Background

Low back pain (LBP), is ubiquitous. An estimated 30-45% of persons aged 18-
55 years have some form of back pain in their lifetime. LBP most commonly
involves one of the following conditions: sciatic nerve entrapment, herniated
nucleus pulposus, direct trauma, muscle spasm due to chronic or overuse
injury, or piriformis syndrome.
Piriformis syndrome (see the image below) is characterized by pain and
instability. The location of the pain is often imprecise, but it is often present in
the hip, coccyx, buttock, groin, or distal part of the leg. The history and
physical findings are key elements in differentiating the more common forms
of LBP and piriformis syndrome. The literature and general knowledge on
piriformis syndrome is limited, compared with that of sciatica or disc
herniation. However, the common findings associated with piriformis
syndrome are agreed upon.

Nerve irritation in
the herniated disk occurs at the root (sciatic radiculitis). In piriformis
syndrome, the irritation extends to the full thickness of the nerve (sciatic
neuritis).
Yeoman first described piriformis syndrome in 1928 as periarthritis of the
anterior sacroiliac joint. The history of this condition stems from one of many
causes of lower back and leg pain. Many patients who underwent
unsuccessful surgery in the lumbosacral region were later found to have
piriformis syndrome.

Epidemiology
Frequency
United States
The female-to-male incidence ratio of piriformis syndrome is 6:1. In one study
at a regional hospital, 45 of 750 patients with LBP were found to have
piriformis syndrome. Another author estimated that the incidence of piriformis
syndrome in patients with sciatica is 6%.

The function of the piriformis muscle is to externally rotate and abduct the thigh. The
sacral plexus is closely associated with the anterior surface of the piriformis muscle.
The lumbosacral trunk and the ventral rami of the first 3 sacral nerves form the sacral
plexus. The sciatic nerve passes inferior to the piriformis muscle.
The sciatic nerve exits the pelvis via 4 routes: (1) The nerve passes anteriorly to the
piriformis between the rims of the greater sciatic foramen. (2) The peroneal portion of
the sciatic nerve passes through the piriformis; the tibial portion passes anterior to the
piriformis muscle. (3) The peroneal branch of the sciatic nerve loops above and
posterior to the piriformis muscle, whereas the tibial branch passes anterior to the
piriformis muscle. (4) The undivided sciatic nerve penetrates the piriformis muscle.
Dysfunction of the piriformis muscle can cause signs and symptoms of pain in the
sciatic nerve distribution, that is, in the gluteal area, posterior thigh, posterior leg, and
lateral aspect of the foot.