Piriformis Syndrome vs Sciatica: Key Differences

Buttock pain radiating down the leg can be debilitating and confusing to diagnose. While many people assume their symptoms are "sciatica," the underlying cause matters significantly for effective treatment. Piriformis syndrome and true sciatica from spinal causes can present similarly but require different approaches. At M.O. Therapy in Markham, we help patients accurately identify the source of their symptoms and receive appropriate treatment.

Understanding the Anatomy

The Sciatic Nerve

The sciatic nerve is the largest nerve in the body, formed by nerve roots from L4-S3 in the lower spine. It travels:

• Through the pelvis
• Under (or sometimes through) the piriformis muscle
• Down the back of the thigh
• Branches into tibial and peroneal nerves below the knee

The Piriformis Muscle

The piriformis is a deep buttock muscle that:

• Originates from the sacrum (base of spine)
• Attaches to the greater trochanter (hip bone)
• Externally rotates and abducts the hip
• Sits directly over (or around) the sciatic nerve

What Is True Sciatica?

True sciatica refers to symptoms caused by compression or irritation of the sciatic nerve roots in the spine.

Common Causes of Spinal Sciatica

Lumbar Disc Herniation:

• Most common cause
• Disc material presses on nerve root
• Usually L4-L5 or L5-S1 level
• Often affects one side

Lumbar Stenosis:

• Narrowing of spinal canal
• More common in older adults
• May affect multiple levels
• Symptoms often bilateral

Spondylolisthesis:

• Vertebra slips forward
• Narrows nerve space
• Can compress nerve roots
• May be degenerative or congenital

Degenerative Disc Disease:

• Disc height loss
• Facet joint changes
• Can compress nerves
• Progressive over time

Symptoms of Spinal Sciatica

• Low back pain (usually present)
• Leg pain following dermatomal pattern
• Symptoms often worse with sitting
• Pain may increase with coughing, sneezing
• Numbness in specific distribution
• Weakness in specific muscle groups
• Reflexes may be affected

What Is Piriformis Syndrome?

Piriformis syndrome occurs when the piriformis muscle irritates or compresses the sciatic nerve as it passes through the buttock.

Causes of Piriformis Syndrome

Muscle Dysfunction:

• Piriformis tightness or spasm
• Muscle overuse
• Trauma or injury
• Inflammation

Anatomical Variations:

• Sciatic nerve passing through piriformis (10-20% of population)
• Bifurcated piriformis muscle
• Anomalous nerve course

Contributing Factors:

• Prolonged sitting
• Wallet in back pocket
• Running and climbing activities
• Hip muscle imbalances
• Sacroiliac joint dysfunction

Symptoms of Piriformis Syndrome

• Deep buttock pain (primary symptom)
• Pain radiating down back of leg
• Symptoms often worse with sitting
• Pain with activities that stretch or contract piriformis
• Tenderness over piriformis muscle
• Pain with hip rotation
• Usually no true back pain

Key Differences

Location of Primary Pain

Spinal Sciatica:

• Usually starts in lower back
• Radiates through buttock to leg
• May reach foot

Piriformis Syndrome:

• Starts in deep buttock
• May radiate down leg
• Rarely affects back

Symptom Patterns

Spinal Sciatica:

• Follows specific nerve root distribution
• Coughing/sneezing increases symptoms
• Sitting typically aggravates
• May have neurological signs (weakness, numbness, reflex changes)

Piriformis Syndrome:

• Less specific pattern
• Coughing/sneezing usually doesn't affect
• Sitting on hard surfaces aggravates
• Neurological exam usually normal

Physical Examination Findings

Spinal Sciatica:

• Positive straight leg raise test
• May have limited back motion
• Neurological deficits possible
• Tenderness over spine

Piriformis Syndrome:

• Tenderness over piriformis muscle
• Pain with hip rotation tests
• FAIR test positive (Flexion, Adduction, Internal Rotation)
• Pace test positive (resisted abduction)
• Usually no spinal findings

Imaging

Spinal Sciatica:

• MRI often shows disc herniation or stenosis
• X-rays may show degenerative changes
• Findings correlate with symptoms

Piriformis Syndrome:

• MRI of spine usually normal
• MRI may show piriformis abnormality
• Often a diagnosis of exclusion

Diagnostic Process

Clinical History

Questions that help differentiate:

• Where did symptoms start?
• What makes symptoms better or worse?
• Any back pain?
• Activities that aggravate?
• Sitting on wallet?
• History of trauma?

Physical Examination

Tests for Spinal Cause:

• Straight leg raise test
• Slump test
• Neurological examination
• Spinal range of motion

Tests for Piriformis Syndrome:

• FAIR test (most sensitive)
• Pace test
• Beatty test
• Piriformis palpation
• Hip rotation assessment

Imaging Studies

When to Image:

• Progressive neurological symptoms
• Red flag signs
• Failure to improve with treatment
• Diagnostic uncertainty

What to Order:

• MRI of lumbar spine for suspected spinal cause
• MRI of pelvis may show piriformis abnormality
• X-rays less helpful but may rule out other conditions

Treatment Approaches

Treatment for Spinal Sciatica

Physiotherapy:

• McKenzie method for directional preference
• Core stabilization exercises
• Nerve mobilization techniques
• Manual therapy as indicated
• Education on activity modification

Other Treatments:

• Medications (NSAIDs, nerve pain medications)
• Epidural steroid injections
• Surgery for severe or progressive cases

Treatment for Piriformis Syndrome

Physiotherapy:

• Piriformis stretching
• Hip strengthening (especially external rotators)
• Gluteal strengthening
• Core stabilization
• Nerve mobilization

Manual Therapy:

• Deep tissue massage of piriformis
• Trigger point release
• Myofascial release
• Dry needling

Activity Modifications:

• Remove wallet from back pocket
• Use cushioned seating
• Avoid prolonged sitting
• Modify aggravating exercises

Other Treatments:

• Massage therapy
• Piriformis injection (diagnostic and therapeutic)
• Botox injection (in resistant cases)

Exercise Programs

Piriformis Stretches

Figure-4 Stretch:

• Lie on back, cross ankle over opposite knee
• Pull uncrossed leg toward chest
• Feel stretch in buttock of crossed leg
• Hold 30 seconds, repeat 3 times

Seated Piriformis Stretch:

• Sit with affected leg crossed over other
• Gently rotate torso toward crossed leg
• Hold 30 seconds, repeat 3 times

Supine Piriformis Stretch:

• Lie on back, knee bent
• Pull knee toward opposite shoulder
• Hold 30 seconds, repeat 3 times

Hip Strengthening

Clamshells:

• Side-lying, knees bent
• Keep feet together, open knees
• Hold 3 seconds at top
• 3 sets of 15 repetitions

Side-Lying Hip Abduction:

• Lie on side, bottom leg bent
• Lift top leg, keeping straight
• 3 sets of 15 repetitions

Bridges:

• Lie on back, knees bent
• Lift hips off ground
• Hold 5 seconds
• 3 sets of 10 repetitions

Core Stabilization

Both conditions benefit from core strengthening:

• Dead bugs
• Bird dogs
• Modified planks
• Bridges

Treatment at M.O. Therapy

Physiotherapy

Our physiotherapists specialize in differentiating and treating these conditions:

Assessment:

• Thorough examination
• Differential diagnosis
• Movement analysis
• Treatment planning

Treatment:

• Manual therapy
• Exercise prescription
• Education
• Activity guidance

Massage Therapy

Our RMTs provide:

• Deep tissue massage
• Piriformis release
• Gluteal muscle work
• Relaxation and recovery

Chiropractic Care

Chiropractic treatment may include:

• Spinal assessment
• Pelvic alignment
• Soft tissue therapy
• Exercise recommendations

Frequently Asked Questions

How do I know if I have piriformis syndrome or sciatica? Key differences include where pain started (buttock vs back), whether back pain is present, and specific physical examination findings. Professional assessment helps differentiate between these conditions.

Can you have both conditions at the same time? Yes, it's possible to have both spinal issues and piriformis syndrome simultaneously, which can complicate diagnosis and treatment. Comprehensive evaluation is important.

How long does piriformis syndrome take to heal? With appropriate treatment, most patients see improvement within 4-8 weeks. Chronic cases may take longer. Consistency with exercises and activity modifications is key.

Will imaging show piriformis syndrome? Standard spine MRI won't show piriformis syndrome. Dedicated pelvic MRI might show piriformis abnormalities, but diagnosis is primarily clinical.

Book Your Assessment

If you're experiencing buttock or leg pain and want an accurate diagnosis, M.O. Therapy in Markham can help. Our team will thoroughly assess your condition and develop an appropriate treatment plan.

Call (905) 201-5827 or book online for your assessment. We offer direct billing and same-day appointments.