Symptoms of Piriformis Syndrome
Piriformis syndrome presents with buttock pain that radiates down the leg in a sciatic distribution, typically worsened by prolonged sitting, and is characterized by the absence of specific neurological deficits that would be expected with true lumbar radiculopathy. 1
Primary Pain Characteristics
- Pain is localized to the buttock with radiation down the posterior leg, often mimicking sciatica but following the sciatic nerve distribution 2, 3
- Pain quality varies and may be described as dull, aching, sharp, or electrical in character 1
- Symptoms are characteristically aggravated by prolonged sitting, which is a hallmark feature distinguishing it from other causes of sciatica 2, 4
- Pain may appear suddenly after activities involving back stretching or trauma 1
Key Distinguishing Features from True Radiculopathy
Unlike lumbar radiculopathy, piriformis syndrome typically does not cause specific dermatomal sensory loss or myotomal weakness 1. This is a critical distinguishing feature:
- Symptoms may mimic L5-S1 disc lesions but without the specific neurological deficits associated with true radiculopathy 1
- Neurological examination results are usually normal 2
- Straight leg raising test is typically negative, unlike in disc herniation where sensitivity is 91% 5, 2
Physical Examination Findings
- Tenderness over the greater sciatic notch and in the buttock region is a consistent finding 6, 4
- Pain is reproduced with flexion, adduction, and internal rotation (FADIR) of the hip 2, 4
- Freiberg sign (pain with passive internal rotation of the extended hip) may be positive 2
- Pace sign (pain with resisted abduction and external rotation of the thigh) may reproduce symptoms 2
- Direct palpation of the piriformis muscle causes pain and may reproduce the patient's symptoms 2
Associated Clinical Features
- In long-standing cases, patients may develop compensatory gait patterns due to chronic pain 1
- External tenderness over the greater sciatic notch is commonly present 6
- The condition is frequently misdiagnosed due to symptom overlap with lumbar radiculopathy and other causes of sciatica 1
Common Pitfall to Avoid
The most important clinical pitfall is assuming all sciatic-type pain represents disc herniation. Piriformis syndrome should be suspected when buttock pain with leg radiation occurs in the absence of dermatomal sensory deficits, myotomal weakness, or reflex changes 1, 2. The presence of pain worsened by sitting and tenderness at the sciatic notch, combined with negative straight leg raise testing, should prompt consideration of this diagnosis rather than pursuing it only as a diagnosis of exclusion 4.