Piriformis Syndrome
WRITTEN BY DR RUSSELL JENSEN Principal Chiropractor — AHPRA Registration: CHI0001927257 Practising chiropractor since 2015
Southside Spine and Sport, Bicton WA .
Trained in Integrative Diagnosis (USA).
Special interest in nerve entrapment, deep gluteal pain, and sciatica.
Piriformis syndrome: what it is, what it isn't, and what actually helps
Piriformis syndrome is one of the most searched diagnoses among people with gluteal and leg pain and in my experience, one of the most over-diagnosed. That's not me dismissing the condition. It's real and I treat it regularly. But because the gluteal region is a busy anatomical neighbourhood, with several muscles and multiple important nerves all sharing a small space, piriformis syndrome is often the label that gets applied when the real problem is something else entirely.
This article covers what piriformis syndrome actually is, what else it's commonly confused with, what you can do at home, and how we approach it in clinic. If you want to understand what's causing your gluteal pain rather than just manage it, this is for you.
What is piriformis syndrome?
The piriformis is a muscle located in the gluteal region. Its job is to externally rotate the hip (turning the leg outward) and assist with hip abduction and extension. It runs diagonally from the sacrum (the triangular bone at the base of the spine) to the top of the femur, and the sciatic nerve passes directly beneath it, or in some people, directly through it.
Piriformis syndrome occurs when the piriformis becomes tight, overloaded, or irritated and that irritation then effects the nearby sciatic nerve, producing pain in the buttock that can radiate into the back of the thigh.
“Piriformis syndrome is also referred to as deep gluteal syndrome, extra-spinal sciatica, and more colourfully, wallet neuritis, named after the habit of sitting on a thick wallet that compresses the gluteal region. All refer to the same basic mechanism: nerve compression in the deep gluteal space from structures other than the spine.”
What causes it?
There are several common routes to piriformis syndrome, and identifying which applies to you matters for choosing the right treatment.
Prolonged sitting is the most common culprit. Spending long hours seated keeps the piriformis at a static length. Over time, this can cause it to contract, become sensitive and irritate the sciatic nerve.
Gluteal weakness is a contributor to a significant portion of cases I see. The piriformis is a relatively small muscle, but when the gluteus maximus, gluteus medius, and gluteus minimus are weak or inhibited, the piriformis is recruited to compensate.
Narrow range of motion in training routines are a frequently overlooked contributor, particularly in people who train regularly but follow programs that prioritise straight-plane movements such as squats and deadlifts. The piriformis is a rotator. When it never gets trained in rotation, it becomes progressively weaker.
Direct trauma to the gluteal region, like from a fall, collision, or impact, can also trigger piriformis syndrome by creating local inflammation and subsequent adhesion formation around the nerve. However this is rare for people chronic pain.
What else could it be? The differential diagnosis
This is the section that matters most, and the one most piriformis syndrome articles skip entirely.
The gluteal region contains not just the piriformis and the sciatic nerve, but also the posterior femoral cutaneous nerve, pudendal nerve and the cluneal nerves (among others). Irritation of any of these produces symptoms that overlap with piriformis syndrome.
“In my clinical experience, a meaningful proportion of patients who present with a self-diagnosis of piriformis syndrome are actually experiencing posterior femoral cutaneous nerve irritation, cluneal nerve entrapment, or a combination of the two. The treatment for each is different. Applying piriformis stretches and massage to a nerve entrapment condition will provide temporary relief at best and increased irritation at worst.”
This is why self-diagnosis from an online search (or a diagnosis made purely on symptom description without hands-on examination) is unreliable for gluteal pain. The symptoms too similar, to distinguish without clinical assessment.
Other conditions worth ruling out include:
Sacroiliac joint dysfunction - which produces localised pain at the back of the pelvis that can refer into the glute
Hamstring tendinopathy - which causes pain at the sitting bone (ischial tuberosity) that worsens with prolonged sitting and loaded stretching
Hip joint pathology - including labral tears and early hip osteoarthritis, which can refer pain around the gluteal region
Disc-related sciatica - which originates in the lumbar spine but produces gluteal and leg pain that can mimic piriformis syndrome
Cluneal nerve pain - as described above, often misidentified as piriformis or SIJ dysfunction
How is it diagnosed?
Diagnosis of piriformis syndrome is clinical, it's made through a combination of history and physical examination, not imaging. MRI and X-ray imaging is sometimes used to rule out disc or hip joint pathology.
In clinic, we use several provocation tests to assess piriformis involvement:
FAIR test (Flexion, Adduction, Internal Rotation) - places the piriformis under stretch and compresses the sciatic nerve, reproducing symptoms if the piriformis is the driver
Pace's test - resisted hip abduction in a seated position, which activates the piriformis isometrically
Beatty's test - side-lying active hip abduction, which loads the piriformis in a shortened position
Direct palpation - firm pressure applied to the belly of the piriformis in the gluteal region, which reproduces the familiar pain in positive cases
The more of these tests that reproduce the patient's symptoms, the more confident the diagnosis. A negative result across all tests suggests the piriformis is not the primary driver, and we look elsewhere.
What can you do at home?
Stretching the piriformis can provide genuine, if temporary, relief and it's a reasonable starting point. The limitation is that stretching alone doesn't address the underlying weakness or the nerve component, so relief tends to be short-lived without something else alongside it.
The modified pigeon pose (loaded)
My preferred exercise is a modified pigeon pose performed as a strengthening movement rather than a passive stretch. The key difference: instead of relaxing into the position, you actively press your raised knee into the surface beneath it (a table, bench, or the floor) with enough force to feel the gluteal muscles working. Aim for 10 controlled repetitions, holding the press for 2-3 seconds each time.
This approach is borrowed from the ATG (Athletic Truth Group) system developed by Ben Patrick, and it's more effective than a passive stretch because it trains the piriformis and surrounding hip muscles in the range where they're weakest (the externally rotated, flexed position) rather than just lengthening them passively.
If you feel anything other than a muscular working sensation during this exercise (sharp pain, radiating nerve pain, or tingling) stop immediately and seek clinical advice before continuing.
Hip external rotation strengthening
Clamshells, side-lying leg raises, and seated external rotation exercises all strengthen the important muscles around the hip. These are most useful as part of a structured program after the acute pain phase has settled.
See our rehabilitative exercises page for guidance on progressive hip strengthening.
When to see a professional
Seek assessment sooner rather than later if any of the following apply:
Your symptoms have persisted for more than 4-6 weeks despite home management
You have radiating pain, tingling, or numbness into the back of the thigh or leg
The pain is waking you at night
Stretching seems to make the symptoms worse rather than better
You're unsure whether what you have is actually piriformis syndrome
You've tried repeated stretching and massage without lasting improvement
The last point is particularly important. Sustained lack of response to piriformis-targeted treatment is a strong signal that the piriformis is not actually the primary problem.
How we treat piriformis syndrome at Southside Spine and Sport
Our approach is built around two questions: is this actually the piriformis, and if so, what drove it to become a problem?
Accurate diagnosis first
Before any treatment, we perform a thorough clinical assessment to confirm whether the piriformis is the primary driver, or whether another structure, a nerve, the SIJ, the hamstring tendon, or the hip joint is responsible. Treatment aimed at the wrong structure is the most common reason people with gluteal pain don't get better.
Soft tissue therapy
Once we've confirmed piriformis involvement, we apply targeted manual therapy directly to the muscle and the surrounding soft tissue, including the sciatic nerve in the deep gluteal space. This is different from general glute massage. We are working with specific depth, direction, and nerve mobility in mind.
Where nerve entrapment is a component, we also apply neural mobilisation techniques to restore normal nerve movement through the area. Learn more about our soft tissue therapy and adhesion release approaches.
Shockwave therapy
For some people we use shockwave therapy to reduce nerve sensitivity and promote healing in the surrounding connective tissue. As with our other services, Radial shockwave is included in our standard consultation fee at no additional cost.
Learn more about our shockwave therapy service.
Progressive strengthening
The final phase, and the one that prevents recurrence, is addressing the gluteal weakness that allowed the piriformis to become overloaded in the first place. We can design a progressive program starting from where the patient is, not where a generic protocol assumes they should be.
How long does recovery take?
For straightforward piriformis syndrome most patients see meaningful improvement within 2-4 sessions. Complex cases take longer, typically 6-12 weeks, because the nerve needs time to settle in addition to the muscle recovering.
The most important factor in prognosis is accurate diagnosis early. Patients who've spent months treating the wrong structure take longer to recover.
Frequently asked questions
What is piriformis syndrome?
Piriformis syndrome is a condition in which the piriformis muscle in the gluteal region becomes tight, overloaded, or irritated, effecting the nearby sciatic nerve. It produces buttock pain that can radiate into the back of the thigh, and is often worse after prolonged sitting.
How do I know if I have piriformis syndrome or sciatica?
Piriformis syndrome typically produces buttock and upper thigh pain that is worse with sitting and eases with movement. Disc-related sciatica usually travels from the lower back through the full length of the leg, often to the foot. The two can co-exist. A clinical examination is the only reliable way to distinguish them.
What causes piriformis syndrome?
The most common causes are prolonged sitting, weakness in the surrounding gluteal muscles causing the piriformis to overwork, and training programs that neglect hip rotation and lateral movements. Direct trauma and anatomical nerve variations can also contribute.
Is piriformis syndrome the same as deep gluteal syndrome?
Deep Gluteal Syndrome and Piriformis Syndrome are terms that are typically interchanged.
What is the best treatment for piriformis syndrome?
In our experience, the most effective approach combines targeted soft tissue therapy to reduce piriformis tension and restore nerve mobility, and progressive gluteal strengthening to correct movement patterns. Stretching alone provides temporary relief but doesn't address the underlying weakness or nerve component.
Can piriformis syndrome go away on its own?
Mild cases often settle within 2-3 months (natural histoy of most problems) with rest and stretching. Difficult cases warrant clinical assessment and are unlikely to fully resolve without targeted treatment.
“Gluteal or leg pain that isn’t improving, or that you’re not sure is actually piriformis syndrome? A proper clinical assessment will tell you exactly what structure is involved and give you a clear path forward.”
Book an appointment online or send us a message if you'd like to ask a question first.
We're based in Bicton and see patients from across Perth's southern suburbs, including Fremantle, Melville, East Fremantle, Cockburn, and surrounding areas.
Reviewed and updated by Dr Russell Jensen, Principal Chiropractor (AHPRA: CHI0001927257),
Southside Spine and Sport — May 2026. Originally published December 2023.
This article is for general information only and does not constitute medical advice. Always consult a qualified health professional for diagnosis and treatment.
