A muscle model with labels

There are numerous buttock muscles.

Piriformis syndrome or a fad?

Piriformis syndrome…or a fad?

The piriformis syndrome has been a topic of discussion since I was in school in the early 1980’s. In some number of patients, the sciatic nerve may run above, below or through the muscle. Of course, whatever the anatomy of a given person, that has been true for their entire life. And it is possible that something unique about their particular anatomy makes a person more vulnerable to buttock pain. We use to think that if the nerve ran through the muscle, then the muscle might get tight and cause sciatica. But like so many pet hypotheses of physical therapists and chiropractors, imputing buttock pain to the piriformis muscle is, and remains, speculative. And it’s not a parsimonious explanation either, given that sciatica is an extrememly common occurence arising from a pinched nerve root in the low back, usually from a disc herniation, hence is almost always a more probably explanation, than is the possibility of piriformis syndrome. As a clinician, fully cognizant of the black box nature of many cases of low back and buttock pain, I don’t need more tenuous possible explanations. It’s better to stick to the well-established cause of buttock pain, and keep an open, undecided mind for other possibilities, rather than commit to an uncertain, improbable cause that, when wrong, will result in wasting a patient’s time and money. And pain to palpation of the buttock region, with all the small muscles of the region, plus the phenomenon of referred pain, and the absense of a reliable clinical test for piriformis causation, all make for an unlikely diagnosis.

Why this fetishistic adoption of this hypothetical meme that is piriformis syndrome?

I think it stems from the poor diagnostic training that is common to chiropractors and physical therapists. Both practitioners can be effective treaters of pain, but their knowledge base and conceptual understanding of spinal pathology are, in my experience, wanting.

In the last 15 years physical therapists, in an effort to gain direct access to patients, i.e. the freedom to treat patients without a doctor’s referral, have increased the duration of their training to acquire PhDs, and hence be called “doctors”. But this extra education is not to acquire differential diagnosis competency. So they still don’t think with the rigor of medical doctor spine specialists, like physical medicine doctors, pain management specialists, orthopedists, and neurosurgeons.

I also don’t think most chiropractors quite understand the pathology of spines. The only reason I am unusually qualified among chiropractors is that I recognized my incompetency upon graduation, and decided to work in orthopedics, physical medicine, and neurosurgery for a combined 23 years after becoming a chiropractor. Plus, while chiropractic worked for me when I was young, it failed to help me when I had a herniated disc, so I read more medical books, and I didn’t drink the chiropractic Kool-Aid in school.

Back to the piriformis muscle. It is one of about 20 muscles in the buttock. It’s not that special. And buttock pain is the rule in sciatic pain, which is extremely common. Nicolas Bogduk agrees with me.

So if someone told you that you have piriformis syndrome, they’re probably wrong…to be kind.

If you have a pain in the butt, you have sciatica until proven otherwise. And I’ve treated sciatica almost daily since 1987. The most effective, non-surgical treatment I’ve seen, and used, by far, is spinal decompression. I’ve been using it since 2006, and everyone with neck and back pain should try it first. It works better, faster, lasts longer, and is cheaper, than all other treatments, most of the time.

If I can help you, call me at 404-558-4015.