Deep Gluteal/Piriformis Syndrome

The deep gluteal syndrome describes buttock pain which can radiate down the back of the thigh and sometimes the entire back of the leg. This condition is caused by irritation or entrapment of the sciatic nerve. Essentially the muscle(s) will become tight and put pressure on the nerve which will then cause the nerve to become irritated. Historically this has been termed piriformis syndrome, however, deep gluteal syndrome is more appropriate as there are many structures that could be involved, not just the piriformis ^{(1, 2)}.

In approximately 70% of cases, the piriformis muscle tends to be involved ⁽⁵⁾. This most commonly tends to occur over a gradual period and the condition is often described as primary or secondary. Primary deep gluteal syndrome has an anatomical cause (symptoms caused by a structure within the body), with variations such as a split piriformis muscle, split sciatic nerve or the path of the nerve overlaps with the muscle. Secondary piriformis syndrome is most common and often occurs because of a fall or after repetitive bending leading to local ischemia (blood flow restriction) ⁽⁴⁾.

This condition affects less than 1% of the general population and is very rare ⁽³⁾. Deep gluteal syndrome is estimated to account for 6%-8% of cases of sciatic pain. Among patients with this condition, fewer than 15% of cases have primary causes ⁽⁶⁾.

Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment (to rule out other potentially involved structures and gain a greater understanding of your physical abilities) to help facilitate an accurate working diagnosis.

Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made. Imaging studies like MRI or ultrasound scans are usually not required to achieve a working diagnosis, but in unusual presentations, they may be warranted.

As part of the sessions with your physiotherapist, they will help you to understand your condition and what you need to do to help the recovery from your symptoms. This may include reducing the amount or type of activity, as well as other advice aimed at reducing your pain. It is important that you try and complete the exercises you are provided as regularly as possible to help with your recovery. Rehabilitation exercises are not always a quick fix, but if done consistently over weeks and months then they will, in most cases, make a significant difference. Simple modifications may include:

• Avoiding prolonged sitting.
• Use of a soft cushion when sitting on hard surfaces.
• Avoiding having your wallet, purse, or anything bulky in your back pocket when sitting.
• You may also receive advice from an appropriately qualified healthcare professional on certain medications which can help reduce your symptoms.

For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to the sport, a rehabilitation programme should incorporate plyometric-based exercises; this might include things like bounding, cutting and sprinting exercises.

As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you might benefit from a further assessment to ensure you are making progress and to establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.

• Soft tissue massage or acupuncture may also be used as an additional adjunct, helping to reduce pain and facilitate functional restoration.
• In severe cases where conservative management has been unsuccessful, other more intrusive treatment options may be explored and this will be discussed at the appropriate time.
• Local anaesthetic and/or steroid injection into the gluteal region may offer symptom relief and allow exercise rehabilitation to be implemented.
• Surgical release of the piriformis muscle and decompression of the sciatic nerve is another option but rarely required.