Sciatica or Piriformis Syndrome?

What is Piriformis Syndrome, explains Vatché Papazian?

Almost all my clients who initially contact me about pain in their buttock and the leg tell me that they have sciatica! I listen patiently to their description of the pain and discomfort they have been experiencing on one side of their body- starting from one of their buttocks and down to their leg. Then I ask how far down the leg? Some say the hamstrings, some include the calves, and some go as far as the foot. But to be fair, 98% of these callers stop at the hamstrings, or in their words behind my thighs or even the calves.

I don’t blame these people for assuming that they have sciatica, for sciatica and piriformis syndrome mimic each other as far as their symptoms (but not the causes) are concerned. These potential clients or patients have already arrived to the conclusion that they are suffering from Sciatica. Most of these people have not even heard of the Piriformis Syndrome, let alone the Piriformis muscle.

The major culprit in these two scenarios – Sciatica and Piriformis Syndrome – is the sciatic nerve itself. It is the longest and largest nerve in the human body. Think of the sciatic nerve as a thick electric wire engulfing within it a few other thinner wires. There are two such nerves and they run from the lower back Lumbar L4 through to Sacral S3. These two nerves travel through the pelvis and down to the end of each leg enabling us to have feeling and sensation in our lower limbs.

Now let us look at each of these conditions separately.

Sciatica: what is it? Sciatica is a sharp (shooting) pain which starts in the lower back and transmits into the glutes (buttock) and down to the back of the leg and as far as the foot and sometimes the toes. It is worth mentioning here, that sciatica usually affects only one side of the lower body depending on which side of the spine is the area affected by degenerative diseases and other conditions.

The pain will exhibit itself in two ways: Acute, in which case it may just show up suddenly and then die away within a few days and sometimes weeks. This will be due to the gradual healing of the affected joints in the spine, ligaments, muscles and nerves. You will need to play a part in this healing process and we shall cover this later in this blog.

Chronic, in which case the pain persists for a few months and medical assistance should be sought to determine the source of the pain. This may be due to degenerative factors, scarring to tissues and damage to nerves.

What causes Sciatica? As the name suggests, the causes of sciatica relate to what happens to the sciatic nerve:

Irritation and compression of the sciatic nerve caused by different factors.
Injury or fracture to the spine causing damage to the nerve.
Narrowing (stenosis) of the spinal canal which can compress the spinal cord and the nerve.
Herniated spinal disc which can bulge and compress the nerve.
Osteoarthritis, a degenerative bone disease in the lumbar area.
Spondylolisthesis of the lower spine where one vertebra slips over the other thus pinching the nerve. (video clip courtesy of Spine-health).
Piriformis syndrome – spasm or tightening of the piriformis muscle in the glutes (buttock) area pressing against the sciatic nerve. (More about this later).

What are the common symptoms of Sciatica?

Pain in the lower back and buttocks.
Pain travelling down the leg – hamstrings, calves and sometimes the foot.
Pain is at its worse when sitting as it puts pressure on the nerve.
Tingling (sometimes burning) feeling down the leg.
Sharp pain when trying to stand up.
Persistent pain on one of the buttocks.

Forms of diagnosis for Sciatica: Your doctor will perform several tests; physical and neurological to start with. The physical one will look for any postural/structural issues with your spine; ROM – range of motion- and will also look for any muscular spasms, curvature and alignment of your spine.

The neurological test will include nerve and muscle reflexes, muscle strength and other neurological behaviour.

Imaging exams may be carried out too, such as X-rays, CT or CAT scans and even an MRI if deemed necessary.

Treatments for Sciatica: The primary treatments for sciatica are through self-care and these include:

Exercise, stretching of the muscles, using ice pack for about 20 minutes on the affected area at regular intervals for a couple of days. Heating pads assist in relaxing the muscles and encouraging blood flow; avoiding strenuous activities which involve bending forward; a dose of bed rest for a couple of days wouldn’t do you any harm.

Pain killers, such as anti-inflammatory drugs – aspirin and ibuprofen – may give some relief. If the pain becomes unbearable, your doctor may prescribe some muscle relaxants to alleviate spasm.

Steroid injection into the painful area, which may give an immediate relief, but it is not necessarily a long-term solution. Some people may benefit with this type of injection but the majority of my clients who have come to see me have said the impact was short term – a month at the most.

Deep tissue massage; stretching exercises to the affected muscles; yoga helps relax the whole body in general and also helps loosen muscle tightness; some people benefit from acupuncture and other complementary therapies.

Surgery, as a last resort, may be recommended by a specialist to correct herniated discs and any structural damage to the spine and the adjoining joints.

Piriformis Syndrome

According to the Cambridge on-line dictionary, the word Syndrome stands for: A combination of medical problems that shows the existence of a particular disease or mental condition. (https://dictionary.cambridge.org/dictionary/english/syndrome)

The piriformis is a small muscle (the shape of a triangular pizza slice) located deep under the gluteus maximus of each buttock. It originates from the lateral surface of the sacrum and inserts into the greater trochanter of the femur (thigh bone). Its function is to rotate the thigh/leg laterally i.e. outwards, away from the body.

And, last but not least, the sciatic nerve runs right underneath the piriformis muscle hence its relevance to our topic.

What are the causes of Piriformis Syndrome?

As the word Syndrome suggests, there is no one particular cause for this condition. This is caused when the piriformis muscle presses against the sciatic nerve thus causing pain in the buttock area, hamstrings, calves and sometimes the foot. Other causes include:

Spasm in the piriformis muscle.
Tight piriformis muscle due to injury or spasm.
Repeated sporting activities such as prolonged running or lunging.
Swelling or inflammation of the piriformis muscle.
Having your wallet inside your back pocket with prolonged driving/sitting in that position. This causes undue pressure the piriformis muscle which then leads to compression on the sciatic nerve.

Symptoms of Piriformis Syndrome

Dull ache in the buttock area.
Numbness and tingly feeling around the buttock area.
Pain can extend down the leg and as far as the foot.
Pain when walking uphill or climbing the stairs.
Pain increases after prolonged sitting or driving.

Diagnosis: there is no one single test to diagnose piriformis syndrome. Diagnosis is derived mainly from the patient’s medical history; description of their symptoms; by physical examination of the buttock area and range of movements of the hip and leg on the corresponding site of the pain.

How to Treat Piriformis Syndrome?

Deep massage therapy by a qualified therapist can release the muscle thus encouraging blood flow and alleviating muscle spasm. This type of treatment can be uncomfortable but, with some perseverance, the results can be rewarding.
Stretching exercises by a physical therapist whether it is a massage therapist, physio, PT to help stretch the muscle and reduce inflammation and spasm.
Ice packs. When the symptoms first start appearing, it is recommended to get some ice cubes in a food bag and place it on the painful spot for about 15-20 minutes to be repeated every 2 or 3 hours. Please make sure not to put ice directly on to the skin to avoid ice burn. This treatment can also be done by another person who could use some gentle massaging movements with the ice pack on the affected area..
Heat treatment. It is recommended that ice treatment is done immediately once the symptoms appear. Heat treatment can be followed suit after a day or two by way of a hot water bottle or a heat pad. Some people find the heat treatment more comfortable than the ice. It is up to the individual to select the one that gives better results. However, where there is inflammation, primary treatment with ice is highly recommended.
Tennis ball. I would not recommend this (painful) method unless you know what you’re doing. It is best that this technique is shown by a massage therapist who would demonstrate it on you manually (sometimes as part of the deep massage treatment) and also supervise you whilst you are trying to do it yourself.

In a future blog, I will add exercises on how to stretch and strengthen the piriformis and the gluteal muscles. Stay tuned!

Vatché Papazian, Massage Therapist

Images courtesy of: webmed.com; dailyvitamoves.com; spine-heath;