Sciatica or piriformis syndrome? Why the distinction matters for your treatment

Most patients who come in telling me they have sciatica don’t have true sciatica. They have piriformis syndrome. The symptoms can feel almost identical — shooting or aching pain from the buttock down into the leg, often described as deep, burning, or electric. But the cause, the diagnosis, and the treatment are substantially different.

Getting the distinction wrong is one of the most common reasons that “sciatica treatment” fails.

---

What sciatica actually is

Sciatica is a symptom, not a diagnosis. It describes pain that follows the path of the sciatic nerve — from the lower back through the buttock and down the leg, sometimes as far as the foot.

True sciatica is caused by compression or irritation of a nerve root in the lumbar spine. The most common causes are:

• Disc herniation — the soft material inside a spinal disc pushes out and presses on a nerve root (most commonly L4, L5, or S1)
• Foraminal stenosis — narrowing of the opening through which the nerve root exits the spine
• Facet joint compression — the posterior joint compresses the nerve root exiting below it
• Spinal stenosis — generalised narrowing of the spinal canal, more common in older patients

Each of these has a specific anatomical pattern, a specific provocation profile, and a specific treatment approach. Treating a disc herniation the same as a facet joint compression produces poor results.

---

What piriformis syndrome actually is

Piriformis syndrome is compression or irritation of the sciatic nerve at the level of the piriformis muscle — a deep external rotator of the hip that sits immediately adjacent to (or, in some people, wrapping around) the sciatic nerve.

When the piriformis is in spasm, overworked, or enlarged, it can compress the sciatic nerve deep in the buttock — producing pain that travels down the leg in a pattern almost identical to nerve root compression in the spine.

“Dr. Devon Savarimuthu, DC, CSCS, says: ‘In my experience, about 30% of patients who come in saying they have sciatica have piriformis syndrome. The treatment protocols are substantially different. That distinction is the whole ballgame.’”

The distinction matters because:

• Piriformis syndrome doesn’t involve the lumbar spine — spinal manipulation or traction won’t fix it
• True sciatica often doesn’t involve the piriformis — stretching the piriformis won’t fix it
• Treating piriformis syndrome as a disc problem can make symptoms worse
• Treating a disc herniation as a piriformis problem delays appropriate care

---

How to tell the difference clinically

Neither a patient nor a general practitioner can reliably distinguish these two conditions based on symptom description alone. It requires a clinical examination with specific provocation testing.

Signs that suggest true lumbar nerve root compression (sciatica):

• Pain that changes with lumbar flexion or extension (disc herniations typically worsen with sitting/flexion; stenosis worsens with extension/walking)
• Positive straight leg raise test — sciatic nerve tension test that reproduces leg pain with the leg at less than 60 degrees
• Numbness or tingling in a specific strip of skin — this points to which nerve root level is compressed
• Weakness in foot or ankle dorsiflexion (L4/L5 involvement)
• Central back pain that radiates into the leg

Signs that suggest piriformis syndrome:

• Deep buttock pain as the primary complaint, with referred pain down the leg
• Pain that worsens with prolonged sitting — specifically with the hip flexed and internally rotated (sitting with legs crossed tends to aggravate it)
• Positive FAIR test — Flexion, Adduction, Internal Rotation of the hip reproduces the deep gluteal pain and referral
• Positive PACE test — resisted hip abduction and external rotation in a seated position
• Pain at the greater sciatic notch on palpation
• No change with lumbar loading positions

Research on the prevalence of piriformis syndrome as a cause of sciatica-like symptoms suggests it may account for a small but clinically important share of cases, and it is easy to miss when the exam jumps straight to the lumbar spine. (Hopayian et al., PM&R, 2019)

---

When imaging is needed — and when it isn’t

MRI of the lumbar spine is the gold standard for diagnosing disc herniation, stenosis, and nerve root compression. If clinical testing suggests true nerve root compression, imaging before treatment is appropriate.

However, MRI findings and symptoms are often poorly correlated. A 2015 study in the American Journal of Neuroradiology found disc bulges in approximately 50% of asymptomatic patients over 40. (AJNR, Jensen et al.) An incidental finding on an MRI doesn’t mean it’s causing your pain.

For piriformis syndrome specifically, standard lumbar MRI will usually be unremarkable — which is one reason it’s frequently missed when imaging is ordered before a clinical examination.

The clinical examination should drive the imaging decision — not the other way around.

---

The Endura approach to sciatica and piriformis syndrome

The first visit is a full structural assessment designed to distinguish between lumbar nerve root pathology and extra-spinal nerve compression. You leave with:

• A specific diagnosis — not “sciatica” as a catch-all
• A written treatment plan targeting the correct structure
• Clarity on whether imaging is needed before treatment begins
• A timeline

If it’s piriformis syndrome, treatment targets the piriformis and the deep hip muscles — not the lumbar spine. If it’s true nerve root compression, the plan targets the specific lumbar structure that’s involved with the right approach for that finding.

If the case requires specialist input — neurology, orthopaedics, or pain management — I’ll tell you at the assessment and help you navigate the next step.

Guaranteed in 6 visits — or the next two are on us.

---

Related reading

• Sciatica treatment at Endura
• The Endura Method
• What actually happens at your first visit

---

Speak With Dr. Devon — (647) 951-5841 You’ll speak directly with Dr. Devon — not a receptionist.

→ Sciatica at Endura → About the Endura Method

---

Dr. Devon Savarimuthu, DC, CSCS practises at Endura Chiropractic, 3440 Yonge St, Lawrence Park, Toronto. Doctor of Chiropractic, Palmer College. CSCS since 2015.