Piriformis Syndrome Osteopathy and Prescriptive Exercise by Osteopaths

What is Piriformis Syndrome?

Piriformis syndrome is a neuromuscular condition characterized by symptoms that includes hip and buttock pain. The pain is often referred down the back of the leg, sometimes into the medial foot. It is often associated with numbness in the posteriomedial aspect of the lower leg as a  the result of an abnormal piriformis muscle or compression/irritation of the sciatic nerve as it travels under or through the muscle. Given its similar presentation to lumbar disc herniation, stenosis, radiculopathy, and neurogenic pain, piriformis syndrome is often difficult to diagnose (Norbury et al. 2012).

Piriformis muscle syndrome (PMS) is defined as an entrapment neuropathy involving compression of the sciatic nerve by the piriformis muscle and entailing a number of symptoms with truncal sciatic pain, initially in the muscles of the buttocks (Michel et al. 2013).

Piriformis Syndrome Osteopath


Piriformis Syndrome may be associated with fibromyalgia and this case report should make physicians aware of neurological aspects of fibromyalgia in which the piriformis muscle is involved. Coexistence of FMS and MPS is not uncommon (Siddiq et al. 2014).

Clinical Diagnosis

The most common presenting symptom of patients with piriformis syndrome is increasing pain after sitting for longer than 15 to 20 minutes. Many patients complain of pain over the piriformis muscle (ie, in the buttocks), especially over the muscle’s attachments at the sacrum and medial greater trochanter (Boyajian-O’Neill et al. 2008)

Symptoms, which may be of sudden or gradual onset, are usually associated with spasm of the piriformis muscle or compression of the sciatic nerve. Patients may complain of difficulty walking and of pain with internal rotation of the ipsilateral leg, such as occurs during cross-legged sitting or ambulation. Spasm of the piriformis muscle and sacral dysfunction (eg, torsion) cause stress on the sacrotuberous ligament. this stress may lead to compression of the pudendal nerves or increased mechanical stress on the innominate bones, potentially causing groin and pelvic pain. Compression of the fibular branch of the sciatic nerve often causes pain or paresthesia in the posterior thigh (Boyajian-O’Neill et al. 2008)

These clinical signs relate, either directly or indirectly, to muscle spasm, resulting nerve compression, or both. Tenderness with palpation over the piriformis muscle, especially over the muscle’s attachment at the greater trochanter, is common. Patients may also experience tenderness with palpation in the region of the sacroiliac joint, greater sciatic notch, and piriformis muscle—including pain that may radiate to the knee (Boyajian-O’Neill et al. 2008).

Osteopathic Treatment of Piriformis Syndrome

The goals of osteopathic manipulative treatment (OMT) for patients who have piriformis syndrome are to restore normal range of motion and decrease pain. These goals can be achieved by decreasing piriformis spasm. Indirect osteopathic manipulative techniques have been used to treat patients with piriformis syndrome (Boyajian-O’Neill et al. 2008)

The two indirect OMT techniques most commonly reported for the management of piriformis syndrome are counterstrain and facilitated positional release. Both techniques involve the principle of removing as much tension from the piriformis muscle as possible Three tender point locations can be addressed with counterstrain—at the midpole sacrum, piriformis muscle, and posteromedial trochanter. To position a patient for counterstrain treatment, the patient is generally asked to lie in a prone position with the affected side of the body at the edge of the examination table. In performing the counterstrain technique, the osteopathic physician brings the patient’s affected leg over the side of the table, placing it into flexion at the hip and knee, with abduction and external rotation at the hip. Facilitated positional release can also be achieved from the position, with compression through the long axis of the femur from the knee toward the sciatic notch. This additional compressive force can reduce patient treatment time from 90 seconds when performing counterstrain to 3 to 5 seconds when performing facilitated positional release (Boyajian-O’Neill et al, 2008)

Direct OMT techniques can be performed using either active or passive methods. The direct OMT techniques that are the most useful in treating patients with piriformis syndrome include muscle energy, articulatory, Still, and high velocity/low amplitude. The muscle energy technique can be applied in the management of piriformis spasm, as well as for associated dysfunctions of the sacrum and pelvis. No absolute contraindications are defined for the muscle energy technique. The patient must understand the required amount of muscular force and the correct direction of this force for the technique to be effective. (Boyajian-O’Neill et al. 2008)

Articulatory OMT techniques are applied by advancing and retreating from a restrictive barrier in a repetitive manner to advance that barrier and increase the range of motion. The presence of osteoarthritis can limit the applicability of this technique secondary to articulatory pain. The Still technique, a specialized form of articulatory treatment, is begun by placing a joint in a relaxed position away from restrictive barriers. Then, with an arching motion, compression is applied to the level of dysfunction and moved toward the restrictive barrier while the patient is passive and relaxed. No absolute contraindications are defined for the Still technique. High velocity/low amplitude technique is most often used in cases of piriformis syndrome to correct associated sacral and pelvic somatic dysfunctions. Extreme caution should be exercised when using this manual technique with individuals who have osteoporosis (Boyajian-O’Neill et al. 2008)


Osteopathic manipulative treatment can be used as one of several possible nonpharmacologic therapies for these patients. Nonpharmacologic therapies can be used alone or in conjunction with pharmacologic treatments in the management of piriformis syndrome in an attempt to avoid surgical intervention (Boyajian-O’Neill et al. 2008).

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Reference List

Boyajian-O’Neill LA, McClain RL, Coleman MK, Thomas PP (2008).  Diagnosis and management of piriformis syndrome: an osteopathic approach. J Am Osteopath Assoc. Nov;108(11):657-64.

Michel F, Decavel P, Toussirot E, Tatu L, Aleton E, Monnier G, Garbuio P, Parratte B (2013). The piriformis muscle syndrome: an exploration of anatomical context, pathophysiological hypotheses and diagnostic criteria. Ann Phys Rehabil Med. 56(4):300-11

Norbury JW, Morris; Warren JKM; Schreiber AL, Faulk C, MD; Moore, Mandel S (2012). Diagnosis and Management of Piriformis Syndrome. Practical Neurology

Siddiq MA, Khasru MR, Rasker JJ (2014) . Piriformis syndrome in fibromyalgia: clinical diagnosis and successful treatment. Case Rep Rheumatol. 2014:893836.

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