Do I Have Piriformis Syndrome or Sciatica?

People often come to us asking: “Do I have piriformis syndrome?”

It’s a surprisingly common question from just about anyone who experiences back pain that radiates down one (or both) of their legs. When you search these symptoms online, most results will come back with the same list of terms: sciatica, a herniated disc, or piriformis syndrome.

The frustrating part is that they all share similar symptoms, so they commonly get mistaken for one another.

Most of us have been there — searching up a symptom, only to be told it could be a variety of different things. And when the mind starts to get overwhelmed by the possibilities, it clings to the bad news first…

So, we’re here to dispel some of that confusion!

Though you ultimately need a formal evaluation for a diagnosis, there are a few distinctions that can help you better understand your symptoms and what they may indicate.

Let’s review!

What is Piriformis Syndrome?

Piriformis syndrome, simply put, is when the sciatic nerve runs beneath the piriformis muscle in your buttocks. Many resources refer to this as a “neuromuscular disorder,” as it’s more of a slight deviation in your anatomy, rather than an issue caused by movement impairments.

With this in mind, it’s time to cut to the chase: you probably don’t have piriformis syndrome!

Yes, this diagnosis can cause pain, numbness, or tingling down the leg… but it’s much less common than the several other diagnoses that share the same symptoms. (Research has shown that only about 0.3 – 6% of people actually have piriformis syndrome!)

And realistically, not everyone who actually has piriformis syndrome will experience painful symptoms. It’s entirely possible for the sciatic nerve to run beneath the muscle without there being any issue or irritation.

If anything, the symptoms will arise when there’s pressure against the piriformis muscle — but, it would have to occur repetitively enough for the nerve to even become that aggravated.

So, now that we’ve pretty much ruled out piriformis syndrome, let’s dive into some alternative diagnoses that could be causing your pain…

So, What is that Pain Down the Back of My Leg?

The direct answer to this question is sciatica.

Contrary to popular belief, sciatica isn’t a diagnosis by itself — it’s moreso a term to identify the specific painful, numb, or tingly sensation that travels down your leg as a result of an irritated sciatic nerve. You’ll usually feel the symptoms increase when stretching the nerve or hamstring muscles.

This technically makes sciatica a symptom of piriformis syndrome and other specific diagnoses. (It’s like how you’d feel pain in your arm with a rotator cuff injury, but you wouldn’t differentiate the arm pain as its own diagnosis.)

Sciatica is the common denominator symptom, and it’s effectively the reason why these diagnoses often get confused… but, there’s more to each pathology that can help you differentiate your pain!

Mechanical Lower Back Pain

This is hands-down the most common problem people deal with.

“Mechanical” low back pain refers to your biomechanics: if anything in your functional movement is off and your body has to compensate with muscles in your low back, that’s where the problems begin.

In this case, you may experience some sciatica — but more likely, a majority of your pain will come from those compensatory movements in the spine. You’ll typically feel the symptoms when moving in one particular direction, like when you lean back and flex the spine or when you side-bend. (Additionally, if the pain occurs with one movement, you’ll probably feel little to no pain when you move in the opposite direction.)

There are honestly a lot of possible risk factors for mechanical low back pain. Effectively anything that can cause compensatory use of your low back muscles can contribute to this problem. Some of the most common causes include poor trunk stability, poor lifting form, decreased flexibility, sustained poor posture, or repetitive movements in one direction.

Because the issue is completely localized to your spine, and it typically only occurs during specific movements, it may seem like the symptoms are inconsistent at first.

This brings up an important aspect of back pain: pay close attention to when you feel it! If you notice it occurring with particular movement patterns rather than as a constant symptom, there’s a good chance that it’s correlated with your biomechanics and can be alleviated with a proper physical therapy assessment and strength training.

Herniated Disc

Another common diagnosis associated with sciatica is a herniated disc, which is when the disc between two vertebrae bulges out and compresses the nerve root at that level. 

Herniated discs aren’t exclusive to the low back — they can technically occur anywhere along the spine and cause that radiating pain down the correlated nerve. The pain you experience will usually suggest what level the herniated disc is at:

Image Courtesy of https://azneuromod.com/dermatomes-link-to-pain/

With sciatica, the herniated disc would be located in your lumbar spine. Alongside the standard tingling or numbness of sciatica, you’ll also feel more consistent pain in the low back, especially with any movement of the lumbar spine. Some people also feel symptoms in both legs, depending on how intense the nerve compression is.

If you find that you’re also experiencing weakness in addition to these symptoms, be sure to seek further medical attention. Weakness indicates that the bulging disc is disrupting the nerve enough to affect muscular functionality, which will require more than just physical therapy alone to alleviate.

People usually sustain herniated discs for one of two reasons: overuse, or movement while the back/spine is under load. This could include anything from poor trunk stability to poor lifting form, and it could also happen if you perform repetitive manual labor or have to stay in flexor-extended positions for long periods of time.

To distinguish a herniated disc from piriformis syndrome, focus on when and where you feel the pain. Piriformis syndrome typically worsens when there’s added pressure against the piriformis muscle, whereas a herniated disc feels worse in the morning and gradually improves throughout the day, staying central to your low back.

You can also gain a better understanding of your symptoms by working with a physical therapist — they can perform bilateral, nerve tension tests that can reproduce symptoms of a herniated disc. Or, you can also request an MRI to clearly identify any issues in the vertebrae.

And this brings us to the next important consideration for understanding your symptoms…

What Can I Do About the Pain?

First thing’s first: dial into the specifics of your symptoms, rather than fixating on all the possible diagnoses associated with sciatica!

Not only will this make things less overwhelming, but it can also help you save time in figuring out what kind of medical professional you should speak to first.

For instance, certain signals suggest that you should start out with a physician: if you’re experiencing noticeable weakness, unusual changes with your bladder or bowel movements, or have distinct saddle paresthesia. These symptoms indicate that your sciatica is more than just general pain and numbness and will likely require further medical expertise, including solutions like injections or operative alternatives.

But! If you aren’t dealing with these distinct symptoms, the issue likely hasn’t progressed enough to require a physician’s immediate attention…

And this is the perfect opportunity to speak with a physical therapist! They can evaluate where your pain is coming from and direct you accordingly — based on their findings, they will either refer you to get imaging or create a physical therapy treatment plan for your recovery.

Final Thoughts

Although sciatica is no fun to deal with, we hope this blog provided some clarity! Piriformis syndrome is a complex diagnosis, but not a common one, and the alternative diagnoses have more concrete answers for recovery and long-term pain relief.

Ultimately, seeking a physical therapist first will save you time. They can guide you towards the best next steps in your recovery and ensure that you’re equipped with the proper knowledge for your care.

By Dr. James Liaw DPT CSCS SCS

Dr. Liaw specializes in working with athletes of all calibers, spending the early part of his career in a sports medicine residency and creating sport-specific rehabilitation programs. He later went on to serve as the team PT for the Idaho Steelheads (Boise’s minor league hockey team) and furthered his expertise in sports rehab, injury prevention, preparticipation screenings, and return-to-sport testing. During his free time, he enjoys climbing (both in the gym and outdoors), watching sports (49er faithful), mountain biking, snowboarding, learning new things, and eating good food.

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