Piriformis Syndrome: The Sciatica Mimic That Physios Miss

The Subject

Marcus Webb, 42, Software Engineer — Austin, TX. When Marcus first walked into Rachel Chen's physical therapy clinic in January 2024, he'd been living with shooting pain down his right leg for over three years. He'd seen two orthopedists, three physical therapists, a chiropractor, and a pain management specialist. He'd had an MRI, two rounds of cortisone injections, and 6 months of generic "back exercises" that did nothing.

Marcus sits 8–10 hours a day at a standing desk he bought but rarely uses standing. He used to run 5Ks on weekends and play recreational basketball. By early 2024, he couldn't sit for more than 20 minutes without the familiar burning ache radiating from his right glute down the back of his thigh. Running was out of the question. His sleep was disrupted. His primary care doctor had mentioned the word "surgery."

His MRI showed a minor L4-L5 disc bulge — something present in roughly 40% of pain-free adults in his age group. Every provider fixated on the disc. Nobody checked the piriformis.

The Problem

Marcus had been diagnosed with lumbar radiculopathy — sciatica caused by a disc pressing on the nerve root. The diagnosis made sense on paper: leg pain, MRI showing a bulge, positive straight leg raise. But the treatments targeting the disc weren't working. The cortisone injections near the spine provided zero relief. The McKenzie extension exercises aggravated his symptoms.

When Rachel Chen performed her initial assessment, three things stood out: (1) Marcus's pain was reproduced by direct pressure on the piriformis muscle, not by lumbar movements; (2) his hip external rotation was severely limited on the right side — 22° vs. a normal 45°; and (3) his FADIR test (flexion, adduction, internal rotation) triggered his exact sciatic symptoms.

The piriformis muscle, located deep in the buttock, runs directly over the sciatic nerve in approximately 15–20% of the population (the nerve passes through the muscle rather than beneath it). When this muscle becomes chronically tight, inflamed, or spasming — often from prolonged sitting, direct trauma, or compensation patterns — it compresses the sciatic nerve. The result is identical to lumbar sciatica: burning, shooting pain down the back of the leg.

Marcus's piriformis wasn't just tight — it was hypertonic and fibrotic, likely from years of sitting with his right leg externally rotated and a direct compression injury from his desk chair's edge. Every provider had looked at the spine. Nobody had looked at the muscle sitting on top of the nerve.

What They Did

Rachel designed a 14-week rehabilitation protocol targeting the piriformis specifically, with four distinct phases. Each phase built on the last — release before retrain, retrain before load, load before maintain.

The Results

By week 8, Marcus's pain had dropped from 8.2 to 3.5 on the VAS scale. He was sitting through full workdays at his desk — something he hadn't done in over a year. By week 12, he completed his first pain-free outdoor run: a slow 1.5 miles that brought him to tears in his driveway. By the final assessment at week 14, every clinical metric had normalized.

The most telling sign: Marcus's FADIR test was negative — the exact provocative test that had reproduced his sciatica for three years now produced zero symptoms. His piriformis was no longer compressing the sciatic nerve. The nerve glided freely through the muscle during hip movement, confirmed by a follow-up neurodynamic test.

Marcus completed his first 5K race in March 2025 — three years after his last one. His time was 28:42, slower than his pre-injury PR, but he crossed the finish line without pain. He continues his 15-minute maintenance routine daily and has had zero symptom recurrence in the 5 months since discharge.

Lessons Learned