Piriformis syndrome: a curable pain in the buttock

For a pain that starts in the butt

I don’t think of reasons to cut

     If a spasm is found

     To relax it I’m bound

And I can change your limp to a strut.

Most of the time if a person comes in with pain going into the buttock, radiating down the back of the leg, accompanied by numbness and tingling, or even weakness, I think about a bad disc pressing on the spinal cord, but I always ask the patient to take one finger and point to where the pain starts.

Every once in a while the patient will point to the buttock and deny any pain in the midline.

On those occasions, I sometimes find a hard triangular lump at the seat of the pain. I mash on that lump and ask if the patient’s pain going down the leg got worse, and, usually, the answer comes back “Yes.”

I diagnose piriformis syndrome this way.

The piriformis muscle runs across the buttock from the sacrum to the outside hip bone at the top of the thigh. The sciatic nerve runs under, or sometimes through the pirirformis, and spasm here can give a person sciatica, the pain and numbness running down the back of the leg. In such a case we say the sciatica comes from the piriformis syndrome, and by the thinnest of coincidences I learned a simple maneuver to relieve it.

During med school I went to the home of a physician to meet a friend giving piano lessons there. While I waited, the doctor, waxing loquacious from whiskey, told me how to apply my shoulder to the flexed knee in an osteopathic manipulative technique I would later learn to call “muscle energy.”

Over the years this tool has given me immense professional satisfaction. Starting with a limping patient in pain, performing a maneuver, and watching the patient sit up and walk without pain is an experience that leaves me grinning for the rest of the day. 

It doesn’t happen very often.

Last week, I diagnosed piriformis syndrom three times, and I manipulated one patient.  I taught one patient how to self manipulate, and for the third I prescribed a muscle relaxant.

As with anything else in medicine, success depends on proper patient selection.  Penicillin works well for strep throat and syphilis but for little else; sciatica from a ruptured disc does not respond to muscle energy manipulation.  

Sometimes a person might be too big or too fragile for me to manipulate.  In those cases I turn to the more commonly used mode of treatment: muscle relaxants.

My favorite, generic metaxolone, costs more, hence the insurance companies rarely pay for it.  All the others bring sedation to the point of sleep so often that, on the rare occasions when I prescribe them, I tell the patient not to operate anything more hazardous than a salad fork. 

I know.  Because of my back problems, I’ve tried them all.


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14 Responses to “Piriformis syndrome: a curable pain in the buttock”

  1. Jason Boyle Says:

    I have exactly what you are describing above. I have only had it for a week, and I think it came in a soccer game. I can still work out etc but I have that hard triangular knot you refer to above. I have been rolling it with a foam roller, what manipulation are you referring to above?

    • walkaboutdoc Says:


      The manipulation I recommended was called “muscle energy” when I was in med school. The muscle involved is usually thought of as an external hip rotator, but the motion I focused on was the its function as hip extensor.

      I can describe the manipulation I recommended, but only your doc can tell whether or not it applies to you.

  2. SK Says:

    Doc – thanks for your post. I believe I am suffering from this condition. The pain started in the butt about a year ago after a big night of celebrating/dancing/etc. A D.O. suggested the muscle spasm in my butt was caused by a bulging disc in the lumbar region, which I was skeptical about. He attempted to treat via epidural steroid injection to the lumber region which provided no relief. Can you describe the self-manipulation maneuver? Alternatively, and probably of better use, could you point me to a YouTube video of someone administering or self-administering this manipulation? Does this video describe it? https://www.youtube.com/watch?v=qcLyd-5xuYM
    Thanks in advance.

    • walkaboutdoc Says:

      Written words describing my technique would qualify as clumsy and ambiguous without pictures. Investigate the term “muscle energy”, and think of the piriformis not just as an external rotator, but a hip extensor.

  3. Paul S. Says:

    Interesting post. I have asked doctors about piriformis syndrome, and they don’t really believe in it. They think it’s rare and not really a real condition. I’m puzzled by that because there’s info all over the internet about it. I am (was) a runner until this injury. I have been struggling with burning pain in my top foot and big toe, but my back MRI is clean. I have a knot in my butt, too, and that pinch feeling. The pain is mild down my leg, but wow it burns my foot. I have been stretching and rolling for months with no relief. What are some other common muscle relaxants that would be good to try? Or maybe in injection into the muscle? Thanks — Paul

    • walkaboutdoc Says:

      I hesitate for obvious reasons to treat without examination. A good place to start would be an osteopath; it was a D.O. who taught me the maneuver to relax the piriformis.

      Rare is in the eyes of the beholder; I see a case or two a year. Some say that means rare, others say that means common. At this phase of my career, it’s rare if I’ve seen under 5 cases in my career. It’s very real, but it’s a spectrum. In the worst case the sciatic nerve actually runs through the belly of the piriformis, and in those cases surgery is the best option (I’ve not seen one).

      I’ve not had nearly as much success using muscle relaxants as manipulation.

      Acupuncture, I would think, would be worth a try. Osler mentions it in his writings, in what is now called locus dolendi needling. Though I would certainly NOT recommend Osler’s “ordinary bonnet pin.”

  4. Sports physicals and good horses | Walkaboutdoc's Blog Says:

    […] enjoyed that patient, who gave me permission to write that I diagnosed piriformis syndrome (see my post from 2010), one of my favorite problems because I can fix it before the person […]

  5. piriformissyndromeblog Says:

    After doing PT, cortisone shots, stretching, I found something that works. My pain was on the outside of my hip. My ortho also found that my major butt muscle was flat. I started an exercise regimen to build said muscle back up. Getting back to my pain: I started sitting on a hard foam roller. It’s more pain than you can imagine but the Piriformis muscle starts to relax. I did it about 3 times a day, at least 10 minutes each. It is amazing how much better I felt in a few days. I found the suggestion on a forum for low back pain. It saved me.

  6. Elle Says:

    How do they diagnose whether the Siatic nerve runs straight through the piriformis muscle? What type of doctor should I see? Would m lumbar MRI show this? I started with an L5/s1 small disc protrusion that i believe has turned into piriformis syndrome… previous symptoms are gone and techniques to shut off the never pain no longer work and now the pain starts directly in the middle of my butt. I’m okay during the day, but night time is excruciating for me, I’m up a couple times with severe pain from my butt to above my ankle and also around my hip. I started getting acupuncture and ‘active release technique’ which has been helping temporarily, but I’m concerned I may need surgery if indeed my sciatic nerve runs through the piriformis. I do get relief from a pill containing acetominophin, magnesium, and caffeine. Also, can someone describe the foam roller technique? How big is it and I just simply sit on it?

    • walkaboutdoc Says:

      Clearly no diagnosis or advice can be given without a physical exam. Which kind of doc? Either orthopedist or FP;should have sports medicine background. As with anything else, if something works, keep it up. If it doesn’t work, forget it. And you can always make things worse with surgery.

  7. Karen Reid Says:

    A couple of more limericks for you:

    A skeleton that’s out of whack
    Causes pain in your butt or your back
    That old piriformis
    Makes pain that’s enormous
    I think it will cause me to crack.

    The sciatic nerve causes pain
    All the way from your foot to your brain.
    A single butt muscle
    Can cause all the fuss, I’ll
    Give in and resort to cocaine.

    I love writing limericks. Just ask and I’ll send you a bunch of good ones, including some about Schroedinger’s cat. By the way, I do suffer from piriformis syndrome and am looking for moves I can do at home to relieve the pain right away.

    Thanks, Karen Reid

    • walkaboutdoc Says:


      So good to hear from another limerick writer.

      Watch your email

      From time to time I start speaking in limericks, which is probably pathologic, and usually brought to a halt by my wife. Thank goodness. As fun as limericks might be, normal people who have normal conversations don’t speak in them. I can usually get by with improvising two during a conversation. I can get in three if I throw out the first four lines and let someone else make up the las

  8. Cheree Says:

    I would like to start off by saying thank you for this information, I truly believed I would need some sort of surgery, overreaction to say the least, but as I read this information my hope has been restored, my confidence up to snuff and I am performing daily leg exercises on a daily, so Thank you again.
    May you keep in touch with your readers.

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