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When you have piriformis syndrome, you will give anything for relief from the persistent chronic pain that resides deep within your buttocks and radiates down your leg. When sitting, standing, or walking is incredibly painful, it’s hard to go to work, spend time with your loved ones, or enjoy your favorite activities.
If conservative treatment options aren’t providing the pain relief you need, it’s time to consider the benefits of surgical treatment. As a board-certified plastic surgeon with additional fellowship training in peripheral nerve surgery, Dr. Eric H. Williams has extensive experience helping patients with piriformis syndrome—and he may be able to do the same for you.
Causes of Piriformis Syndrome
Piriformis syndrome is typically caused by the irritation or compression of the sciatic nerve as it passes through or beneath the piriformis muscle in the buttocks. Some factors that can contribute to this irritation or compression include:
- A natural anatomical variation where the sciatic nerve passes through the piriformis muscle
- Imbalances between the muscles in the hip and pelvic region that alter the mechanics of how the piriformis muscle functions and lead to increased pressure on the sciatic nerve
- Direct trauma to the piriformis muscle or the surrounding area, such as what occurs with a hip injury, fracture, or fall
- Engaging in activities that involve repetitive hip movements, such as running, cycling, or prolonged sitting
Diagnosing Piriformis Syndrome
Common symptoms of piriformis syndrome include:
- The most common symptom seems to be severe refractory pain in the central buttock that can be described as sharp and stabbing, but some patients will experience more of a dull, chronic gnawing aching pain.
- Some will experience true “sciatica” symptoms, a radiating pain down the back of the leg. This will most often trigger a medical workup of the spine and not the sciatic nerve. In the case of piriformis, the spine will be normal.
- Pain that is triggered or worsened by activities that involve the use of the piriformis muscle, such as walking, climbing stairs, running, or stretching, is a sign of piriformis syndrome.
- Many patients report muscle weakness in the lower leg, which may include the hamstring muscles in the back of the thigh or the muscles in the lower leg below the knee.
- Tingling sensations or pain in the lower back of the thigh, lower leg into the top of the foot, or the sole of the foot are common.
- Patients often report difficulty sitting for long periods and trouble sleeping due to constant pain.
Obtaining a correct diagnosis is crucial in treating piriformis syndrome, but this condition is often misdiagnosed because of overlapping symptoms. For example, it can be mistaken for a herniated disc or superior cluneal nerve entrapment.
Conservative Treatments for Piriformis Syndrome Don’t Adress the Cause of the Condition
Common treatments for piriformis syndrome include:
- Physical therapy with a licensed physical therapist
- At-home exercises to stretch, lengthen, and relax the piriformis muscle with a foam roller
- Nerve gliding exercises
- Ice and heat therapy
- Medications
- Deep tissue massage
- Dry needling
- Botox (botulinum toxin) injections
Unfortunately, these treatments do not always work because they may not address the underlying causes of the condition. This is especially important to understand if you’re relying on medication to manage your piriformis pain.
Both over-the-counter and prescription pain relievers can provide temporary relief, but they tend to do nothing for the underlying cause of the pain. If the nerve is chronically compressed or pinched, they do not “unpinch” the nerve. It’s the same principle as if your friend broke her leg while hiking in the woods and you stuck a gag in her mouth instead of taking her to the emergency room. The gag would keep her from screaming too loud, but her pain would persist until the fracture was properly treated.
If it feels like your piriformis syndrome won’t go away, you may need to change your approach and target the cause of the nerve compression. This may be the only way to get permanent relief.
Surgical Options for Piriformis Syndrome Treatment
A common surgical option that peripheral nerve surgeons use to treat piriformis syndrome is to remove the piriformis muscle which compresses the lumbosacral plexus and the sciatic nerve deep within the pelvis, and to release these structures from other tethering structures like scar tissue or thick fibrous bands. Dr. Williams prefers to remove nearly the entire piriformis muscle to decompress and release the nerve once the diagnosis of piriformis syndrome is secure. The muscle is not required for normal function.
This surgery will not affect the way the patient moves or walks. The piriformis muscle is part of a synergistic system of muscles in the buttocks. Other muscles in the area will “pick up the slack” for the portion of the piriformis muscle affected by the surgery.
Nerve decompression or nerve “release” surgery focuses on relieving the compression or irritation of the sciatic nerve caused by the piriformis muscle, or other structures that cross over the nerves. The surgeon accesses the affected area, which may involve a traditional open incision or minimally invasive techniques, and then carefully decompresses the sciatic nerve from tissue that crosses over the nerve, which may involve releasing any surrounding tissues or fibrous bands that are compressing the nerve.
The goal of sciatic nerve decompression surgery is to alleviate the pain, tingling, and numbness associated with piriformis syndrome by ensuring that the nerve can function without any obstructions.
Recovering From Piriformis Syndrome Surgery
Surgery for piriformis syndrome is performed on an outpatient basis, so you’ll be able to return home that day. You’ll need someone to drive you home because the anesthesia used during surgery can affect your judgment and reaction time.
The time it takes to recover varies from person to person, but most patients are back to their normal activities within four to six weeks. Dr. Williams will answer your questions about driving, returning to work, and engaging in recreational activities before your surgery takes place.
Dr. Williams would expect you to be able to walk for daily activities with either crutches, a walker, or a cane immediately after surgery. You should not require a wheelchair unless you will need to be walking long distances, such as traveling through the airport or going shopping immediately after surgery. Most patients no longer require walking aids after a few days to a week. Activities can be increased slowly as tolerated.
Success of Piriformis Surgery
The success of sciatic nerve decompression or piriformis muscle release surgery is typically measured by how well it resolves the patient's symptoms and enhances their quality of life. Most patients experience significant relief immediately after surgery, followed by a steady improvement in symptoms throughout the recovery period.
Here’s what some of Dr. William’s patients have to say about their experience with surgical treatment for piriformis syndrome:
- Cynthia said, “I got my life back after surgery with Dr. Williams. I can walk with my grandkids at the zoo. I can walk at the Audubon with my camera for miles on the uneven terrain of rocks and sand. It's really nice to be able to enjoy life again. I am hugely grateful for Dr. Williams' help. I don't know where I would be without those life-changing surgeries he performed for me.”
- Debbie said, “Dr. Williams has given me my life back by removing my piriformis muscle after 20 years of sciatic pain in my right leg. He’s caring, compassionate, and truly wants to help chronic pain patients.”
- Chloe said, “Dr. Williams removed my piriformis muscle and relieved me of my sciatica pain. I am so thankful for him and all of his staff for the relief that they were able to provide me and making the process as easy as possible! I highly recommend Dr. Williams to anyone in chronic pain!”