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Piriformis Syndrome, Low Back Pain, & Sciatica

by Dr. Stephen Gangemi on August 23, 2011

Many people suffer from hip pain, back pain, piriformis syndrome, and what is thought to be “sciatic pain”, which is often not true sciatica, but another type of pain known as sclerotenogeous pain. Hip flexion problems are very common in runners and those who use their bodies to jump and kick. Extension-type pains are very common too and can cause pain when you sit, walk, and climb stairs.

Your sciatic nerve is a thick nerve originating from many fibers in the lower back and sacral area. Actually it’s the sensations in the lower leg & foot – weakness, pain, numbness – that are typically true signs of “sciatica” symptoms as the sciatic nerve comes out from behind the knee and branches out into the tibial nerve and common peroneal nerve where they supply movement and sensations to much of the lower leg and foot. Pain above the knee – usually referred to as sclerotenogeous type pain – is pain originating from a muscle, tendon, or ligament. That is usually what is causing pain in the lower back and hamstring/thigh area, if not a local muscle or tendon strain. Though there may be disc involvement as well as other nerve related problems, (other than sciatica), most lower back, thigh pain, and hip pain is from muscular imbalances as well as inflammation in the body.

The muscles discussed in the accompanying video have significant involvement in the stability, strength, and movement of the lower back, hip, and legs.

Piriformis – this muscle  extends from under the front side of the sacrum and attaches to the greater trochanter in the upper leg. The major action is to laterally rotate the hip as well as turn the foot out. The sciatic nerve actually comes out right under the piriformis, but in 15-20% of people, it goes through it. “Piriformis syndrome” irritates the sciatic nerve. An imbalance in the muscle often causes pain and  can cause the foot to turn outwards. Since the pirformis muscles stabilize the sacrum and therefore the base of the entire spine a person can have pain all the way up to their neck or down to their foot from a piriformis issue.

Gluteus maximus – this powerful muscle extends the hip and rotates the thigh laterally a bit too,  just like piriformis. Many people think they’re having hamstring pain or hip pain from a bad disc, when really it’s because they have a glut max that isn’t functioning properly. Also, a lot of knee pain is because of a strained glut max. This muscle also makes up a significant amount of the ITB – another common injury I discuss here.

On the front side of the body are the  psoas and abdominals muscles and they are often involved in low back pain, hip pain, sciatica, and disc problems. Leg flexion, hip rotation, and the ability to reach down and touch your toes is made possible by the action of these two muscles. So pain performing these movements means that they are not working correctly. Can’t sit up because of pain or weakness from laying on your back? Pain putting on your shoes or flexing forward to pick something off the ground? Pain running, jumping, or kicking? Psoas and abdominal involvement.

No stretching! No orthotics!

I'm a board certified chiropractic physician and clinical nutritionist with a passion for true natural health care. I implement dietary & nutritional therapies, exercise & movement practices, and lifestyle changes along with manual therapy techniques to help the body heal and prevent illness and injuries.


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  1. jfitz permalink

    Great video. I learned a lot. But I couldn’t help noticing the poor posture on the ballerina. Hyperextended knees, tucked pelvis etc. I’m off to watch the itb video. Thx.

    • Thanks. Far from poor posture though. It may look that way a bit on the video but you’re looking at a professional dancer in peak condition for what her job, art, and body requires. Dancers work to develop certain muscles and patterns so they can perform various static and dynamic movements including many that are not very forgiving on the body over time, especially if there are muscular imbalances. That tucked pelvis and hyperextended knee you see is a benefit to her performance and not at all due to any muscular imbalance.

  2. jfitz permalink

    I don’t understand how hyperextended knees don’t mean an imbalance of tibialis anterior and posterior. And with the tucked pelvis, an imbalance of hamstring and quad. My concern with my clients that are high performance athletes are where there bodies will be in thirty years. Where does the posture that allows for her craft lead her down the road. I only mentioned it in the first comment because I find that tucked pelvis and hyperextended knees lead regular people down the road towards piriformis syndrome and assorted back pains. I really appreciate your replying to my comment.

    • An imbalance of those muscles you mention would mean that, for example, there is an over-facilitation of the tib anterior and an inhibition of the tib posterior, or vice-versa. Just because there is some hyperextension or even a bit of asymmetry from left to right or front to back doesn’t necessarily mean there is an imbalance. You’re correct that it is common and those body postures clues are great to look for, but for someone like Lara (since that’s who we’re talking about), I’ve even treated her backstage after a pretty intense performance. There are no imbalances in those pelvis muscles or lower leg muscles, at least resulting in the posture you’re referring to. Even once I correct the muscles that may need to be treated and everything is balanced, the knees don’t become any less hyperextended. In essence, they’re functioning very normally for her – everything is balanced and firing when it needs to fire, and relaxing accordingly too. Now “regular people” as you note, and I agree with, most likely would be a walking disaster.

  3. Erin permalink

    This was really informative for me. I am a 51 year old active woman who has been struggling with sciatic pain from my buttock down into my calf. I had an MRI of my back which did not show nerve compression but a bulging disk and another disk with some uncovering which I’ve been told is really quite normal for my age. My doctor suggested nerve root injections into my back. I really had no relief after the first one so he suggested a second one. During the second injection I felt extreme pain in my calf muscle. Unfortunately the next day I was in far worse pain than I was when I went in. I had back painful back spasms just making my bed or brushing my teeth and unrelenting calf pain. I had told him that I thought from the get go that the problem was my piriformis, but thought he knew better than me so I went in for the injection. After the second injection when I went for a follow up he suggested I see a dr for a piriformis botox injection. I had not had the injection yet. That dr put me on neurotin for nerve pain and said that some blood may have pooled after the second nerve root injection. When you were explaining where you feel pain (the trigger point) for the piriformis on the side of the buttock, that is exactly where my pain is when I touch that area I get shooting pain into my calf. I also have a lot of hip pain when walking. After seeing this video I am now contemplating getting a piriformis injection. I used to be able to use the elliptical at my gym every day and do walking lunges and weight lifting, After the second injection I got on the elliptical and the pain in my calf was so bad I had to get right off. Walking my dog has also become a challenge as I have to stop and take breaks when the calf pain gets too bad. This has totally disrupted my life, doing housework is difficult, my exercise routine which keeps me sane has been interrupted and driving my son to college and being in the car for 10 hour that day caused me to suffer horribly the next day.

  4. Erin permalink

    I also wanted to add that I never had any back pain at all when I went to see my doctor my pain was in my buttock and hip and then progressed to horrible calf pain. Now when I walk my dog I do experience some lower back pain and spasms and hip pain and of course the calf pain, the back pain did not start till after the injections which I so regret ever getting. I wish you practiced in upstate New York.

  5. VincentBaxter permalink

    Thanks a lot for all the information. I’ve been regularly frequenting a clinic for back pain and while I feel a lot better these days I never took the time to really look up the cause of my symptoms.

  6. Zondra H permalink

    For the last two years I have had some on and off shooting pain from my hip to my knee. The video was very informative in explaining which muscles and nerves were likely the culprits, so thank you for clearing that up, but I would like to know if being “pigeon-toed” could also be the problem. From what I know (basically a brief trip to the podiatrist when I was younger) I should have grown out of it, but never did. I am almost 18, is there still a way to correct this problem and if I am experiencing said back pain, is it because my hips are causing my legs/feet to point in? Thank you for taking time to consider my comment.

    • I don’t see that to be a problem – a reason for pain – as long as all the muscles are working properly.

  7. Judy permalink

    I just had a bladder lift surgery. I have been left with extreme pain in my hip and lower back. Physical therapy has not helped. What do you think happened?

    • Hard to say w/o seeing you. Surgery can cause musculoskeletal problems though; more common than you’d think.

  8. Cat permalink

    I’m a 19 year old female that’s very active and plays a lot of sports. Recently I’ve been experiencing pain in the left side of my lower back that starts right on the pelvic bone (like where you would see back dimples) and it goes into my hip. It’s probably the worst at night when I lie on my back or sides I can feel the pain go straight down my leg. Rather than a sharp pain it’s more dull and uncomfortable which causes me to be restless and move around a lot. When I sit down the pain is concentrated in and around my hip. I was wondering if it could be possible that there is a cyst on my pelvic bone that may be putting pressure on nerves? If you have any other thoughts or suggestions on what might be the cause I would really appreciate it.

    • Most likely not a cyst but of course I can’t diagnose you via internet. :) Have it checked out by a qualified doc or therapist. Many times there are muscular and fascia trigger points that need to be addressed and as I note, for women, there can be an ovarian cyst or uterine fibroid causing those glute muscular issues; (something to consider if you have hormonal issues too).

  9. Liz Killoran permalink

    Enjoyed the video. I kept getting diagnosed as having bursitis or sciatica, but I think the Psoas and Ab muscles are the culprits! I have strong cramping in the middle of my right quad so bad that I cannot touch my toes, even when sitting. And forget lifting my right leg, I get shaky and a lot of pain attempting that. There are times I feel my leg will buckle (give out on me) if I walk too fast and my thigh is cramping so badly it makes my right foot “pigeon-toed”. I am going to try those “trigger points” you mentioned, I am actually excited about seeing if these help my leg.

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