Piriformis syndrome or sciatica? The answer might be less important than you think.
Did you know there's no proven way to tell piriformis syndrome apart from sciatica that starts in your back? Good news though, it might not matter what you have.
TLDR
- Piriformis syndrome and low back sciatica squeeze the same nerve, so they're hard to tell apart.
- Piriformis syndrome is uncommon, and how uncommon is debated.
- First-line care is pretty much the same either way.
- With sciatica I skip deep hamstring and figure-4 stretches. Foam rolling my hips instead.
- Keep moving, keep walking, give it weeks to months.
Sciatica and the piriformis
Sciatica is that numbing, shooting or radiating pain from your low back into one of your glutes and down your leg. Sciatica comes from irritation or compression of the sciatic nerve or the nerve roots that form it, and that can happen in a few different places.
The piriformis is a small muscle that lies deep to the gluteus maximus (your big butt muscle) and turns your thigh outward. This muscle can compress the sciatic nerve where the nerve runs past it [1].
So is the nerve being squeezed in your lumbar spine (low back), or by the piriformis a little further down? It's very hard to tell, because the same nerve producing the same symptoms is being compressed [1].
And how common is piriformis syndrome? Turns out, not very common [2]. Estimates run anywhere from about 0.3 to 6 percent of low back pain cases [2], and a 2025 review put it as high as 5 to 8 percent of low back pain cases [3]. So it's uncommon, and still debated.
Can you tell them apart?
A 2017 systematic review looked at how piriformis syndrome is defined and tested for [1]. Some common features are buttock pain, pain that gets worse when sitting, tenderness deep in the buttock near the sciatic notch, and pain when the muscle is put under tension [1]. The study concluded that the accuracy of these tests and symptoms can't be judged from the studies done so far, so there's no proven way to tease out piriformis syndrome from other causes of the pain [1].
Take the straight leg test, where someone lifts your straightened leg while you lie on your back. It's a common check for nerve root pain from a bulging or herniated disc. But it tensions the same nerve whether the piriformis or a source in the low back is trapping it. So it could be positive for both and won't distinguish between the two [1].
I occasionally have sciatica symptoms myself, and when I was a teenager I went down the rabbit hole of trying to learn about piriformis syndrome. Maybe it was a buzzword…maybe it was popular at the time. But it's a bit of a fruitless labour, because we tend to want to do the same things almost regardless of what we have [4].
Stop poking the bear
I've had sciatica. This is what I do:
- Stop poking the bear and give that nerve a chance to calm down.
- Gently mobilize.
- Build up spinal stability and the muscles around the hips and spine. My free Back Again Basics programs walk you through which exercises to do and how many sets and reps.
A lot of people with a sore back think they need to stretch, stretch and stretch. In my opinion, if you have sciatica, lots of stretching is the opposite of what you want to do. Positions like a deep hamstring stretch combine hip flexion with a straight knee, and cadaver studies show that strains the sciatic nerve [5]. Add a lot of spinal flexion, like in a deep figure-4, and as a biomechanist I'd expect even more strain.
You may feel some temporary relief in the tight muscles, but in my experience you're also pulling on a nerve that's already irritated, which can keep it sore for longer. Those two stretches still flare my own sciatica.
What I recommend instead is foam rolling, or stretches with your spine in a more neutral position, to ease the tight muscles without putting as much tension on the nerve. My personal favourite is foam rolling the muscles of the hip.
Cadaver studies show that lifting a straight leg with the toes pulled up puts the sciatic nerve under tension [5]. As a biomechanist, I'd add tucking your chin and rounding your torso to that list: put them all together and that's when the nerve is under the most tension. Avoid that combo as much as possible until the nerve calms down. I wrote a whole newsletter on this back in July, with nerve glides to try: Does Stretching Help Sciatica?
So you have sciatica. What should you do?
A lot of people's first instinct is medication, some sort of immediate treatment, or surgery. But a 2020 trial of approximately 500 people with sciatica compared usual care with matched care, where the people judged most likely to need it were fast-tracked to an MRI and a spine specialist within 4 weeks [6]. And what they found is that the matched care, fast-tracking included, didn't make symptoms settle any faster than usual care (a median of 10 vs 12 weeks, not a significant difference) [6].
Conservative care is typically recommended before anything else [2, 4]. Not injections, not surgery, not going to specialists.
- My number one recommendation is to keep moving. Find the movements that don't add to your sciatica and keep doing them.
- In my opinion, walking is the first thing to protect. It's how we get around in this world. If walking hurts, try shorter walks with short rests rather than stopping altogether. If your leg symptoms are getting steadily worse, scale back and check in with your clinician.
- Try unloading positions like lying on your back with your hips and knees bent to 90 degrees (90-90), or countertop unloading, where you lean on your forearms on a counter to take some weight off your back. Many people find these relieving.
- Physio-led sessions and exercise geared towards not aggravating sciatica and rebuilding your capacity are the recommended first-line treatment [4].
- Rotate positions through the workday. I found this highly beneficial with my own sciatica. If you stand a lot at work, sit occasionally. If you sit a lot, stand occasionally.
If you notice new trouble controlling your bladder or bowels, or numbness around your groin or inner thighs, get medical care the same day.
Recovery takes weeks to months: in that 2020 trial, people took a median of about 10 to 12 weeks to feel much better or fully recovered [6]. So don't be upset if you don't feel relief immediately. You've got to play the long game. My own sciatica sits at about a 0 or 1 out of 10 these days, from sticking with this kind of conservative approach.
As always, have a great weekend.
Best,
Mitch
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References
[1] Hopayian and Danielyan, 2018 (online 2017). Four symptoms define the piriformis syndrome: an updated systematic review of its clinical features. Eur J Orthop Surg Traumatol 28(2):155-164. doi:10.1007/s00590-017-2031-8
[2] Vij et al., 2021. Surgical and non-surgical treatment options for piriformis syndrome: a literature review. Anesth Pain Med 11(1):e112825. doi:10.5812/aapm.112825
[3] Alrabai et al., 2026 (online 2025). Piriformis syndrome is often overlooked as a cause of gluteal pain and sciatica: diagnostic challenges and the role of imaging, a narrative review. HSS J 22(2):192-196. doi:10.1177/15563316251392059
[4] Hopayian et al., 2023 (online 2022). A systematic review of conservative and surgical treatments for deep gluteal syndrome. J Bodyw Mov Ther 36:244-250. doi:10.1016/j.jbmt.2022.12.003
[5] Boyd et al., 2013. Impact of movement sequencing on sciatic and tibial nerve strain and excursion during the straight leg raise test in embalmed cadavers. J Orthop Sports Phys Ther 43(6):398-403. doi:10.2519/jospt.2013.4413
[6] Konstantinou et al., 2020. Stratified care versus usual care for management of patients presenting with sciatica in primary care (SCOPiC): a randomised controlled trial. Lancet Rheumatol 2(7):e401-e411. doi:10.1016/S2665-9913(20)30099-0
Disclaimer: this content is educational only and does not constitute medical advice. See a practitioner if you suspect serious spinal trauma from a fall or accident, or if you experience any of the following red flag symptoms: loss of bowel or bladder control, numbness in the groin or saddle area, rapidly worsening leg weakness, back pain with fever or feeling generally unwell, or unexplained weight loss with back pain.