Conditions We Treat
Piriformis Syndrome
At a glance
Piriformis syndrome is deep buttock pain, sometimes with sciatica-like pain down the leg, caused when the sciatic nerve is irritated by the piriformis muscle rather than by a disc in the spine. It is usually worse with sitting and most often affects adults in middle age. Treatment combines careful assessment of the back and hip, soft tissue work and a stretching and strengthening programme, with dry needling and shockwave therapy supported by randomised trials.
Twenty minutes into a meeting, a deep ache settles into one buttock. Sometimes it creeps down the back of your thigh. You shift onto the other side, then stand up and walk around, and it eases until you sit again. Press into the middle of the buttock and you find a spot that is surprisingly tender.
The piriformis is a small, flat muscle that runs from the base of the spine to the top of the thigh bone, deep beneath the larger gluteal muscles. The sciatic nerve passes right beside it on its way into the leg. When the muscle is irritated or overloaded, the nerve can be irritated in this tight space. Piriformis syndrome is one form of what is now called deep gluteal syndrome, and it is estimated to account for 0.3% to 6% of low back and posterior thigh pain. Most cases follow some kind of insult, such as a knock to the buttock, long periods of sitting, running or walking long distances or a leg length difference, while a smaller number come from natural variations in how the nerve runs past the muscle (Vij et al., 2021).
This is what separates it from the more familiar form of sciatica. Disc-related sciatica starts in the lower spine, and a disc herniation is its most common cause (Yürük et al., 2024). With piriformis syndrome, it is the piriformis muscle in the buttock that irritates the nerve, so the spine is not the source. A systematic review of its clinical features found four that stand out: buttock pain, pain made worse by sitting, tenderness near the greater sciatic notch (the deep hollow in the middle of the buttock) and pain with any movement that puts tension through the piriformis. The same review noted that a normal straight leg raise test does not rule it out (Hopayian & Danielyan, 2018).
The two can look alike, and scans do not always settle the question. In a 2024 study of 110 people with sciatica seen at a pain clinic, 27 were diagnosed with piriformis syndrome after a diagnostic injection, and incidental findings on imaging did not predict who had it (Yürük et al., 2024). That is why we assess the lower back, the hip and the buttock together at our Sandton practice, testing reflexes, strength, sensation and nerve tension alongside hip movement and the tests that load the piriformis. If the picture points towards the spine or needs a closer look, we can refer you directly for X-rays, ultrasound or a specialist opinion.
Treatment starts conservatively. A 2026 systematic review of 12 studies found that combining stretching with other rehabilitation, such as muscle energy techniques or strengthening exercises, generally gave greater improvements in pain, function and range of motion than stretching alone (Aali et al., 2026). Our approach follows that pattern: soft tissue work and muscle energy techniques for the piriformis and surrounding hip muscles, mobilisation of the hip and lower back where they are stiff and a graded rehabilitation programme that builds strength through the hip and trunk. We also look at what is loading the muscle, from long hours in the car to a jump in running distance.
Because the piriformis sits so deep, dry needling is a useful way to reach it directly, and needling the piriformis is a routine part of how we treat this condition. Dr Matthew Proctor lectured myofascial dry needling to chiropractic master's students at the University of Johannesburg for many years. In a randomised trial, three sessions of dry needling produced a clinically meaningful reduction in pain at one week compared with a waitlist group (Tabatabaiee et al., 2019). Shockwave therapy offers a needle-free alternative. A 2026 randomised trial of 48 patients compared three sessions of radial shockwave with three sessions of dry needling, both alongside a home stretching routine. Both groups improved significantly in pain, disability and function at one and three months, with no significant difference between them (Dede et al., 2026).
Occasionally, buttock and leg pain comes with symptoms that need same-day medical attention. International guidelines agree on numbness or altered feeling around the groin, bottom or inner thighs and new problems with bladder or bowel control, and many also include new weakness in the leg (Hennessy et al., 2025). They are uncommon, but if you notice any of them, go to your nearest emergency unit rather than waiting for an appointment.
In pain now? Same-day appointments available at our Sandton rooms.
Book OnlineCommon symptoms of piriformis syndrome
- Deep, aching pain in one buttock
- Pain that builds the longer you sit
- A tender spot deep in the middle of the buttock
- Pain, tingling or numbness spreading down the back of the thigh
- Pain when crossing the affected leg over the other knee
- Discomfort when the hip is turned inward or stretched
- Shifting your weight off one side when seated
- Difficulty getting up after sitting for a while
- Tight, restricted hip movement on the affected side
Buttock pain that keeps returning every time you sit is worth having assessed early, so the right source is treated from the start.
Located on Rivonia Road in Morningside, we treat patients from Sandton, Bryanston, Rivonia, Fourways and across Johannesburg.
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Frequently Asked Questions
The typical picture is a deep ache in one buttock that builds the longer you sit. A systematic review of its clinical features found four that stand out: buttock pain, pain made worse by sitting, tenderness deep in the buttock near the greater sciatic notch and pain with movements that put tension through the piriformis muscle. Some people also have sciatica-type pain or numbness spreading down the back of the leg.
Piriformis syndrome is one cause of sciatica, but the nerve is irritated in the buttock rather than where it leaves the spine. Buttock tenderness, pain on sitting and pain when the piriformis is stretched point towards it, while a normal straight leg raise test does not rule it out. The two can overlap, so the place to start is a hands-on assessment of the lower back, hip and buttock together.
Yes. Conservative care is the first-line approach, and our treatment combines soft tissue work and muscle energy techniques for the hip muscles, mobilisation of stiff joints in the hip and lower back and a graded stretching and strengthening programme. Where it suits you, we add dry needling or shockwave therapy, both of which have been tested in randomised trials for piriformis syndrome.
Yes, and we needle the piriformis directly as part of treatment. In one randomised trial, three sessions of dry needling produced a clinically meaningful reduction in pain at one week compared with a waitlist group. A 2026 trial found that dry needling and shockwave therapy, each combined with home stretching, both improved pain and function at one and three months.
Recovery time varies from person to person. In a 2026 randomised trial, people treated with either shockwave therapy or dry needling alongside a stretching routine had improved significantly by one month and kept that improvement at three months. Your progress is reviewed at each visit and the plan adjusted to match.
Stretching helps, but it works better as part of a broader plan. A 2026 systematic review of 12 studies found that combining stretching with other rehabilitation, such as muscle energy techniques or strengthening exercises, generally gave greater improvements in pain, function and range of motion than stretching alone.
References
- Hopayian K, Danielyan A. Four symptoms define the piriformis syndrome: an updated systematic review of its clinical features. European Journal of Orthopaedic Surgery & Traumatology. 2018;28(2):155-164.
- Vij N, Kiernan H, Bisht R, et al. Surgical and non-surgical treatment options for piriformis syndrome: a literature review. Anesthesiology and Pain Medicine. 2021;11(1):e112825.
- Yürük D, Can E, Genç Perdecioglu GR, Yıldız G, Akkaya ÖT. Prevalence of piriformis syndrome in sciatica patients: predictability of specific tests and radiological findings for diagnosis. British Journal of Pain. 2024;18(5):418-424.
- Aali S, Rezazadeh F, Imani F, Moradzadeh N, Prisacaru C, Badicu G. Effectiveness of stretching techniques in piriformis syndrome management: a systematic review. European Journal of Translational Myology. 2026. Online ahead of print.
- Tabatabaiee A, Takamjani IE, Sarrafzadeh J, Salehi R, Ahmadi M. Ultrasound-guided dry needling decreases pain in patients with piriformis syndrome. Muscle & Nerve. 2019;60(5):558-565.
- Hennessy O, Devitt AT, Synnott K, Timlin M. Assessment and early investigation of cauda equina syndrome: a systematic review of existing international guidelines and summary of the current evidence. European Spine Journal. 2025;34(4):1545-1551.
- Dede BT, Toktaş M, Kurnaz S, Oğuz M, Bağcıer F, Aytekin E. Extracorporeal shock wave therapy versus dry needling for piriformis syndrome: a randomized clinical trial. Turkish Journal of Physical Medicine and Rehabilitation. 2026;72(1):39-47.