A Pain in the Butt – is it Sciatica or Piriformis Syndrome?
Have you ever had a pain in your buttock and just didn’t know what it was? Typically the terms sciatica and piriformis syndrome are commonly thrown around by GP’s, friends and the good old Dr Google search!
It's time to remove the guesswork and make you a bit more educated as to what the source of your problem is. Both problems are similar only in the area of the body that they affect. The source of the symptoms and how they are managed can be entirely different – this is where it pays to know what you are dealing with so that you can get a resolution to your symptoms.
A common problem with buttock pain is misdiagnosis and mismanagement leading to it lasting much longer than it actually should. Both issues can be easily diagnosed and there are plenty of treatment and exercise options to help you.
In this blog we are going to look at some basic anatomy and causes, then dive into each problem in a bit more detail and conclude with the solutions to both issues!
Taking a look at some anatomy helps us to understand the structures involved in sciatica and piriformis syndrome.
This diagram above is of the buttock and top of the thigh from behind. You can see from the close interaction between the piriformis and sciatic nerve as to why these 2 conditions can become confused and also overlap. The piriformis muscle originates at the bottom of the spine and attaches on to the head of the thigh bone. The sciatic nerve exits the spine and runs underneath the piriformis and extends down the back of the leg.
The 2nd image above shows the origin of the sciatic nerve and that its branches beginning at the L4, 5 and S1 2, 3 levels of the spine before joining together, travelling through the buttock region before going into the thigh and splitting at the knee.
Next, let’s take a look at each condition to identify what it is and what similarities and differences they have with each other.
Piriformis syndrome can be defined as:
“Piriformis syndrome is a condition in which the piriformis muscle, located in the buttock region, spasms and causes buttock pain. The piriformis muscle can also irritate the nearby sciatic nerve and cause pain, numbness and tingling along the back of the leg and into the foot (similar to sciatic pain)” (www.spine-health.com).
Causes of piriformis syndrome are commonly reported from sporting activities such as running, hill walking and forms of gym-based exercise – typically it may be due to poor technique, imbalances within local muscle groups or a sudden change in the amount of exercise that is being performed. Another common cause is compression due to sitting on hard seating or in a poor position which can compress the nerve.
Symptoms of piriformis can include localised buttock pain at the location of the muscle which extends into the larger buttock area. Pain can cause changes in comfort of sitting and ability to perform simple movements such as walking and standing without discomfort. Tingling can also be reported. Symptoms of piriformis syndrome can be reduced within 4-8 weeks if the cause and pain are managed properly
It is important to note that in severe cases the nerve compression can cause symptoms to extend down into the thigh – which is where the similarities lie with sciatica, however, this is not true sciatica. The cause of the pain is the piriformis muscle being compressed or tight with primary symptoms of localised buttock pain which in turn puts strain on the sciatic nerve causing secondary symptoms.
Sciatica can be defined as:
“Sciatica is a term used to describe nerve pain in the leg that is caused by irritation and/or compression of the sciatic nerve. Sciatica originates in the lower back, radiates deep into the buttock, and travels down the leg.” (www.spine-health.com)
Now – this is where the 2 pathologies can become a little confused as it does state that compression of the sciatic nerve causes sciatica and piriformis syndrome is compression of the sciatic nerve – however with sciatica the compression of the nerve typically comes from the nerve root which is where it exits the spine – which is above the piriformis muscle.
Causes of sciatica can often be much different from piriformis syndrome. Commonly if you have suffered a spinal disc injury at L4/5 region – a bulge in the disc can press on the nerve root causing pain symptoms. Because the nerve root exits the back through facet joints – it means it can be compressed at this area by having an overly tight back and the nerve being trapped by a tight facet joint. Sciatica involving a disc injury can take extended periods to reduce, ranging from 3-6 months. If it is due to tightness in the back then this can resolve within 2-3 months.
Common ways to develop sciatica are injuries while lifting, working in prolonged flexed positions and poor posture or extended sitting times. As a safety note – if you have back and leg pain accompanied by bladder or bowel dysfunction or numbness in your genitals or a total loss of the ability move your foot – you must proceed to an A&E, some disc bulges can cause significant compression to nerves that help your body’s vital functions and can be irreversible if not managed in a timely fashion. These symptoms happen to very small percentage of people with disc issues but it is important to make you aware.
Symptoms of sciatica usually include back pain in the lumbar region – with piriformis syndrome you do not get any back pain as it is local compression of the nerve below the level of the spine/nerve root. The back pain will then typically extend down the back of the thigh and in worse cases can go all the way to the foot. Pins and needles/tingling and even numbness can felt in the lower limb. Simple functions of washing, dressing and bending from the lower back may be difficult, walking and movements of the lower limb will also be compromised. A tightness type pulling pain is described down the back of the leg with sciatic symptoms – as well as intense pain shooting down the leg in short bursts.
Treatment & Prevention
If you are struggling to identify the cause or type of back, buttock and / or leg pain you have – visiting a healthcare professional or injury specialist would be advised – as discussed before the management of each problem differs due to its cause and so does the management plans in how you treat each problem. Gain the best diagnosis you can before starting a treatment plan.
Treatment from a therapist for sciatica and piriformis syndrome would likely involve the same treatments. Focus would be placed on soft tissue techniques ranging from spinal mobilisation (for sciatica), sports massage and deep tissue massage and percussive therapy (Theragun G3Pro) for the affected areas to help reduce tightness and tension.
If you have particularly bad nerve pain from either problem then acupuncture is an excellent way of managing pain levels in a comfortable way. Nerve pain can affect the mobility of your leg and often the buttock and thigh may be painful to touch. Acupuncture can effectively aid reduction in nerve pain and is painless to perform.
Progressing your care at home and independently will involve exercises to help mobilise the affected areas and begin to regain strength. If you have had sciatica then back mobility exercises combined with neural mobility exercises will benefit you. If the problems have been more due to piriformis then the focus of the exercises will be local to the gluteal muscles. Self-treatments for managing pain levels can include foam roller and mobility tools (see our blog on this topic) – this is an effective way to manage pain levels and aid the reduction in tension of muscles in the surrounding areas.
Prevention of both problems comes with a careful approach to exercise, new activities and postural positions. Pilates is also an effective way to strengthen the lower back and glute muscles to make your body more robust. Take a look at our previous blog on Pilates – A Self-management Guide to Lower Back Pain.
Here are a selection of simple exercises that you can try at home to start managing your symptoms of sciatica and piriformis syndrome. The first 3 would be best for sciatica when the back has some involvement.
- Knee Hugs – lie on your back and gentle hug either one of both of your knees towards your chest – go as far as your symptoms allow – the goal will be to gain full range of movement. This exercise helps you to maintain the lower backs range of movement in bending / flexion.
- Lumbar Twists – In a crook lying position, keep your knees together, take your knees to each side as far as they will go. This rotates the lower back, mobilising the facet joints of the back and also loosening the lower back muscles.
- Prone Extension – Lie on your front, place your forearms on the front and push up gently just lifting your chest off the floor. You may feel some gentle pressure in the back but should not feel sharp pain. If you do, do not push in to the intense pain. Gently hold the exercises for a few seconds and return to a flat position and repeat.
For the symptoms of piriformis and sciatica which occur in the buttock, thigh and leg – take a look at these exercises to get you started.
- Seated Sciatic Nerve Glider – in a chair, sit up with good posture in to extension. With the affected leg, pull your toes towards you and gently straighten the leg and then bend it again. This must be performed slowly and should look like you are performing a slow kick with your toes pointed up. Do not kick fast as this can aggravate the nerve and make things worse. Aim to perform this exercise until the leg becomes a bit achy then rest. This exercise can be performed throughout the day when needed.
- Piriformis Stretch – relaxing the piriformis can help to reduce pressure on the sciatic nerve which can add to your leg pain. Lie on your back and pull your knee in to your chest on the side that is affected and point it diagonally over your opposite shoulder and hold for 20-30 seconds. This will target the small glute muscle which can commonly be compressing the sciatic nerve. Repeat as many times as you need to.
- Mobility Ball / Foam Roller – targeting any of the sore areas with mobility or roller tools is recommended. A foam roller to the back can ease tension, a mobility tool in to the piriformis or sciatic nerve can help to alleviate pain levels. You will feel some discomfort in the tissue but after you finish it should feel like a relief from pain. These tools can help to relax the tight tissue such as the piriformis and also reduce nerve pain.
Seated Sciatic Nerve Glider
Mobility Ball / Foam Roller
Mobility Ball / Foam Roller
Mobility Ball / Foam Roller
So – to summarise – the main difference between piriformis syndrome and sciatica is that piriformis syndrome is mostly local buttock pain and in worse cases some leg pain. Sciatica is typified with lower back pain, buttock pain and leg pain which tracks down the back of the leg.
To best manage this you need to define which problem you have and what components need to be treated and how.