Jordan Loewenstein, D.C. | La Jolla Chiropractor
Quick answer: “sciatica” just means pain along the sciatic nerve. Most of the time the nerve is being irritated where it leaves the spine, by a disc or a narrowed opening. Some of the time it is being irritated further down, in the buttock, where it passes beneath (or occasionally through) the piriformis muscle. The two feel similar in the leg but behave differently: piriformis syndrome is usually worse with sitting, tender deep in the buttock, and comes with little or no back pain. It also responds to a different treatment, which is why getting the source right matters more than the label.
Someone comes in with a deep ache in one buttock that shoots down the back of the thigh. They have already been told it is sciatica. They may have had an MRI that showed a small disc bulge, and they have been stretching their hamstrings for three months without much change. Sitting through a movie is the worst part of their week. When I press deep into the buttock, I find the spot immediately, and they usually say some version of “that is exactly it.”
That is not a disc. That is a muscle roughly the size of your thumb, sitting under the glutes, that has become tight and irritable enough to bother the nerve running underneath it.
The piriformis runs from the front of the sacrum out to the top of the femur. It rotates the hip outward when the leg is straight and helps pull the thigh out to the side when the hip is bent. The sciatic nerve exits the pelvis right beneath it; in a minority of people the nerve actually pierces the muscle. When the piriformis is short, tight or in spasm, it can compress or irritate the nerve directly. The modern term for this group of problems is deep gluteal syndrome, since the piriformis is not the only structure back there that can trap the nerve, but piriformis syndrome is the name most people know.
Common triggers are long hours of sitting, especially on a hard surface or with a wallet in one back pocket; a sudden increase in running or hill work; a fall onto the buttock; and weak glutes that leave the piriformis doing more stabilising work than it is built for. It is a small fraction of all leg-pain cases, roughly 6 to 8% in most estimates, but a large fraction of the stubborn ones.
No single test is definitive, so I build the picture from the history and a cluster of findings:
Because the hamstring was never the problem. Pulling on a nerve that is already irritated by a tight muscle above it tends to make things worse, not better. The muscle that needs attention is the piriformis and the deep hip rotators around it, and the muscle that needs strengthening is the gluteus medius, so the piriformis can stop doing its job.
On the first visit (45 minutes) I take the history, check hip and lumbar range of motion, run the orthopaedic and nerve tests above, and with you face down I look at how the pelvis is sitting and palpate the deep gluteal muscles. If the picture fits piriformis syndrome, I treat it the same day.
Treatment is mostly hands-on soft tissue work, using Active Release Technique to lengthen the piriformis and free the nerve where it runs beneath it, combined with adjustments of the pelvis and lumbar spine when they are restricted. Follow-ups are 30 minutes. Early sessions can be uncomfortable in the way that a deep, specific release is uncomfortable; that eases quickly as the muscle lets go.
The homework is where the lasting change happens: a piriformis stretch you can do in a chair, a figure-four stretch, hip mobility work, and glute strengthening with side-lying leg raises and clamshells progressing to bridges and hip thrusts. Most people notice the sitting tolerance improving within two to three weeks. The full program is on my piriformis stretches and exercises page.
If the exam points to the nerve root instead, the plan changes and so does the homework; that is the sciatica program.
How do I know if my sciatica is from the piriformis or a disc?
Piriformis syndrome usually has little or no back pain, deep tenderness in one buttock, pain provoked by sitting, and no true weakness or reflex change. Disc-related sciatica typically includes back pain, is worse with bending or coughing, and can produce numbness, weakness or reflex changes. An exam sorts them out better than an MRI.
Does piriformis syndrome show up on an MRI?
Usually not. Standard lumbar MRI images the spine, not the buttock, and small disc bulges seen on MRI are common in pain-free people. Piriformis syndrome is a clinical diagnosis based on history and examination.
What is the best stretch for piriformis syndrome?
The seated figure-four stretch and the supine knee-to-opposite-shoulder stretch are the most useful. Stretching the hamstrings is not helpful and can aggravate an irritated nerve.
Can a chiropractor treat piriformis syndrome?
Yes. Treatment combines soft tissue release of the piriformis and deep hip rotators, adjustment of any restricted pelvic or lumbar joints, and a progressive stretching and glute-strengthening program.
How long does piriformis syndrome take to get better?
With targeted treatment and consistent home exercise, most people notice better sitting tolerance within two to three weeks and substantial improvement in six to eight. Long-standing cases take longer.
Buttock pain that runs down the leg and gets worse when you sit? Book a first visit at my UTC San Diego office and let me find where the nerve is actually being irritated.
Dr. Loewenstein diagnoses the actual source of your pain before treating it — soft tissue work, adjustment, and rehab in one visit. Most major insurance accepted, no packages or contracts.