Deep Gluteal/Piriformis Syndrome
1. Introduction
The deep gluteal syndrome describes buttock pain which can radiate down the back of the thigh and sometimes the entire back of the leg. This condition is caused by irritation or entrapment of the sciatic nerve. Essentially the muscle(s) will become tight and put pressure on the nerve which will then cause the nerve to become irritated. Historically this has been termed piriformis syndrome, however, deep gluteal syndrome is more appropriate as there are many structures that could be involved, not just the piriformis (1, 2).
Frequently Asked Questions
- The piriformis is a deep hip muscle that helps move the hip as well as providing stability when standing and walking. A large nerve you may have heard of known as the sciatic nerve passes underneath this muscle and, if irritated, can cause symptoms and pain and sometimes altered sensations.
- Piriformis syndrome affects less than 1% of the general population and is very rare (3).
- The incidence of this can be slightly higher in specific groups such as runners.
- No.
- With the right advice and exercises, this condition generally recovers well.
- It is not linked to other serious pathologies.
- Sedentary females, typically over 40 years old (3).
- Those who have strained the piriformis through an injury or overuse.
- Those with anatomical variations of the piriformis and/or the sciatic nerve.
- Individuals who have weakness of the surrounding hip muscles.
- Pain when walking and/or running.
- Pain with prolonged sitting, especially on firm surfaces.
- Pain can travel from the buttock into the back of the thigh, and even down the entire back of the leg
- Get input from a musculoskeletal specialist who can provide a condition-specific exercise programme.
- Modify your activity by avoiding prolonged sitting, particularly on hard surfaces.
- On average between 6-12 weeks with appropriate rehabilitation.
- In more severe cases, symptoms may persist for up to 6 months (6).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
- Pain in the centre of the buttock (3).
- Tenderness over this region in almost all instances (3). This may be accompanied by burning or cramping in the back of the thigh or buttock (3).
- There may be an associated tingling sensation and/or weakness due to the entrapment of the sciatic nerve (3).
- Tends to present following long periods of sitting, typically more severe after 30 minutes (3).
3. Causes
In approximately 70% of cases, the piriformis muscle tends to be involved (5). This most commonly tends to occur over a gradual period and the condition is often described as primary or secondary. Primary deep gluteal syndrome has an anatomical cause (symptoms caused by a structure within the body), with variations such as a split piriformis muscle, split sciatic nerve or the path of the nerve overlaps with the muscle. Secondary piriformis syndrome is most common and often occurs because of a fall or after repetitive bending leading to local ischemia (blood flow restriction) (4).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing deep gluteal syndrome. It does not mean everyone with these risk factors will develop symptoms.
- Sedentary females, typically over 40 years old (3).
- Those who have sustained damage to the piriformis from an acute injury or trauma.
- Those with anatomical variations of the piriformis and/or the sciatic nerve.
- Individuals who have weakness of the surrounding hip muscles.
5. Prevalence
This condition affects less than 1% of the general population and is very rare (3). Deep gluteal syndrome is estimated to account for 6%-8% of cases of sciatic pain. Among patients with this condition, fewer than 15% of cases have primary causes (6).
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment (to rule out other potentially involved structures and gain a greater understanding of your physical abilities) to help facilitate an accurate working diagnosis.
Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like MRI or ultrasound scans are usually not required to achieve a working diagnosis, but in unusual presentations, they may be warranted.
7. Self-Management
As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your symptoms. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference. Simple modifications may include:
- Avoiding prolonged sitting.
- Use of a soft cushion when sitting on hard surfaces.
- Avoiding having your wallet, purse, or anything bulky in your back pocket when sitting.
- You may also receive advice from an appropriately qualified healthcare professional on certain medications which can help reduce your symptoms.
8. Rehabilitation
Our clinicians will design a bespoke rehabilitation plan comprising of education, advice and certain exercises working on flexibility and strength. Your physiotherapist will provide ongoing support so that you are able to effectively manage your symptoms and prevent reoccurrence.
Below are three rehabilitation programmes created by our specialist physiotherapists targeted at addressing deep gluteal syndrome. In some instances, a one-to-one assessment is appropriate to individually tailor targeted rehabilitation. However, these programmes provide an excellent starting point as well as clearly highlighting exercise progression.
9. Deep Gluteal/Piriformis Syndrome
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme contains a variety of low-level hip strengthening and stabilisation exercises. You will also be introduced to exercises specifically aimed at the sciatic nerve. Where nerves are concerned it is important to work into a sensation of mild tension or discomfort only. Pain should not exceed 3/10 on your perceived pain scale whilst completing this exercise programme.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This is the next progression. More emphasis will be placed on strengthening and stabilising exercises and the exercises specific to the sciatic nerve will also change, but the sentiment regarding mild tension or discomfort remains. Pain should not exceed 3/10 on your perceived pain scale whilst completing this exercise programme.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This programme is a further progression with challenging progressive exercise. The same principles regarding low-level discomfort and tension remain where the sciatic nerve is concerned. Pain should not exceed 3/10 on your perceived pain scale whilst completing this exercise programme.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to the sport, a rehabilitation programme should incorporate plyometric-based exercises; this might include things like bounding, cutting and sprinting exercises.
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you might benefit from a further assessment to ensure you are making progress and to establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.
11. Other Treatment Options
- Soft tissue massage or acupuncture may also be used as an additional adjunct, helping to reduce pain and facilitate functional restoration.
- In severe cases where conservative management has been unsuccessful, other more intrusive treatment options may be explored and this will be discussed at the appropriate time.
- Local anaesthetic and/or steroid injection into the gluteal region may offer symptom relief and allow exercise rehabilitation to be implemented.
- Surgical release of the piriformis muscle and decompression of the sciatic nerve is another option but rarely required.
References
- Martin, H.D., Reddy, M. & Gómez-Hoyos, J. (2015). Deep gluteal syndrome. Journal of hip preservation surgery, 2, 99-107.
- Franklyn-Miller, A., Falvey, E. & McCrory, P. (2009). The gluteal triangle: a clinical patho-anatomical approach to the diagnosis of gluteal pain in athletes. British journal of sports medicine, 43, 460-466.
- Hopayian, K., Song, F., Riera, R., & Sambandan, S. (2010). The clinical features of the piriformis syndrome: a systematic review. European Spine Journal, 19, 2095-2109.
- Michel, F., Decavel, P., Toussirot, E., Tatu, L., Aleton, E., Monnier, G., Garbuio, P. & Parratte, B. (2013). Piriformis muscle syndrome: diagnostic criteria and treatment of a monocentric series of 250 patients. Annals of physical and rehabilitation medicine, 56, 371-383.
- Filler, A.G., Haynes, J., Jordan, S.E., Prager, J., Villablanca, J.P., Farahani, K., Mcbride, D.Q.,Johnson, J.P. (2005). Sciatica of nondisc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment. Journal of Neurosurgery: Spine, 2, 99-115.
- Fishman, L.M., Dombi, G.W., Michaelsen, C., Ringel, S., Rozbruch, J., Rosner, B. & Weber, C. (2002). Piriformis syndrome: diagnosis, treatment, and outcome—a 10-year study. Archives of physical medicine and rehabilitation, 83, 295-301.
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Lower Back, Buttocks, Upper Legs
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Spondylolisthesis
A term to describe a slight change in position (usually further forward) of one vertebra relative to the vertebrae below.
Sacroiliac Joint Dysfunction
Pain originating from the sacroiliac joint at the base of your back where the spine joins the pelvis.
Mechanical Back Pain
Lower back pain caused by structures in the back, such as joints, bones and soft tissues.
Lumbar Spinal Stenosis
Narrowing of the spaces though which lower back spinal nerves travel which can result in weakness, pain and reduced function.
Lumbar Disc Injury
Lumbar discs sit between each of the bones of the spine. Problems can occur when these discs become irritated.
Low Back Pain and Sciatica
Sciatica is a symptom describing pain and/or pins and needles down the back of the leg.
Greater Trochanteric Pain Syndrome
A condition affecting the tendons that insert into outside of the hip. A common cause of pain felt around the hip and pelvis.
Femoroacetabular Impingement
A condition that results in pain in the groin, hip and down the front of the thigh.
Femoral Nerve Radiculopathy
This is where the nerve that supplies the front of the leg is irritated and causes pain/numbess.
Cauda Equina Syndrome
A rare but serious condition as a result of compression of the nerves at the base of your spine.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Ankylosing Spondylitis
A rare condition that can cause joint stiffness and pain, often worse at night and when resting.