Piriformis Syndrome Mimicking Sciatica: A Case Report and Physiotherapy-Based Conservative Management

Patient Information

• Age: 42
• Gender: Female
• Occupation: Office worker
• Presenting Complaint: Right-sided buttock pain radiating to the posterior thigh for 4 months
• History of Present Illness:
  The patient reported insidious onset pain aggravated by prolonged sitting and driving. Walking and standing temporarily relieved the symptoms. No history of trauma or previous back problems.

Medical History: Non-contributory
Family History: Non-contributory
Medication History: Occasional NSAIDs with minimal relief

Clinical Findings

On physical examination, the patient exhibited localized tenderness and pain reproduction consistent with Piriformis Syndrome. Notably, lumbar spine palpation and neurological assessment were unremarkable, helping differentiate it from lumbar radiculopathy.

Palpation

• Tenderness over the right piriformis muscle was elicited upon deep palpation of the mid-buttock, approximately midway between the sacrum and greater trochanter.
• The pain was localized, deep, and dull in nature, with radiation toward the posterior thigh upon sustained pressure.
• No swelling or visible muscle atrophy was noted.

Provocative Tests

Several orthopedic special tests were conducted to reproduce symptoms and assess the mechanical involvement of the piriformis muscle:

• Freiberg’s Test
  • The patient was in a supine position with the hip in neutral. The examiner passively internally rotated the extended hip.
  • This maneuver stretched the piriformis, reproducing the patient’s deep gluteal pain.
  • Positive on the right side, indicating piriformis irritation.
• FAIR Test (Flexion, Adduction, Internal Rotation)
  • Performed in the side-lying position on the non-affected side.
  • The affected hip was flexed to 60°, adducted, and internally rotated while stabilizing the pelvis.
  • The test provoked buttock pain, confirming compression of the sciatic nerve by the piriformis.
  • FAIR is considered one of the most sensitive tests for Piriformis Syndrome and was clearly positive in this case.
• Pace Sign
  • The patient was seated with hips flexed at 90°, knees bent. She was instructed to abduct both hips against manual resistance.
  • The test reproduced pain and weakness in the right buttock, indicating piriformis involvement.
  • Mild weakness was noted in resisted abduction, likely due to pain inhibition rather than neurological deficit.

Neurological Examination

A thorough neurological assessment of the lower limbs was performed to exclude radiculopathy:

• Muscle strength: Normal (5/5) in hip flexors, extensors, abductors, quadriceps, hamstrings, and ankle dorsiflexors/plantarflexors bilaterally.
• Deep tendon reflexes: Normal and symmetrical (patellar and Achilles reflexes present).
• Sensory testing: No hypoesthesia or paresthesia noted in L4, L5, or S1 dermatomes.
• Straight Leg Raise (SLR) Test: Negative bilaterally, further supporting the absence of lumbar nerve root irritation.

Interpretation

The combination of:

• localized piriformis tenderness
• positive FAIR, Freiberg’s, and Pace tests
• and a normal neurological exam with a negative SLR

strongly suggested a peripheral entrapment of the sciatic nerve at the level of the piriformis muscle, rather than spinal origin sciatica. This clinical presentation, supported by imaging ruling out discogenic causes, confirmed the diagnosis of Piriformis Syndrome.

Diagnostic Assessment

• Lumbosacral MRI: No disc herniation, no nerve root impingement
• Pelvic MRI: Mild hypertrophy of the right piriformis muscle; sciatic nerve deviation noted
• Diagnosis: Piriformis Syndrome based on clinical findings and imaging correlation

Therapeutic Intervention

The patient underwent a comprehensive 6-week structured physiotherapy program, designed to address muscular imbalance, nerve irritation, and biomechanical contributors to Piriformis Syndrome. The program included the following components:

1. Stretching Program

Objective: To reduce piriformis muscle tension and increase flexibility in the surrounding musculature, thereby minimizing sciatic nerve compression.

• Piriformis Stretch (Supine and Seated Variants)
  • Supine: The patient lay on her back, flexed the affected leg, and brought it across the opposite knee, gently pulling the thigh toward the chest while keeping the pelvis neutral.
  • Seated: While seated, the affected leg was crossed over the opposite thigh, and the patient leaned forward at the hip to stretch the gluteal and piriformis region.
  • Prescription: Held for 30 seconds, 3–5 repetitions per session, 2–3 sessions daily.
• Hamstring Stretch
  Tight hamstrings may increase posterior chain tension, aggravating sciatic symptoms. A straight-leg hamstring stretch was employed with a towel or strap to avoid lumbar flexion.
• Hip External Rotator Stretch
  Addressed the deep six lateral rotators to reduce compression on the sciatic nerve. This included stretches in the pigeon pose and supine figure-4 position.

2. Strengthening Exercises

Objective: To correct muscle imbalances, improve pelvic alignment, and enhance dynamic stabilization of the lumbopelvic-hip complex.

• Gluteus Medius and Maximus Activation
  Weakness in these muscles can contribute to compensatory overuse of the piriformis.
  • Clamshells: Side-lying position, knees bent, lifting the top knee while keeping feet together.
  • Glute Bridges: Supine, knees bent, lifting pelvis while engaging glutes and core.
  • Standing Hip Abduction with resistance bands to promote lateral hip stability.
• Core Stabilization
  Lumbo-pelvic stability is essential to reduce compensatory strain on the piriformis.
  • Exercises included: Modified planks, dead bugs, and bird-dogs.
  • Focus on activating transverse abdominis and multifidus with pelvic neutral cues.
• Prescription: 2–3 sets of 10–15 repetitions per exercise, performed on alternate days to allow for neuromuscular adaptation.

3. Manual Therapy

Objective: To relieve localized soft tissue tightness and reduce muscle hypertonicity through hands-on techniques.

• Deep Tissue Release of Piriformis
  The therapist applied sustained pressure using fingers, knuckles, or an elbow to release taut bands and nodules in the piriformis muscle belly.
• Myofascial Release
  Slow, low-load manual traction of the gluteal fascia and piriformis region aimed to release fascial restrictions affecting nerve gliding.
• Trigger Point Therapy
  Identified and deactivated myofascial trigger points that reproduced referred pain patterns.

Sessions lasted 20–25 minutes, twice per week for the first 3 weeks.

4. Electrotherapy Modalities

Objective: To facilitate analgesia, reduce muscle spasm, and promote tissue healing.

• Ultrasound Therapy
  • Parameters: 1 MHz frequency, pulsed mode (20% duty cycle), 5 minutes per session
  • Targeted at the piriformis and adjacent tissues to promote deep tissue healing and reduce inflammation.
• TENS (Transcutaneous Electrical Nerve Stimulation)
  • Applied over the gluteal region using a dual-channel unit
  • Settings: High-frequency (80–100 Hz) for pain modulation via gate control mechanism
  • Duration: 20 minutes per session, 3–4 times weekly

5. Ergonomic and Postural Advice

Objective: To minimize mechanical stress on the piriformis muscle during daily activities.

• Workstation Modification
  • Lumbar-supportive chair with adjustable height and foot positioning
  • Instruction on sitting with hips above knees and avoiding crossing legs
• Activity Modification
  • Scheduled standing breaks every 30–45 minutes during sedentary tasks
  • Avoidance of prolonged external hip rotation while sitting
• Sleep Posture Education
  • Use of a pillow between the knees in side-lying position to reduce piriformis stretch
  • Avoid prone lying or excessive lumbar extension at night

Progression and Monitoring

• The patient was reassessed weekly using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) to monitor progress.
• Exercise intensity and complexity were increased progressively, based on tolerance and functional improvements.
• At week 4, dynamic tasks such as step-downs and single-leg stance drills were introduced to improve functional hip control.

Follow-Up and Outcome

• Week 2: 40% improvement in pain (VAS 8 → 5)
• Week 4: Pain significantly reduced; resumed normal walking and light activity
• Week 6: VAS reduced to 2; full return to work and function
• 3-month follow-up: No recurrence reported

Discussion

Piriformis Syndrome remains a controversial and underdiagnosed cause of sciatica. Distinguishing it from lumbar radiculopathy requires careful history, physical examination, and imaging to rule out spinal pathology.

The piriformis muscle can irritate the sciatic nerve at the point it exits under the muscle belly and over the gemellus/obturator internus complex. The FAIR test and palpation tenderness are key indicators. In this case, clinical signs coupled with MRI helped confirm the diagnosis.

Conservative treatment, particularly physiotherapy, has shown strong outcomes in symptom resolution. According to Kirschner et al. (2009), up to 80% of patients respond to non-surgical interventions. Our case confirms the effectiveness of a tailored physiotherapy protocol involving stretching, strengthening, manual therapy, and ergonomic advice [1-4].