Piriformis Syndrome

Piriformis Syndrome

Mitsutoshi Hayashi

Mitsutoshi Hayashi

Doctor of Medicine, specialist in the Japanese Society of Rehabilitation Medicine, specialist in the Japanese Society of Orthopaedic Surgery, specialist in the Japanese Society of Rheumatology, staff to strengthen JOC, and sports physician certified by the Japan Sports Association

Doctor's Edition

In piriformis syndrome, sciatica appears during racing such as marathons and training for sports, and various symptoms, such as buttock pain and posterior thigh pain, occur.

Disease Overview

During training, such as running, sciatica develops, and one is often asked how to handle an athlete who has pain in the buttocks, particularly when the hip joint is internally rotated.
A particularly complex and weak type of hip joint motion involves rotation (internal and external rotation). If the athlete has any pain in the hip joint when it is internally rotated, the external rotators may be stiff, and the underlying sciatic nerves may be compressed.
This disorder is called piriformis syndrome.

Cause and mechanism of onset

A particularly complex and weak type of hip joint motion involves rotation (internal and external rotation). If the athlete has any pain in the hip joint when it is internally rotated, th e hip joint external rotators may be stiff and the underlying sciatic nerves may be compressed.
Although the anatomy around the gluteal sciatic nerve is complex, refer to the anatomy (Fig. 1). The cause may be due to an abnormal process of the piriformis muscle.

Piriformis Syndrome 1

Figure 1 Piriformis muscle: pear-shaped muscle in the middle of the figure.



The main symptom is sciatica, which is caused primarily by sports. It causes a variety of symptoms, including buttock pain and posterior thigh pain. Tightness of the piriformis may cause pain when the hip joint is pressed for external rotation or passive internal rotation. Especially if the sciatic nerve is compressed, the straight-leg raising (SLR) maneuver (leg extension lift) may increase symptoms. The piriformis muscles are tight and compress the underlying sciatic nerve, similar to a herniated lumbar spine disc, from which it must be distinguished. In contrast, the piriformis muscle loosens when the hip joint is passively externally rotated.

Manual examination

The Freiberg test is a provocative test in which the piriformis muscle becomes tight and more painful when internal rotation is forced in hip joint flexion.

Piriformis Syndrome 2

Figure 2 Freiberg test. Symptoms may be increased if the sciatic nerve is compressed.

Treatment and rehabilitation


Stretching is helpful in dealing with sports situations. In the 90-degree flexion position of the knee joint with the player in the prone position, the piriformis muscle is contracted isometrically by resisting the external rotation of the hip joint, and the extensor of the external rotators of the hip joint is extended (Photo A).
Gradual changes in the angle of internal rotation (resistance angle) during stretching can stretch the piriformis muscle and reduce the symptoms of compression of the sciatic nerve. However, be careful not to add too much resistance, because it is a very delicate muscle.
If conservative treatment, such as analgesic medications, nerve blocks, or physical therapy, is difficult or fails, surgery may be done to cut the piriformis muscle away and release the sciatic nerve.

Piriformis stretching

Photo Stretching of the piriformis

Yoshizumi Iwasaki

Yoshizumi Iwasaki

NATA certified athletic trainers, certified athletic trainers from the Japan Physical Education Association, and chairman of the Japan Core Conditioning Association (JCCA)

Trainer’s Edition


The piriformis is a so-called deep inner mass, so it is not easy to target, strengthen, or stretch the piriformis muscle. However, adequate stretching of the hip joint may help prevent this disorder from occurring. If discomfort begins in the deeper layers of the buttocks, stretching can be modified with awareness of the area.

On-site evaluation and first aid

As a muscle, some strong external force can cause a tear or partial tear of piriformis. However, many piriformis syndromes may be caused by muscle induration from overuse. Of course, if the muscle is left intact after a muscle rupture, the scar may become large and connected, impairing the original stretch ability of the muscle and causing symptoms. When restarting, please ensure that the doctor has provided a release.

The piriformis muscle restart test begins with checking for numbness in the legs and discomfort in the buttocks during daily activities, followed by standing with one leg opening the eyes, (2) one-leg calf raises (also called heel raises), and (3) one leg hops. If this can be accomplished, the person should go to the field, gymnasium, etc., and be tested for (4) dashing, (5) bounding, and (6) turning forward or backward. In addition, check movements according to the type and level, player position, etc. with the supervisor and coach to determine if the player should eventually return to practice and resume play.


Before you return to a full game, you should also remember to test readiness for the game with the basic movements from the athletic perspective. In piriformis syndrome, numbness is a major problem. Continuing conditioning and after-care to prevent recurrence must be done with extreme caution.
It is true that people with discomfort in the buttocks, numbness in the legs, and a doctor's consultation are often instructed only to "ice" and "rest" even if they are diagnosed with piriformis syndrome. Since the piriform muscle is located in a very deep position, it is necessary to take the position shown in Photo 1 and devise how to cool the part targeted for icing.

Piriformis Syndrome 1

Photo 1 Icing: Place one knee forward in the recumbent position so that it hits the affected area as much as possible.
The same position (Photo 2) is also used when using an ultrasound device to warm the depths. Massage (Photo 3) is not excluded.

The same position (Photo 2) is also used when using an ultrasound device to warm the depths. Massage (Photo 3) is not excluded.

Piriformis Syndrome 2

Photo 2 Ultrasound treatment: Put the knee forward in the recumbent position and devise an angle to allow heat to reach the affected area.

Piriformis Syndrome 3

Photo 3 Massage: Because it is a deep muscle, finger pressure and deep friction massage are used.

Piriformis Syndrome 4

Photo 4 Common buttock stretching

Piriformis Syndrome 5

Picture 5 Adjust the position of extension, such as by pulling the whole foot toward the chest.

Piriformis Syndrome 6

Photo 6 Common buttock stretching. Adjust the position of the buttock and foot to make fine adjustments of position of extended hip joints.

Piriformis Syndrome 8

Photo 7 Flexion of the hip joint with knees inverted

Piriformis Syndrome 10

Photo 8 Crawl on all fours, and cross your legs. From this condition, the back leg is straightened while the front buttock is straightened.

Piriformis Syndrome 12

Photo 9 Repeat the stretching in the previous photo with using stretch ball (S size). Roll the stretching ball until the expected buttock muscle is stretched.

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