Background
Piriformis syndrome is a condition that involves the piriformis muscle, a small muscle located deep in the buttocks near the hip joint. The piriformis muscle plays a role in the external and internal rotation of the hip, the stabilization of the pelvic region and femoral head in the acetabulum.

Piriformis syndrome occurs when the piriformis muscle becomes tight, inflamed, or irritated, leading to compression or irritation of the sciatic nerve. The sciatic nerve is the largest nerve in the body and extends from the lower back down through the buttocks and into the legs. When the piriformis muscle puts pressure on the sciatic nerve, it can result in symptoms such as:
Symptoms
Pain: Typically, there is pain in the buttocks and can radiate down the back of the leg. The pain may be sharp, burning, or tingling in nature.
Numbness and tingling: Along the path of the sciatic nerve, there may be sensations of numbness, tingling, or pins and needles in the buttocks and leg.
Weakness: Some individuals with piriformis syndrome may experience weakness in the affected leg.
Causes
Piriformis syndrome can be caused by various factors, including overuse or repetitive activities that put strain on the muscle, injury, prolonged sitting, muscle imbalances, or anatomical variations (see below). It is more common in athletes, runners, and individuals who engage in activities that involve repetitive hip movements.
Diagnosis
Diagnosis of piriformis syndrome can be challenging as its symptoms may overlap with other conditions such as herniated discs, spinal stenosis, nerve tethering (see below) or sciatica. Physicians may use physical examinations, medical history, and imaging tests to rule out other causes and arrive at a diagnosis. There is no definitive test for piriformis syndrome.
Diagnosis of piriformis syndrome is made by the patient’s report of symptoms and by physical exam using a variety of movements to elicit pain to the piriformis muscle.
Treatment
Treatment for piriformis syndrome typically includes a combination of conservative measures such as rest, ice or heat application, physical therapy, stretching exercises, and anti- inflammatory medications. In some cases, corticosteroid injections may be used to reduce inflammation and relieve pain. In severe or persistent cases, surgery may be considered, but it is relatively rare.
The Anatomy

The sciatic and peroneal nerve, pictured below is the thickest and longest nerve in the body. Sometimes both nerves pass the underside of the piriformis muscle before dividing (first image on left), and sometimes they divide and only the sciatic nerve passes through the piriformis muscle (second image). Other times they both pass through the piriformis muscle before travelling down the back of the leg, and eventually branching off and ending in the top and the sole of the feet. (See third image). Compression of these nerves, particularly in the instances of pictures 2 and 3, can be caused by spasm of the piriformis muscle.


How does the muscle compress the nerve?
The compression of the sciatic nerve by the piriformis muscle is a mechanical action. The exact mechanism by which the piriformis muscle compresses the nerve is not fully understood, and there may be multiple contributing factors. However, there are a few proposed mechanisms that could explain how the compression occurs:
Muscle Tightness: When the muscle tightens, it can put pressure on the sciatic nerve, which runs very close to or in some cases, through the muscle.
Muscle Spasm: In some cases, the piriformis muscle may go into spasm, causing it to contract forcefully and compress the nearby sciatic nerve.
Anatomical Variation: The sciatic nerve and the piriformis muscle have a close anatomical relationship in some individuals. As described above, in some people, the sciatic nerve may pass through or underneath the piriformis muscle rather than beside it. If the piriformis muscle is tight or spasms, it can put direct pressure on the nerve.
Inflammation: Inflammation of the piriformis muscle can occur due to injury or overuse. Inflammation can cause the muscle to swell, leading to pressure on the sciatic nerve.
The combination of tightness, spasms, anatomical variation, and inflammation can lead to irritation and compression of the sciatic nerve, resulting in the symptoms associated with piriformis syndrome, such as pain, numbness, tingling, and weakness in the buttocks and leg.
Stretching
If it is established that your client does have piriformis syndrome, a stretching programcan be very effective. As mentioned above, it may need to be combined with strengthening of the gluteal muscles in the region. The following stretches need to be explored with care. Stretching at least 3 days per week will be important for the first 4 to 6 weeks in order to get the symptoms under control.
The seated gluteal stretch
Practice both variations of this stretch to shift the stretch through the entirety of the gluteal region.
The kneeling abductors
Although another gluteal stretch, the focus is the lateral gluteal region, in particular the gluteus medius, minimus and region of the insertion of the piriformis.
Stretching the posterior muscles of the thigh and leg
While piriformis syndrome is commonly associated with pain and discomfort in the buttock’s region, it can also cause symptoms that extend along the entire pathway of the sciatic nerve. The sciatic nerve is the longest nerve in the body, running from the lower back through the buttocks and down each leg, so when the piriformis muscle compresses or irritates the nerve, the symptoms can radiate along its entire course.
In some cases, the pain, numbness, tingling, or weakness associated with piriformis syndrome can extend from the buttocks down the back of the thigh and calf and even into the foot. This pattern of symptoms is often referred to as “sciatica” since it involves irritation of the sciatic nerve.
Stretching the hamstrings and calves can be useful for individuals experiencing piriformis syndrome or sciatica-like symptoms. These stretches can help alleviate tension in the muscles surrounding the sciatic nerve, which may contribute to compression or irritation of the nerve.
The standing straight leg hamstring stretch/posterior thigh
Stretching the calf/posterior leg
Stretching the calf muscles can be useful for individuals experiencing piriformis syndromeor sciatica-like symptoms. While the primary focus in piriformis syndrome is often on the piriformis muscle and its relation to the sciatic nerve, tight calf muscles can indirectly contribute to the overall tension and mechanics of the lower leg and affect the nerve’s function.
Stretching the peroneal/lateral leg
The sciatic nerve divides into two main branches: the tibial nerve and the common fibular (peroneal) nerve. The common fibular (peroneal) nerve has a course along the outside of the knee and down the lower leg, where it innervates the muscles in the peroneal group (also called fibularis muscles) which plays a role in ankle and foot movement. If this nerve or its branches become irritated or compressed, it can lead to symptoms like pain, tingling, or weakness in the lower leg or foot.
Tightness in the muscles of the lower leg, such as the peroneal muscles, can potentially exert pressure on the nerve or its branches. Stretching the peroneal muscles located on the outside of the lower leg can therefore be beneficial for individuals experiencing piriformis syndrome or sciatica-like symptoms.
Similar symptoms:
Information for the practitioner
Piriformis syndrome and nerve tethering are distinct conditions, although they both involve the sciatic nerve and can cause similar symptoms. Let’s clarify the differences between the two:
Piriformis Syndrome: As mentioned earlier, piriformis syndrome occurs when the piriformis muscle compresses or irritates the sciatic nerve. The tight or spasming piriformis muscle puts pressure on the nerve, leading to pain, numbness, tingling, and weakness in the buttocks and leg. This compression is often due to mechanical factors, as explained in the previous response.
Nerve Tethering: Nerve tethering, also known as neural tethering or nerve entrapment, is a condition where anerve becomes adhered or attached to surrounding tissues (such as muscles, ligaments, or scar tissue) and is restricted in its normal movement. This restriction can cause tension on the nerve, leading
to similar symptoms as seen in piriformis syndrome, including pain, numbness, tingling, and weakness.
While both piriformis syndrome and nerve tethering can result in sciatic nerve-related symptoms, the underlying causes are different. In piriformis syndrome, the compression is primarily caused by the piriformis muscle’s mechanical action. In contrast, nerve tethering involves the nerve being tethered or stuck to nearby structures, which leads to tension and irritation.
Like piriformis syndrome, nerve tethering can occur at various locations along the path of the sciatic nerve, not just in the vicinity of the piriformis muscle. It can happen at different points in the nerve’s course, such as in the lower back, buttocks, or thigh.
Diagnosing nerve tethering can be challenging, and it requires a careful evaluation by a qualified healthcare professional. Treatment for nerve tethering often involves physical therapy to improve nerve mobility, and in some cases, surgical intervention may be necessary to release the nerve from the tethering structures.
In summary, while piriformis syndrome and nerve tethering share similarities in symptoms related to the sciatic nerve, they are distinct conditions with different underlying causes. A proper medical evaluation is essential to differentiate between the two and determine the appropriate treatment approach.
Can stretching help?
Stretching can be beneficial in some cases of nerve tethering, but it should be approached with caution. Nerve tethering involves the nerve being restricted or adhered to surrounding tissues, which can lead to tension and irritation. Stretching the affected area may help to improve nerve mobility and reduce symptoms, but it should be done under the guidance of a healthcare professional to avoid exacerbating the condition.
Here are some important points to consider:
Proper Assessment: Before attempting any stretching exercises, it is crucial to have a thorough evaluation by a qualified healthcare provider, such as a physical therapist or an orthopaedic specialist. They can determine whether nerve tethering is the cause of the symptoms and tailor a suitable treatment plan.
Gentle Stretching: If deemed appropriate, stretching exercises should be gentle and specifically targeted to the affected area. Stretching should never be forceful or cause pain, as this can potentially worsen nerve irritation.
Nerve Gliding Exercises: Nerve gliding exercises, also known as neural gliding or nerve flossing, may be incorporated into a treatment plan for nerve tethering. These exercises involve gentle and controlled movements that help mobilize the nerve without causing excessive tension.
Avoid Overstretching: Overstretching can put additional strain on the tethered nerve and surrounding structures, leading to increased irritation. It is crucial to
follow the guidance of a healthcare professional to ensure safe and effective stretching techniques.
Individualized Approach: Treatment for nerve tethering is highly individualized, and what works for one person may not be suitable for another. A healthcare professional can design a personalized stretching and rehabilitation program based on the specific needs and condition of the patient.
Other Treatment Modalities: In addition to stretching, other treatments such as physical therapy, manual therapy, and modalities like ultrasound or electrical stimulation may be used to address nerve tethering and relieve symptoms.
Remember, nerve tethering can be a complex condition, and self-treatment without proper guidance can potentially worsen the situation. If you suspect you may have nerve tethering or are experiencing symptoms related to nerve compression, it is essential to seek medical evaluation and advice from a qualified healthcare professional for appropriate diagnosis and treatment.
Quiz
Piriformis syndrome involves compression or irritation of the sciatic nerve by the piriformis muscle. (True)
Piriformis syndrome is caused by inflammation of the sciatic nerve. (False)
The piriformis muscle is located in the lower back. (False)
Piriformis syndrome can cause pain, numbness, and weakness in the buttocks and leg. (True)
Nerve tethering involves the sciatic nerve becoming attached to surrounding tissues. (True)
Nerve tethering can only occur near the piriformis muscle. (False)
Stretching exercises can help improve nerve mobility in nerve tethering. (True)
Nerve tethering can lead to sciatica-like symptoms. (True)
Stretching the hamstrings can indirectly affect the sciatic nerve in piriformis syndrome. (True)
Stretching the calf muscles cannot influence piriformis syndrome symptoms. (False)
Sciatica is the same as piriformis syndrome. (False)
The piriformis muscle is a large muscle responsible for hip flexion. (False)
The sciatic nerve runs through the centre of the piriformis muscle in all individuals. (False)
The primary mechanism of piriformis syndrome is nerve tethering. (False)
Nerve tethering can be diagnosed using X-ray imaging. (False)
Stretching exercises should be performed forcefully to achieve maximum benefit. (False)
Nerve tethering can occur at various locations along the sciatic nerve’s pathway. (True)
The sciatic nerve extends from the lower back to the feet. (True)
Nerve tethering can be caused by muscle tightness. (True)
Stretching the peroneal muscles may help with piriformis syndrome. (True)
The piriformis muscle is located deep within the buttocks. (True)
Nerve tethering can be diagnosed through a physical examination. (True)
Stretching exercises can improve ankle and foot mobility. (True)
Piriformis syndrome occurs when the sciatic nerve is compressed by the hamstring muscles. (False)
Nerve tethering is not related to the sciatic nerve. (False)
Stretching exercises can potentially reduce tension in the lower leg in nerve tethering. (True)
The piriformis muscle is responsible for knee flexion. (False)
Nerve tethering is a condition involving nerve entrapment. (True)
Stretching the calf muscles can help indirectly impact the sciatic nerve in piriformis syndrome. (True)
The hamstrings are responsible for extending the knee and flexing the hip. (True)
The peroneal muscles are located on the inner side of the lower leg. (False)
The peroneal muscles consist of two main muscles: the peroneus longus and peroneus brevis. (True)
The peroneal muscles are responsible for plantarflexion and eversion of the foot. (True)
The biceps femoris is the most medial (innermost) of the hamstrings muscles. (False)
Stretching the peroneal muscles can have an impact on piriformis syndrome symptoms. (True)
The gastrocnemius is one of the muscles located in the posterior compartment of the leg. (True)
The sciatic nerve is the longest nerve in the body and originates from spinal nerve roots L4 to S3. (True)
The peroneal nerve is one of the branches of the sciatic nerve and supplies the lateral muscles of the leg. (True)
The sciatic nerve runs deep to the gluteus maximus muscle in the buttock’s region. (True)
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