonophoresis, the use of ultrasonic energy to drive the cuta-
neous transport of medication molecules, have both been
advocated as adjuncts to physical therapy though neither has
been studied extensively in the treatment of patients with pir-
iformis syndrome.48
Surgery and Prevention
As a last resort, surgery has been occasionally used in cases that
have failed to resolve with the use of other treatment mea-
sures. The goal of surgery in these cases is to reduce any ten-
sion under which the piriformis muscle may be placed, as
well as to explore the sciatic notch to ensure that there are no
fibrous bands or constrictions compressing the sciatic nerve.8,11
Prevention of repetitive trauma (ie, microtrauma) may
prove effective in decreasing a patient’s risk of piriformis syn-
drome. Correcting biomechanical deficiencies and functional
adaptations to those deficiencies can reduce the incidence of
piriformis syndrome.5,47
Conclusion
There are many gaps in knowledge regarding piriformis syn-
drome. An increase in the breadth and depth of our under-
standing of this condition is necessary for optimal patient care.
Additional research is needed for patients with piriformis syn-
drome, primarily concerning epidemiologic factors, risk factors,
and optimal treatment. The length of time from symptom
onset to initial presentation is not known and needs to be
studied further. The proportion of patients presenting with
low back pain who demonstrate symptoms and signs consis-
tent with piriformis syndrome is also unknown and merits
further consideration.
Piriformis syndrome is a complex condition that is often
not considered in the differential diagnosis of chronic hip and
low back pain. To aid diagnosis, several tests have been devel-
oped to recreate the pain by actively contracting or passively
stretching the piriformis muscle and compressing the sciatic
nerve. Radiographic studies and neuroelectric tests are pri-
marily used to narrow the differential diagnosis toward piri-
formis syndrome by ruling out other pathologic conditions.
A holistic approach to diagnosis involves a thorough neu-
rologic history and physical assessment of the patient, inclu-
sive of the osteopathic structural examination, based on the
pathologic characteristics of piriformis syndrome. Osteopathic
manipulative treatment can be used as one of several possible
nonpharmacologic therapies for these patients. Nonpharma-
cologic therapies can be used alone or in conjunction with
pharmacologic treatments in the management of piriformis
syndrome in an attempt to avoid surgical intervention.
Acknowledgments
We thank Angela K. Imes; Nancy Stroud; Mary Clark; Lindsey E.
Malloy, DO; Tyler Feikema; and Kevin D. Treffer, DO, for their
assistance with this article in manuscript form.
stretching techniques. It is important for the physician to
clearly demonstrate the stretches that the patient is expected
to perform. It is also advisable to have the patient perform
these exercises for the first time in the office, where the physi-
cian can observe and modify the patient’s techniques, as
needed. If the patient demonstrates excessive difficulty in
understanding or performing the exercises, the physician can
refer the patient to a licensed physical therapist for assistance.
If a patient is able to perform the required exercises at
home, he or she should be advised to do so in multiple short
sessions each day, with each session lasting only a few minutes.
Physical therapy in a professional setting is commonly per-
formed in two or three sessions per week for the duration of
the treatment regimen, with each session lasting somewhat
longer than it would take the patient to perform the same
actions independently during a home exercise session.46
The ultimate goal of physical therapy is symptom elimi-
nation through a systematic program designed to increase the
range of motion of the surrounding muscle groups and joints,
as well as to increase the supporting strength of these muscle
groups. In particular, the strengthening of the adductor mus-
cles of the hip has been shown to be beneficial for patients
with piriformis syndrome.17
Several studies5,22,46,47 have reported that additional ben-
efit can be derived from physical therapy modalities, such as
heat therapy, cold therapy, BTX-A injection, and ultrasound.
Heat or cold therapy is usually most effectively applied before
the physical therapy or home therapy sessions because it may
lessen the discomfort associated with direct treatment applied
to an irritated or tense piriformis muscle.22,46,47 Injections of
BTX-A, when used as an adjunct to physical therapy, have
been shown to produce more pain relief than lidocaine with
steroids or placebo.48 Iontophoresis, the use of electrical current
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Figure 8. Coinvestigator Rance L. McClain, DO, demonstrates appli-
cation of the counterstrain technique of osteopathic manipulative
treatment as used to treat the piriformis counterstrain point. (Pho-
tograph by Michael D. Roach.)
(continued)

664 • JAOA • Vol 108 • No 11 • November 2008
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