What is Piriformis Syndrome?
Piriformis syndrome affects 6 to 36 percent of low back pain patients
The piriformis muscle is located in the buttocks near the hip joint and helps stabilize that joint when walking. Beginning in the lower spine, the piriformis muscle connects to the top of each femur and assists in rotating the hip and turning the leg and foot outward. The sciatic nerve passes under the piriformis muscle; a small percentage of the population may have the sciatic nerve running through the muscle. When a person has Piriformis Syndrome they likely have chronic and intense pain mimicking sciatica since the muscle is compressing or irritating the sciatic nerve.
Since piriformis syndrome doesn’t show up on scans, such as MRIs, CT scans, or X-rays, it’s hard to diagnose. There is no definitive medical test that indicate piriformis syndrome and since it isn't common, many doctors aren't looking for it. In March of 2015, Drs. Hal David Martin, Manoj Reddy, and Juan Gomez-Hoyos proposed that Deep Gluteal Syndrome is a more appropriate terminology for the condition, as there are many structures capable of causing sciatic nerve entrapment in the gluteal space and the piriformis muscle is just one.
How is Piriformis Syndrome Diagnosed?
Much of the diagnostic process for piriformis syndrome involves ruling out other potential causes of the pain, such as lumbar spine irregularities or injuries. The diagnostic process depends on a review of the patient’s medical history, knowledge of spinal health and abnormalities, and patient reports of pain and other symptoms.
Treatment and diagnoses in Western medicine, for any medical condition or disease, are based largely on objective measures such as blood work, labs, and traditional diagnostic imaging and physical examinations. Pain, however, is subjective and every patient experiences it differently. Therefore, treatment of pain depends on medical personnel viewing the patient as a credible reporter of their own pain. This can put the patient at odds or in conflict with the caregivers who are charged with their treatment.
Many patients with piriformis syndrome benefit from nonoperative treatment such as physical therapy, anti-inflammatory medications, and local steroidal injections. However, there is a small subset of patients for whom nonoperative measures won’t be successful, and the patient will require a surgical decompression of the sciatic nerve. There are instances where a patient who receives surgical decompression develops scar tissue around the sciatic nerve; scar tissue can contribute to continued symptoms, and in such cases, the scar tissue may require surgery to remove.
Piriformis Syndrome and Lumbar Spine Pain
One year ago I suffered from debilitating lower back and leg and foot pain that I now know to be piriformis syndrome.
In a period of 7-1/2 months, I saw five physicians and specialists. I started with my general practitioner, was referred to a total of three orthopedic surgical specialists, then came a pain management specialist and anesthesiologist, and in the midst of it all, one emergency physician who saw me for a total of nine minutes. I was charged over $900 in copays for the privilege of those nine minutes.
I was told repeatedly that the symptoms I described and the pain levels I felt were not justifiable. My MRI scans and X-rays showed moderate degenerative disc disease, four bulging/herniated discs in my lumbar spine, and osteoarthritis in my spinal column, but no one could see what was happening in my gluteus muscles. I was told time and again I simply couldn't be experiencing things like numbness in my left leg and chronic pain reaching a 10 on a 1-10 pain scale. I couldn't find any relief for the pain, not spinal injections or a myriad of medications, and I was in just as much pain laying down as I was sitting up or standing.
Finally, after nearly eight months, I was referred to a pain intervention specialist at a local hospital's neurology clinic who listened and believed me. After a set of sacroiliac joint injections failed to provide relief, and in consideration of my health history and other symptoms such as numbness and tingling in my left leg and foot, I was diagnosed with piriformis syndrome. After working with my pain interventionist for two months, we had a diagnosis that hadn't been reached in the previous months by five physicians and specialists. I believe the key difference in treatment was my newest doctor trusted me to be an accurate reporter of my own pain and symptoms where the others had not.
When it comes to pain as sharp as piriformis syndrome, it's no wonder women notice it more often than men.
I have had three sets of local steroidal injections into my piriformis muscle to date. I’ve received a great amount of relief from these injections, enough so that I am able to walk unassisted, drive myself to various appointments and treatment centers, and participate in water aerobics and muscle training sessions as part of my continued rehabilitation. However, after 12 months, I am still unable to work outside of the home or even to work full-time from home. My pain interventionist and I have a wonderful relationship and communicate quite well. He openly admitted to me in April of this year that he’s just not sure what to do for me long-term. That's what it is like to have a rare medical condition.
My physician and I had hoped that because I had such success with my first round of steroidal injections that physical therapy and continued rehab would resolve my pain, at least mostly. However, the longest period of relief I have experienced is about six weeks, the shortest just two or three weeks. Due to high out-of-pocket costs and increased risk of infection and scar tissue, local injections are not a suitable long-term solution. I am currently awaiting an appointment with an orthopedic/hip specialist and surgeon at Vanderbilt Hospital in Nashville, Tennessee. The goal of the appointment is an assessment of whether or not a piriformis release or decompression procedure may be the right next step for me.
Living with Piriformis Syndrome
I encourage anyone with chronic pain symptoms such as I have described here to explore the possibility of a piriformis syndrome or deep gluteal syndrome diagnosis with your physician. If you find that your doctor(s) simply won’t listen to you, know that you are not alone, especially if you are a woman.
In a study observing gender-related pain biases, researchers found that there was a “growing body of evidence” that indicated significant differences in pain response and treatment between men and women. Women are more likely to experience pain and be more sensitive to it. When it comes to pain as sharp as piriformis syndrome, it's no wonder women notice it more often than men.
Robert H. Shmerling, MD, associate professor of medicine at Harvard Medical School and Clinical Chief of Rheumatology at Beth Israel Deaconess Medical Center in Boston says piriformis syndrome appears to be more prevalent among women though the reason for this is not known. Other risk factors include, but are not limited to: being overweight/obese, a history of sciatic nerve pain, bulging discs, anatomical abnormality in the piriformis muscle, or other spinal problems.
We, as patients, are our own best advocates. If you feel that your physician is not treating you well or not hearing you in regard to your pain and other symptoms, request a referral to another physician; do it again and again until you find the right one. We all deserve the best quality of life afforded to us and just because we don’t fit into any particular medical checkbox doesn’t mean we aren’t experiencing real symptoms and legitimately debilitating pain.