What is piriformis syndrome?
The piriformis runs from the front of the sacrum to the top of the thigh bone and helps rotate the hip outward and stabilise the pelvis. The sciatic nerve passes right beneath it in most people, and in some it passes through or above the muscle. When the muscle is overloaded, in spasm or injured, it may irritate the nerve and surrounding tissue. Piriformis syndrome is an accepted but somewhat debated diagnosis because it overlaps with other causes of buttock and leg pain. See sciatica stretches and hip bursitis.
Symptoms
- Deep, aching pain in the middle of the buttock.
- Pain that worsens after prolonged sitting, driving or sitting on hard surfaces.
- Pain with climbing stairs, running, squatting, or rotating the hip.
- Tenderness over the piriformis muscle.
- Pain, tingling or numbness spreading down the back of the thigh, usually not below the knee.
- Pain when lying on the affected side or when crossing legs.
- Relief when standing up or walking.
- Typically no significant back pain or weakness; if present, consider a spinal cause.
Causes and risk factors
- Overuse: running, cycling, rowing, repeated hill work or heavy squats.
- Prolonged sitting, especially on a wallet or hard seat.
- Direct trauma or a fall on the buttock.
- Muscle imbalance: weak glutes and tight hip rotators, poor core control.
- Leg length difference and flat feet.
- Sudden increases in training volume.
- Anatomical variation in how the sciatic nerve passes the muscle.
- Previous hip or spine surgery.
Piriformis syndrome versus sciatica from the spine
- Disc-related sciatica: pain often starts in the lower back, shoots below the knee, may worsen on coughing, sneezing or bending forward, and can cause foot weakness. See lower back strain.
- Piriformis syndrome: pain focused in the buttock, worse sitting, tenderness over the muscle, usually no back pain, rarely below the knee.
- Hip joint problems cause groin pain and stiffness.
- Sacroiliac joint pain is felt near the dimples above the buttock.
- Gluteal tendon and bursa problems cause pain on the outside of the hip.
- A clinician’s examination and sometimes MRI help separate them.
How it is diagnosed
Diagnosis is clinical. A clinician examines your back, hips and legs and uses tests such as the FAIR test (flexion, adduction, internal rotation), the Pace test (pain on resisted hip abduction and external rotation while seated) and palpation of the muscle. MRI, nerve conduction studies and sometimes ultrasound are used mostly to exclude other causes, such as disc herniation, spinal stenosis, hip joint disease or tumours. Image-guided injection can serve as both a diagnostic and therapeutic tool.
Self-care and activity changes
- Take a break from sitting every 30 minutes; stand, walk and stretch.
- Avoid sitting on a wallet or hard seats; use a cushion.
- Reduce or modify aggravating activities (hills, deep squats, high mileage) and return gradually.
- Apply heat before stretching, and ice after activity if sore.
- Use self-massage with a ball or foam roller on the buttock, gently, avoiding intense pressure directly over the nerve.
- Take paracetamol or anti-inflammatories briefly if suitable.
- Sleep on your side with a pillow between your knees.
- Avoid crossing legs.
Stretches
- Supine figure-four stretch: lie on your back, cross one ankle over the opposite knee, pull the thigh toward your chest; hold 30 seconds.
- Seated piriformis stretch: sit, cross one ankle over the opposite knee, lean forward with a straight back; hold 30 seconds.
- Knee-to-opposite-shoulder stretch lying on your back, gently, if comfortable.
- Pigeon pose or modified version, with caution if knees or hips are sensitive.
- Hip internal rotation stretch lying with knees bent and feet wide, letting the knees fall inward.
- Stretch 2–3 times a day, to mild tension, never to sharp pain or nerve tingling.
Strengthening exercises
- Glute bridges and single-leg bridges.
- Clamshells and side-lying hip abduction.
- Monster walks with a resistance band.
- Bird-dog and dead bug for core control.
- Step-ups and split squats for functional strength.
- Aim for 2–3 sessions a week, increasing load gradually over 6–12 weeks.
- Tight muscle is often weak muscle; strength often relieves it better than stretching alone. See hamstring stretches.
Medical treatment
- Physiotherapy: manual therapy, dry needling, exercise and gait or running retraining.
- Medicines: short courses of NSAIDs or muscle relaxants; neuropathic pain medicines in selected cases.
- Injections: local anaesthetic or corticosteroid under ultrasound guidance; botulinum toxin in some resistant cases.
- Shockwave therapy in selected patients.
- Surgery (piriformis release) is rare and reserved for severe cases not responding to months of treatment.
- Most people improve over weeks to a few months.
When to see a doctor
- Buttock or leg pain lasting more than 2–4 weeks despite self-care.
- Numbness, tingling or weakness in the leg or foot.
- Loss of bladder or bowel control or numbness in the saddle area: urgent.
- Severe pain at night or at rest, fever or unexplained weight loss.
- Pain after a fall or injury.
- Pain spreading below the knee with back pain.
- You are unsure whether the pain comes from your back, hip or buttock.
Three common situations
A runner with deep buttock pain after increasing mileage: reduce load, stretch and strengthen the glutes.
An office worker with buttock pain after long meetings: sitting breaks, a cushion and hip stretches.
A person with back pain, leg weakness and cough-related shooting pain: more likely a disc problem; see a doctor.
Key points to remember
Piriformis syndrome causes deep buttock pain that worsens with sitting and mimics sciatica. Break up sitting, stretch and strengthen the hips and core, and see a clinician if you have nerve symptoms or red flags. Our physiotherapy team can assess your back, hips and buttock and design your programme.
This guide is for general information and does not replace an assessment by your own doctor or physiotherapist.
Questions about piriformis syndrome
These answers are general information and do not replace an examination or individual medical advice.
What does piriformis syndrome feel like?
Deep aching in the buttock, worse with sitting, sometimes with pain or tingling down the back of the thigh.
How is it different from sciatica?
Sciatica from the spine often starts in the back and may reach below the knee; piriformis pain is focused in the buttock.
How long does it take to heal?
Often weeks to a few months with stretching, strengthening and activity changes.
Should I stretch or rest?
Both: reduce aggravating activity, stretch gently and build hip and core strength.
Does sitting make it worse?
Yes; take breaks every 30 minutes and avoid hard seats.
Do I need surgery?
Rarely; most people recover with conservative treatment.
Sources
This guide is for general information and does not replace medical advice. How a problem is diagnosed and treated depends on your examination and medical history. If you think you have an emergency, contact your local emergency services.