The diagnosis of piriformis syndrome is an inherently flawed process, since although the piriformis muscle might indeed be involved in creating symptoms through sciatic nerve compression, there is almost always some deeper root origin that is causing the muscle to constrict the nerve and this true causation is rarely the focus of diagnostic or treatment efforts. In essence, diagnosing piriformis syndrome is often only a small part of the larger symptomatic causation and since the actual underlying root source is rarely sought out and resolved, symptoms will likely continue far into the future. Reports from patients with chronic symptoms verify this truth 100%.
This guide examines why the diagnosis of piriformis muscle pain syndromes is often flawed from the start and advises patients of what they can do to improve their diagnostic and therapy efforts considerably.
Piriformis syndrome is most often diagnosed by chiropractors, massage practitioners, physical therapists and sports medicine doctors. Outside of these circles, piriformis syndrome is virtually unheard of in the larger healthcare sector.
Diagnosis is usually made as a revision to a previous theory of pain causation that did not respond favorably to treatment. Over 85% of patients who eventually receive a piriformis muscle-related diagnosis, were originally told that some spinal cause was the reason for their pain. Most of these cases involved sciatica that was thought to be linked to a herniated disc in the lumbar spinal region.
Diagnosis is usually made based on symptomatic expression, combined with a lack of evidence linking said pain to any lumbar causation. In some cases, pure speculation and a rudimentary physical exam provide enough subjective evidence for a caregiver to justify the diagnosis, while in other cases, further practices are used to further narrow down the possibility of piriformis-related pain.
Injection therapies are commonly used to numb the region during the diagnostic process. If Lidocaine or Botox injected into the piriformis causes the patient to enjoy relief, then the diagnosis is often affirmed. Some patients might also undergo focused imaging of the piriformis muscle using CT or MRI technologies. In these cases, the diagnostician might look for direct damage displayed by the muscle, such as injury or scar tissue. The diagnostician may also inspect the muscle to see if it demonstrates a rather common structural abnormality wherein the sciatic nerve runs directly through the structure of the muscle, rather than simply beneath it, as is deemed anatomically normal.
We see many diagnostic errors commonly associated with the evaluation of piriformis syndrome. We receive confirmation that these mistakes are made over and over again in the letters and forum submissions you send us. Below are listed many of the blunders we witness on a daily basis that lead to misdiagnosis and eventually to failed treatment targeting the piriformis muscle structure:
Care providers often cite pain elicited by manual pressure on the piriformis as being proof positive that the muscle is indeed the source. This is baseless, since the region is known to be a sensitive trigger point for many people, being that it contains the sciatic nerve and many local neurological nerve tissues.
Care providers cite symptomatic relief elicited via anesthetic injection into the piriformis as being proof positive that the muscle is the root cause of pain. Since the injected substances spread, they will affect the area regionally, possibly numbing the entire sciatic nerve. This can relieve symptoms that might occur due to many possible reasons, including spinal causation. Furthermore, even if the substances used stop muscular spasming, in the manner of Botox, no explanation is provided as to why the muscle is spasming in the first place.
Finally, diagnostic imaging that shows the nerve-through-muscle structural irregularity is often used to justify the diagnosis. Many people demonstrate this atypical anatomical formation, yet have no pain. Meanwhile, the majority of people who are diagnosed with piriformis syndrome do not demonstrate this structural abnormality. However, in all fairness, diagnosis is more prevalent among people who do demonstrate the atypical nerve placement, but this does not indicate the accuracy of the diagnosis, only the frequency that it is made. Since treatment statistics are not good for long-term resolution of pain, one must suspect that the diagnostic pronouncement is not accurate in many instances, regardless of whether the anatomy is deemed to be typical or atypical.
Our experience shows that the piriformis muscle is indeed involved in many sciatica pain expressions, both unilaterally, and less commonly, bilaterally. However, we rarely see cases where the piriformis is the actual source of the problem due to injury or the simple innocuous demonstration of the nerve-through-muscle irregularity. Instead, we usually see piriformis syndrome as yet another symptom of a larger pain problem.
Many patients are suffering from sciatica nerve pain problems, but the piriformis is not involved at all, regardless of anatomical irregularities that place the nerve inside the muscular tissues. In these cases, the cause of pain might be spinally-motivated, due to some other direct sciatic nerve impingement issue locally, enacted by disease or caused by the ischemic process.
In other patients, the piriformis is indeed in spasm and clamping down on the sciatic nerve, but why is this occurring? This question is usually left out of the diagnostic equation and treatment is rendered targeting the piriformis itself. No wonder results of this type of care are disappointing. This approach is just another example of symptomatic treatment, rather than curative care seeking to resolve the root origin of pain.
In our experience, the piriformis is often clamping down on the sciatic nerve due to simple oxygen deprivation. This chronic spasm condition is virtually always related to the mindbody process and not any circulatory concern. In these circumstances, the best approach to care is certainly knowledge therapy and results of said treatment are excellent as long as no structural issue is the underlying true cause of pain.