The piriformis syndrome can be a bane for many athletes, particularly among those who perform endurance sports. Competitive distance runners keep a strict training schedule and are notorious for being able to rattle off their mileage for the day, week, and even year-to-date. Most have learned to create time in their busy running schedule for strength training, foam rolling, sleeping, and meal preparation. 

If there is one thing they cannot afford, it would be injury. So when a local competitive marathoner came to physical therapy with new onset back and buttock pain when he crossed his legs to tie his shoes, the race to get back on the road was on. We ran (pun intended!) through all the necessary questions; he had not changed his shoes, running surface, mileage, or anything else related to running, but he had added a new element to his training: stair climbing at the local college football stadium. 

In this case, the runner had a “typical’” tightness in his hips, but his tightness was usually bilateral and what he described as a “general achy” feeling. The new pain was only on his right side and was deep in his buttock region. He noticed that his pain worsened while he was sitting during his long commute to work. The tightness was relieved by a forward fold stretch. 

He also noted a burning pain in the back of his right thigh and pointed to a particular spot near the center of his buttocks that was the most painful. It takes a keen clinician to know this was not low back pain at all; it seemed to be textbook piriformis syndrome.

Piriformis syndrome was first described by Yeoman nearly 100 years ago. The cardinal features of the condition have long included: pain that worsens with bending or lifting and is relieved by traction; a palpable tube-like mass over the piriformis muscle; positive piriformis test; and pain with prolonged sitting. Over time, a host of non-specific symptoms have been associated with piriformis syndrome, which make it a challenge for clinicians to diagnose. Some researchers have also challenged the findings and ideas of Yeoman about the nature of piriformis syndrome.

Since the dawn of this diagnosis, it has been hidden under the veil of other common low back related conditions. This is easy to believe considering the incidence of low back pain has long been high and is only getting higher. 

Freburger et al. studied the increased prevalence in low back pain from 1992 to 2006 and found that more than 80 percent of adults will experience at least one episode of disabling low back pain during their lifetime. Epidemiological studies of piriformis syndrome have shown it may be responsible for as many as six percent of all cases of low back pain and/or sciatica. Estimates of the number of new cases of low back pain and sciatica annually are in the neighborhood of 40 million, which would be approximately 2.4 million cases of piriformis syndrome each year. 

The onset of piriformis syndrome is typically in the fourth and fifth decades of life and affects female patients six times more often than males. It has been suggested that the wider pelvis characteristically found in women may be a causative factor in development of piriformis syndrome. However, the jury is still out on whether there is a direct cause-and-effect relationship. 

While there are a variety of causes of piriformis syndrome, the clinical presentation seems to be consistent. The patient with piriformis syndrome typically reports deep pain in the gluteal region that may have associated paresthesias (shooting, burning, tingling) into the posterior thigh. Although the reports of pain location and quality are similar across patients, they can vary significantly with respect to intensity. A savvy clinician would be able to recognize the objective findings relative to piriformis syndrome, which allows patients to start treatment early and avoid long-term pain and dysfunction. 

Inability to diagnose piriformis syndrome in a timely manner may lead to a cascade of other conditions, including chronic pain, paresthesias, and muscle weakness. Delaying a correct diagnosis is not only costly for the patient in terms of pain and dysfunction but also, quite literally, as it may involve expensive diagnostic imaging that nearly always turns up negative. Time spent on ineffective or unnecessary therapeutic interventions can delay relief and the return to normal daily activities. 

Deciding that piriformis syndrome is the cause of a patient’s pain and symptoms may be delayed because there are several conditions that can mimic piriformis syndrome or occur concurrently. It is important that trochanteric bursitis, sacroiliac joint dysfunction, disc injury, and facet joint arthropathy have been ruled out to ensure the chosen treatment is targeting the correct tissue. 

Anatomy of the piriformis muscle

A thorough understanding of the anatomical relationship between the piriformis muscle and the sciatic nerve is needed to recognize piriformis syndrome. The hip is a ball-and-socket joint where inherent stability is provided by the bony structure. The hip joint not only relies on this bony stability but also on many large and small muscles to create movement to provide the endurance necessary to support the weight of the body against gravity. 

piriformis muscle

Image: Johannes Sobotta – https://commons.wikimedia.org/wiki/File:Sobo_1909_295.png

Piriformis, latin for “pear-shaped,” is found deep to the gluteal muscles in the pelvic cavity. It is the most superficial of the deep hip rotators. It originates medially on the lateral border of the sacrum and the sacrotuberous ligament and travels inferolaterally through the greater sciatic foramen (an opening formed by the sacrotuberous and sacrospinous ligaments) and greater sciatic notch of the ilium to attach on the greater trochanter of the femur. 

The piriformis is quite important in hip joint function as it serves many different roles. When the hip is extended, piriformis is predominantly an external rotator, but when the hip is flexed, it acts as an abductor. Piriformis is innervated by the L5, S1, and S2 nerve roots which may provide at least some of the explanation for why pain in this region is often confused with disc-related pain. Lumbar disc pathology most commonly affects the L4 to L5 and L5 to S1 levels.  

The sciatic nerve is well known as the largest peripheral nerve in the body. It is made up of the nerve roots from L4 to S3 and divides into two major branches: the tibial nerve and the peroneal nerve. 

The nerve fascicles of these two branches are separate but travel together in the proximal course of the nerve; this means proximal nerve injury can preferentially affect one branch or the other. The peroneal branch is thought to be more often involved in piriformis syndrome because it is less robust than the tibial nerve and runs laterally in the sciatic notch making it more vulnerable to compression. The course of the sciatic nerve is such that if the piriformis muscle is inflamed or irritated, the nerve will be affected and a sciatica-like pain will result. 

The anatomy of the sciatic nerve can vary among individuals. One Ethiopian study found that, among a sample of 28 cadavers (56 limbs total), about 11 percent of them had variations of the location of the sciatic nerve relative to the piriformis. Another 14 percent showed sciatic nerve variation in relation to the popliteal region of the thigh. And among that group, three lower limbs “showed trifurcation of sciatic nerve into three major divisions (tibial nerve, common peroneal nerve and an unusual trunk) in the middle of the popliteal fossa.” 

Another study from Greece identified about six percent of 147 cadavers that had variations of the sciatic nerve and piriformis relationship . 

It is important to note that several other variations in the relationship between the sciatic nerve and piriformis have been identified but only the proximal split has been associated with an increased prevalence of piriformis syndrome. 

Piriformis syndrome symptoms

The cardinal symptom of piriformis syndrome is pain that increases after sitting (e.g.  with the legs crossed) for greater than 15 to 20 minutes. Most other clinical signs have a direct or indirect relationship with muscle spasm, nerve compression, or both.

Other common clinical complaints associated with piriformis syndrome are chronic pain in the hip and gluteal area that is often dull, pain when getting out of bed, difficulty with prolonged walking or stair climbing, pain in the posterior aspect of the leg (thigh, calf, and/or, foot), and deep posterior hip pain that worsens with hip motion. Ninety percent of cases of piriformis syndrome are unilateral. 

Historically, the sciatica-like pain associated with piriformis syndrome has been discussed as a function of anatomical variation; the idea that there are several structures in the subgluteal space may create a non-discogenic sciatic nerve entrapment has been embraced.

Entrapment neuropathy is the term used to describe compression of a peripheral nerve- the sciatic nerve. In this case, it would be at an area of anatomical vulnerability. In cases of piriformis syndrome, this entrapment occurs as the piriformis passes laterally through the greater sciatic foramen, which is superior to the sciatic nerve. 

Signs and symptoms of entrapment of the sciatic nerve by the piriformis muscle may include pain, tingling, skin sensitivity, numbness and/or weakness. The quality of pain is often used to differentiate neuropathic pain from musculoskeletal pain, but terms like radiating, burning, or tingling should be taken with a grain of salt as these are non-specific and can be present in pain of musculoskeletal origin. 

Objective findings such as sensory loss or muscle weakness should be used to correlate subjective pain descriptions in diagnosing neuropathic pain. In the case of piriformis, lower extremity strength (specifically hip external rotation and abduction), sensation, and reflexes should be tested. 

The symptoms of piriformis syndrome are typically mild as far as entrapment neuropathies are concerned. This clinician should expect the neurological examination to be normal but to find positive, piriformis-specific special tests during their objective examination. Although patients may report paresthesias, sensory loss is rare. Even more rare than sensory loss is marked weakness. The diagnosis of piriformis syndrome relies heavily on eliciting tenderness upon palpation to the inferomedial aspect of the buttocks in the region of piriformis. 

If a patient has lower extremity sensory loss or weakness of sciatic nerve innervated muscles (hamstrings, adductor magnus), it is critical to rule out secondary causes of sciatic neuropathy before proceeding with the diagnosis of piriformis syndrome.

Piriformis syndrome causes

The etiology of piriformis syndrome may be described as primary or secondary. Primary piriformis syndrome can be tied to an anatomical cause, such as split piriformis muscle, split sciatic nerve, or an uncommon sciatic nerve path. Causes of secondary piriformis syndrome may be macrotrauma, microtrauma, or local ischemia. Less than 15 percent of cases are primary piriformis syndrome. In fact, the prevalence of secondary piriformis syndrome in people reporting low back pain has been reported to be 5 percent to 36 percent.

The mechanism of injury in secondary piriformis syndrome may be macrotrauma such as a fall landed on the buttocks that leads to inflammation, muscle spasm or both, microtrauma including overuse from running or direct compression, or the tightness or inflammation caused by damage to the muscle causing decreased blood flow in the region. In 90 percent of people, the sciatic nerve travels deep to the belly of piriformis, but in the case of an early division of the nerve into its tibial and peroneal branches, the relationship of the nerve to the muscle may be a predisposing factor in the development of piriformis syndrome.

It is believed that piriformis syndrome results from the impingement of the sciatic nerve by the piriformis muscle as they cross paths in the greater sciatic foramen of the pelvis. The proximity of the sciatic nerve to the location of piriformis exposes the nerve to potential irritation or entrapment as a result of injury to the muscle. 

The two most common potential mechanisms of compression are spasm and inflammation that cause hypertrophy and compression of the nerve between fascicles of the muscle belly. The anatomy of the piriformis is such that it becomes taut with just a few degrees of hip flexion which creates compression and reproduces feelings of sciatica any time a straight leg raise is performed. 

The blurred boundaries between what is piriformis syndrome and what is a secondary cause of sciatic neuropathy make it challenging to define a unique symptom cluster for piriformis syndrome. Increased tone, tightness, and hypertrophy of piriformis along with sacroiliac joint or piriformis muscle swelling could all be contributing causes to the impingement of the sciatic nerve in the greater sciatic foramen. Imaging studies have shown hypertrophied piriformis in athletes across all sports including distance runners and football quarterbacks alike. 

Does piriformis syndrome go away? 

Piriformis syndrome typically responds well to conservative treatment. Fishman et al. reported that 79 percent of patients with piriformis syndrome will have symptom resolution through conservative measures. Management of piriformis syndrome may include a combination of relative rest, muscle relaxers, anti-inflammatories, and physical therapy that involves restoring range of motion, improving flexibility, building strength and massage. Patients who fail conservative management may find relief from steroid injections, botox, or even surgery

Diagnosis of piriformis syndrome

The lack of a single, gold-standard test for identifying piriformis syndrome makes this a challenging diagnosis to make. Patients with piriformis syndrome typically report localized buttock pain and/or pain that radiates to the thigh or leg, point tenderness in the region of the muscle belly, and pain provocation with special tests. Physical examination should center on objective tests that lengthen the piriformis and apply manual pressure around the sciatic nerve for painful or discomforting symptoms. Tenderness to palpation of the muscle belly and sacral insertion are also often present. 

Piriformis syndrome is thought of as a diagnosis of exclusion. Differential diagnosis may be difficult because the patient will often report sciatica-like symptoms including pain that radiates into the posterior aspect of the thigh or the L5 and S1 dermatomes. Once other neurological and musculoskeletal causes of pain have been excluded, piriformis syndrome can be implicated. Alternate diagnoses to consider include lumbosacral radiculopathy, sacroiliac joint injury or dysfunction, facet joint arthropathy, intervertebral disc pathology, or trochanteric pathology. 

On examination, tightness or contraction of piriformis will cause the hip to rest in external rotation. When these individuals lie supine, their ipsilateral hip will fall into external rotation; this can be easily identified at the foot by looking for bilateral differences in the position of the toes. This is known as “piriformis sign.”

Other clinical findings may include buttock pain, tenderness to palpation around the sciatic notch, and symptoms reproduction during special tests. The most commonly used test to implicate piriformis is the FAIR test. The test is performed in supine and the hip is moved into flexion, adduction and internal rotation (FAIR). Overpressure can be applied through increased internal rotation (force through the ankle) or adduction (downward force through the knee).  

 

 

The Freiberg Maneuver (forceful internal rotation of the hip in supine with knee extended) is positive if the patient’s symptoms of gluteal pain or sciatic nerve paresthesias are reproduced. 

 

 

The Pace Maneuver begins with the patient seated with their legs dangling over the side of an examination table. The examiner resists hip abduction at the knees and the test is positive if the patient demonstrates weakness, uncoordinated movement (shaking or juddering), or symptoms are reproduced. 

 

 

The Beatty Maneuver is performed in a side-lying position on the unaffected side with the knees slightly bent. The patient actively abducts the affected side several inches. The test is considered positive for piriformis syndrome if pain is reproduced in the deep gluteal region but can also be indicative of lumbar disc disease if low back pain is present.

 

 

Criteria for inclusion/exclusion in the diagnosis of piriformis syndrome have been proposed by Han et al

Inclusion criteria are:

  1. Deep-seated buttock pain with radiating pain, especially intolerable sitting pain
  2. Tenderness of the piriformis muscle 
  3. Positive provocation test
  4. Positive findings on CT or MRI; asymmetry or enhancement around the sciatic nerve
  5. Pain relief with local anaesthetic or steroid injection

Exclusion criteria are:

  1. Symptoms of neurological claudication
  2. Positive LaSegue’s or straight leg raise test
  3. Sensory changes on nerve root innervations
  4. Radiculopathy on electromyography
  5. Effective caudal or epidural block

Using these criteria, piriformis syndrome would be diagnosed if four or more of the inclusion criteria are met and all exclusion criteria were absent. Clinically, it would be difficult to achieve four inclusion criteria due to the lack of immediate access to advanced imaging or injections, but these lists were included to illustrate differences in signs of piriformis syndrome versus other neurological origins of pain.

Piriformis syndrome treatments

Piriformis syndrome can be treated both pharmacologically and non-pharmacologically.  Anti-inflammatory, analgesic, and muscle relaxer medications have all been used successfully in the treatment of the syndrome. Conservative management centers on physical and massage therapy that includes stretching, strengthening, and a gradual return to functional activities. 

In cases where conservative management has failed, injections have been successful. Lidocaine, corticosteroids and botulinum toxin have all been used under fluoroscopic or ultrasound-guided injection. 

Fifty patients with unilateral hip and/or leg pain with a positive FAIR test and/or trigger point pain in the piriformis muscle participated in a study on the effectiveness of local anesthetics and corticosteroid injections. The patients were randomly assigned to one of two groups; the first group received an injection of lidocaine only (local anesthetic) while the second group received lidocaine plus betamethasone (local anesthetic plus corticosteroid). The study found a highly significant reduction of pain when the patients were at rest, in motion, at night, and with long duration sitting, standing or lying in both treatment groups. 

Stretching the piriformis muscle in an effort to relieve compression of the sciatic nerve is a mainstay of conversative treatment of piriformis syndrome. The most effective stretching position is similar to the FAIR test where the patient lies supine and then moves into hip flexion, adduction, and internal rotation. Overpressure can be applied through a downward force at the knee from the patient’s ipsilateral hand, an external rotation force at the distal tibia from the patient’s contralateral hand, or both. 

Stretching can also be performed in a seated position with the affected leg crossed over the unaffected leg in a figure-4 position; the patient can either pull their ipsilateral knee to their contralateral shoulder or hinge forward at the hips to intensify the stretch. Stretching of piriformis should be followed by strengthening of the hip abductors and external rotators.  

A prospective study of 250 patients (with an additional 30 controls) with piriformis syndrome found that it took an average of seven weeks of analgesics, muscle relaxers, and physical therapy that included massage for half of the patients to reach complete symptom resolution. The program included stretching for the hip flexors, quadriceps, hamstrings, adductors, and piriformis.Additional elements of the physical therapy program were contract-relax stretching to piriformis, Transcutaneous Electrical Nerve Stimulation (TENS), abdominal strengthening, and McKenzie based flexibility exercises.

The combination of medication and rehabilitation treatment including TENS for analgesia was successful in about 51 percent of patients. Those who did not find relief with the initial program were given Botox injections. Fifteen of 19 patients that were unresponsive to conservative treatment methods underwent surgery with ‘good’ or ‘very good’ results. It is clear from these results that conservative rehabilitation has a major role in the treatment of piriformis syndrome. 

A 2019 short-term study showed promising results for the use of dry needling in the treatment of piriformis syndrome as pain was reduced for one week following intervention. Thirty-two patients with a confirmed piriformis syndrome diagnosis were randomly allocated to a treatment group or waitlist (control) group.  

The treatment group underwent three sessions of ultrasound-guided dry needling of the piriformis with pain measured at baseline, after 72 hours and after one week. At a one-week follow-up, the treatment group reported nearly a three-point reduction in pain using the Visual Analog Scale (VAS) that measures pain from 0 to 10, with 0 indicating no pain and 10 indicating the worst possible pain. 

Surgical management of piriformis syndrome may create nerve decompression through release of the tight muscles or removal of adhesions and scar tissue from the nerve. As in any procedure, surgery is never a guarantee of symptom resolution and as such, it should only be considered as a last resort.  

Readers are advised to consult with a physician or other qualified medical professional to determine which course of treatment is best for them. 

Piriformis syndrome exercises

Electromyography (EMG) is commonly used to assess the activity levels in pre-identified muscles during specific exercises. Muscle activation is measured via electrical activity levels with the assumption that exercises that produce higher levels of activation in a muscle, are better choices for strengthening that specific muscle.   

EMG activity is measured as a percentage of maximum voluntary isometric contraction (MVIC) where it is accepted that a minimum of 40 to 60 percent MVIC is necessary to produce a strengthening stimulus. 

A systematic review of the EMG activity of dynamic hip abduction and external rotation exercises found that standing exercises produced more muscle activity than their side-lying counterparts. In the review, seated machine exercises produced the most overall activity but because there was only one study that used this mode of exercise, comparison to the activity levels produced in the other two positions is limited. 

The review found that EMG activity was either high (>40-60% of MVIC) or very high (>60% of MVIC) in the following exercises: lateral step-ups, pelvic drop (heel taps), transverse lunges, side bridges with abduction, and standing hip abduction with a resistance band at the ankle. 

Giphart et al. investigated the role of the piriformis in hip rehabilitation exercises and found the highest EMG activity with prone heel squeezes, single leg bridges, side-lying hip abduction with external rotation, and resisted hip extension. 

A study from the Journal of Sports Physical Therapy looked at gluteal muscle activation during common rehabilitation exercises and discovered that EMG activity was highest in side-lying hip abduction, single leg squat, lateral band walks, and the single-leg deadlift. 

The end-goal of physical therapy for piriformis syndrome is to have used a systematic program to eliminate symptoms, restore range of motion, and increase strength and endurance for functional activities.

How to sleep with piriformis syndrome 

Finding a sleeping position while battling piriformis syndrome does not have a “one-size-fits-all” approach. Much like everything else we do, sleep positions should be performed within moderation. There is no single position that is “right” for sleeping, but research suggests that if we can avoid stomach sleeping, we should follow the evidence. Our bodies like variety and as such, the secret to success may be in alternating between lying supine and side-lying on either side.   

One of the biggest daily living challenges of piriformis syndrome is the difficulty this condition creates for the patient’s sleep schedule. In what is likely the most well known study on intradiscal pressure, Nachemson established that pressures in the low back are lowest in the supine and side-lying positions. These positions are desirable for low back pain because when disc pressures are low, nerves are not being compressed and relief is found. In piriformis syndrome, these are also positions of relief, maybe because of the low intradiscal pressures or they allow the piriformis to remain in a neutral position.  

Supine

While sleeping supine may be great for our backs because it creates less stress through the spine as gravity is able to keep our weight centered over the normal curves of our back (this can be further emphasized by placing a pillow or bolster under the knees), it may need some modification for those with piriformis syndrome. In supine, most people will allow their legs to fall into external rotation from the hip when lying on their back. This short position for piriformis decreases compression on the nerve but may simultaneously contribute to muscular tightness. 

If symptoms are moderate to severe, it may be beneficial to instruct the patient to place a pillow on the outside of the symptomatic leg so that the hip remains in neutral rather than falling into external rotation which allows piriformis muscle length to be maintained. 

Similarly, those with piriformis syndrome should avoid sitting “criss-cross applesauce” as this allows the hips to rest in external rotation and reinforces the short, tight position of piriformis. An alternative position is long-sitting (sitting with legs outstretched in front of the body, knees extended) with effort made to maintain the kneecaps and toes pointed toward the ceiling (neutral hip position).  

Side-lying

Side sleepers can find relief of low back and piriformis syndrome pain by allowing normal spinal curves to be maintained and piriformis to rest at neutral length. In side-lying, it is critical that a pillow is placed between the knees so that the top leg doesn’t fall into adduction and internal rotation (the long position of piriformis which lends to compression of the sciatic nerve). 

Prone (sleeping on stomach)

The Mayo Clinic suggests sleeping on your stomach not only wreaks havoc on the low back because of the increased lordosis created by elevating the head with a pillow, but it also may create neck problems as a result of the head being turned in one direction for a period of time. If the patient absolutely must sleep on their stomach, educate them on elevating their hips and lower abdomen with a pillow to decrease the emphasis on lordosis in this position.

Piriformis massage

Massage therapy has been used very successfully in the treatment of piriformis syndrome.  It is imperative that the massage therapist maintains excellent communication with the patient while working in this area and that appropriate draping is utilized. Treatment should start with the most superficial muscle, gluteus maximus. Gluteus maximus is integral to correct biomechanics of the entire hip region (low back, hip, and pelvis) and thus using it as a starting point will improve overall motion in the area. 

piriformis syndrome massage

Photo: Penny Goldberg

This region is somewhat tender on most individuals which makes it susceptible to reactive tightening when touched. Starting with an open palm to create a broad contact surface can help your patient remain comfortable and relaxed. Once gluteus maximus tightness has been reduced, you can start to work toward the underlying piriformis muscle.  

The piriformis is quite deep, and thus, getting to it with manual therapy can be very uncomfortable. Again, taking measures to reduce reactive muscle tightening are of utmost importance. One way to do this is with an active engagement lengthening technique

To perform this maneuver, start with the patient lying prone. Passively flex the patient’s knee on the involved side and place the hip in full external rotation. 

piriformis syndrome massage

Photo: Penny Goldberg

First, ask the patient to hold as you gently pull their lower leg toward you and then instruct them to slowly release the contraction as you continue moving their leg into internal rotation. As this movement occurs, apply a slow stripping technique directly over piriformis, moving forward along the muscle three to four  inches with each movement. 

piriformis syndrome massage

Photo: Penny Goldberg

This can be repeated several times until the entire length of the muscle has been addressed. This technique should be followed by stretching and strengthening to enhance neuromuscular control of the recently restored hip motion.

To address the hip abductors with massage, start at the lateral pelvis with broad contact strokes. These strokes should address the entire length of gluteus medius and minimus from the iliac crest to the greater trochanter of the femur. Following initial relaxation, specific deep techniques can begin. 

piriformis syndrome massage

Photo: Penny Goldberg

Tissue damage at the musculotendinous junction or tendinosis are common in individuals with long standing hip pain. Deep friction massage in the region of the tendons may encourage healing through fibroblast proliferation to repair the damaged collagen matrix in the tendon. 

Also, active engagement techniques may also be used to address hip abductor tightness and restrictions. To perform these techniques, the patient should be lying with the affected side up.

piriformis syndrome massage

Photo: Penny Goldberg

Ask the patient to actively move into adduction as far they are able, even if this is below the level of the table. As they move into maximal adduction, the massage therapist can perform a deep stripping technique over the hip abductor group.  

This is known to be very painful and the massage therapist should move slowly and cautiously so that the patient has ample time to provide feedback on tolerance. Myofascial “trigger points” may also need to be addressed in this area using the therapist’s body or a pressure tool.  

Further Reading: Myofascial Pain Syndrome: Revising the Cinderella Hypothesis

It may be beneficial to educate your patient on self-care techniques to support the progress being made with physical and massage therapy. The first step in self-care is identifying the correct muscles to be targeted. The piriformis has an integral role in hip stability and works symbiotically with all of the other muscles of the pelvic girdle. It is critical to instruct patients that while working on piriformis may provide the most immediate relief, attention to the gluteals, hip abductors, hip flexors and adductors will all lead to long-term relief and a successful return to pain-free activities. 

To focus on the hip flexors, using a large firm ball or foam roller, the patient should be instructed to start with the ball or foam roller under their abdomen in prone and their body weight supported by their upper extremities. Effort should be made to apply pressure through the proximal third of the anterior thigh as this is the location of trigger points in the iliopsoas. The hip abductors should be targeted by sitting on the ball or foam roller with the affected leg crossed over the unaffected in a figure-4 position. 

Tender areas in the lateral hip are most often found in the regions of the lateral border of the sacrum (medial attachment of piriformis), the head of the femur, and the greater sciatic notch. If weight bearing work as described above is too intense for the patient, they can begin with the ball or foam roll in the same position against a wall.  

We have learned a lot about the diagnosis and treatment of piriformis syndrome in the last 100 years. What’s clear from decades of work is that if we listen to the patient’s story and do a thorough clinical examination, we can confidently make this diagnosis and start delivering the correct treatment so that the patient can return to activity quickly, safely, and without recurrence.  

Follow Dr. Penny Goldberg on Twitter: @nikegal7