Piriformis syndrome, often causing sciatica, is frequently overlooked in patients undergoing lumbar MRI scans seeking the source of buttock and leg pain. The condition can be diagnosed with simple physical tests and is generally less invasive to treat compared to herniated lumbar disks, yet many physicians are uncertain on how to manage it effectively. The document emphasizes the need for awareness and proper diagnosis to prevent unnecessary surgeries for patients misdiagnosed with spinal issues.

2. Piriformis Syndrome
Are We Missing It?
Dr. Jayant Sharma MS (ortho) ,DNB, MNAMS
Consultant (Sports Medicine)

3. Introduction
 In the United States each year,
 1.5 million people have lumbar MRI scans to look
for the cause of the buttock and leg pain called
'sciatica'.
 More than 1.2 million of those scans fail to find the
cause in the spine.
 Three hundred thousand of the scans are sufficiently
positive that the patient has lumbar spine surgery. Of
the 300,000 surgeries, as many as 25% fail to
relieve the pain
 In many cases this is because the diagnosis of a
spinal cause for the sciatica was incorrect.
www.neurography.com/Images/Piriformis/Piriformis1

4. Introduction
 Piriformis syndrome also causes
sciatica. Its treatment is much less
invasive and severe than the
treatment of herniated lumbar disks.
However, many doctors never
consider piriformis syndrome as a
possible diagnosis. Many physicians
who are aware of it are uncertain how
to properly diagnose and treat it.

5. The muscle
 Origin
 Insertion
 Its relation to sciatic nerve

7. Abnormal anatomy
 Approximately 15% of Cadavers
exhibit that instead of Sciatic
Nerve passing below the muscle
it,
Passes through
Or
Above the Piriformis.

8. Pathophysiology
 Pecina : Hypothesized that
Sciatic Nerve passing thru
Tendinous portion of Piriformis
is susceptible to compression.
 Pace & Nigle : Myofascial pain
syndromes caused by trauma.
 McCrory : “PELVIC OUTLET
SYNDROME”; due to extra
spinal compression.
Mccory P, Bell.S-Sports Medicine 1999:27:261-74.Mccory P, Bell.S-Sports Medicine 1999:27:261-74.

9. Causes
OVERLOAD:
Exercise on hard
surface
Exercise on uneven
surface
Exercise after long
layoff
Exercise with worn
out shoes
Prolonged Sitting
BIOMECHANICSBIOMECHANICS::
On toe runningOn toe running
Banked road runningBanked road running
Stiff back musclesStiff back muscles

10. AIMS
 To study the patients of radicular low
backache for Pirifomis syndrome
 To follow up these cases for 6 months
and evaluate the present protocol of
management.

11. Materials and methods
 This study was conducted at AHRC,
Indore from Feb. 06 to July 2006.
 All patients complaining of low
backache at Ortho OPD,LBA Clinic,
and sports medicine clinic were
considered for screening for
Piriformis syndrome.

12. Classification
A.Primary
Myofascial pain caused by trauma.
B. Secondary
 Tumors
 Endometreosis
 Adhesions of T.H.R.
 Inflammation
 Malunited fractures
 Pelvic Outlet Syndrome
Papadopoulos SM, Arch Neurl.1990-1144-6Papadopoulos SM, Arch Neurl.1990-1144-6

13. Diagnostic criteria
History
 C/O - pain radiating to ipsilateral
hip, thigh, below knee.
 Exacerbated by activity -
adduction & internal rotation.
 Sitting Intolerance.

14.  FADIR TEST
 STRECHING TEST OF FREIBERG
 PACE TEST - lying with painful buttock up
and knee on table, resisted lifting up of
knee in fixed position elicits pain, rules out
pain of O.A., Disc
 SLRT +ve with relief of pain on ER.
 P/R Examination - tender mass spindle
shaped, this is the intrapelvic part of
the muscle

15. FAdIR

16. PACE
PACE

19.  In few cases when patient showed
strong clinical signs and was not
responding to physiotherapy, we
asked for an MRI.

20. No role of X-rays,
Neurophysiological Tests are
consistent with Peroneal
Division of Sciatic Nerve.
Nerve conduction shows delayed
F&H waves reflex.
MRI is diagnostic

22. Treatment protocol
For first 72 hrs
 Rest
 NSAIDS
 Muscle relaxants
 ULTRASONIC MASSAGE
After 72 hrs
 Stretching
 DTFM
 US Massage

26. After two weeks
 Local injection(3)
1. LA
2. LA + Depo medrol
3. Perisciatic
Parziale J, American Journ.Orthop,1996;25,819-23Parziale J, American Journ.Orthop,1996;25,819-23

27. Surgery
Robinson
 Piriformis muscle release
 Sciatic nerve Neurolysis.
 No effect on power of the external
rotators and abductors of hip.
 Position - Lateral
 Incision - Posterior approach
(Southern’s)

28.  Steps - insertion of
piriformis is palpated
after splitting gluteus
maximus.
 Tendon is palpated
and divided & grasped
with Allis forceps, and
dissected till its exit at
Sciatic notch.
 Full weight bearing in
5-10 days.
 Avoid prolonged
sitting for 4-6 weeks.

30.  Neurotoxin
 Clostridium botulinum
 Inhibits release of Acetylcholine
 Leads to functional denervation of
muscles
 Effective for SIX months
 U.S.F.D.A.approved since December
2000.
Botox

31. Observations
 Total patients of LBA- 754
 Patients of PS 67
 11 males and 56 females (1:5)
 36 right sided and 31 left sided
 No. of patients with significant reduction of
pain on VAS at two weeks- 50
 At four weeks 64
 17 patients were subjected to injections
 Of the remaining four two lost to f/up
 Two were subjected to MRI and when
confirmed they were operated.

32. Conclusion
 Piriformis syndrome is underdiagnosed
and undertreated entity.
 It is easy to diagnose with few physical
signs.
 When in doubt ask for an MRI
 The radiologist should be asked to look for
piriformis syndrome while screening the
spine
 With this many cases can be saved from
undergoing surgery.

33. Take home message
Piriformis syndrome
should be considered
as an important
differential diagnosis
in backache patients.

34. With best wishes
ARIHANT HOSPITAL AND RESEARCH CENTRE, INDORE