This is a question I am often confronted with in our rehabilitation program as we see so many clients who have been misdiagnosed and consequently mistreated. Many back-related injuries and chronic pain conditions share many symptoms that are very similar to other injuries, and in the case of Piriformis syndrome and Sciatica, the similarities in symptoms and pain are very close. However these two injuries are very different, and the approach to treating although similar in some regard will have some key elements that are significantly different. The common theme both injuries do share is that they are in over 90% of all cases caused by postural imbalance and movement dysfunction. To quote Dr. Evan Osar in his book about Common Hip & Shoulder Dysfunction - "Osteoarthritis, more accurately described as a degenerative joint disease, is just one manifestation of poor movement strategies, it is not simply a process of getting old." And like Dr. Osar I have found in over 15 years of working with all ages, and many different injuries, that those who improved stability and movement had less injury, less pain, and could not only prevent problems but correct them once the right program was adopted. In this article, we hope to share some of those secrets, and help you get rid of your pain for good.

What Is The Difference Between Sciatica & Piriformis Syndrome

1: Sciatica

Sciatica refers to pain, tingling, and/or numbness felt along your sciatic nerve.

The sciatic nerve runs down the back of the thigh, down the shin to the toes, and can be traced back to the nerve roots that exit the spine at L4/5 and L5/S1. The pain felt in your butt and legs is when the sciatic nerve is being pinched. This usually occurs in your lumbar spine (lower back). For example, a disc bulge or herniated disc which would be the most common back injury we see may irritate anyone of the five sciatic nerve roots that comprise your sciatic nerve, which in turn sends symptoms shooting down your sciatic nerve.

This is where people may think they have piriformis syndrome, when in fact it is a problem coming from the lumbar spine. The key to eliminating this comes down to finding the cause of the nerve pinch which you will find is related to postural and movement dysfunctions. Bone spurs can be a potential cause of this problem but in many cases, it is postural and movement related.

The pain trigger with this problem is often seen with bending actions.

2: Piriformis Syndrome

The main difference between these two conditions is the location of the problem and the pain trigger.

The piriformis muscle is not located in your lumbar spine, instead it is located in your butt underneath the big gluteal muscles. It is located right near the sciatic nerve, which is where the problem begins.  When the Piriformis begins to overwork, (due mainly to the instability of the hip and pelvis, more on this later), it begins to thicken and shorten, developing trigger points but even worse it may compress the large sciatic nerve. The compression feels like a deep aching pain in the butt or radiating sharp nerve pain that extends along the middle of the rear thigh, the exact same symptoms of sciatica we just looked at.

The pain trigger is usually movements that require significant strength and stability in a single leg stance. Due to inflammation and weakness within the gluteal muscles the body cannot stabilize the hip and the end result is compression of the sciatic nerve.

You can see how it can be easily assessed as sciatica when in fact it is a different problem altogether.

Watch the video below for a more detailed explanation of piriformis syndrome causes.

How Can You Find Out Which One You Have?

As I said in the introduction it is vital you get a medical diagnosis before you try to treat your problem.

To get a correct diagnosis you will need to consult a therapist or Doctor skilled in looking for these problems. Diagnosis of both conditions should involve a review of the patient’s medical history, a physical examination looking for movement dysfunction and instability and possibly even x-ray or MRI. A good therapist will often be able to correctly make a diagnosis by using a process of elimination. Your goal should not to just get out of pain but to find out what the cause of the problem was in the first place and devise a plan to remove it or change it.

The corrective strategy may vary quite a lot, but you will find that there are some common threads to both conditions which I will now explain.

Why Hip Dysfunction Is Common To Both Problems?

Today's modern medicine when it comes to chronic pain is to look at the area in pain and get rid of it. Our approach to treating pain is that it is a real inconvenience and that there must be some kind of pill, tablet or medical intervention to just get rid of it. While all the while being completely ignorant to WHY the pain is there in the first place. This how a relatively simple problem that could be easily corrected using simple exercises and drills, grows to be a very big painful injury needing a lot of time and money to correct. We must move beyond treating symptoms and begin looking at treating the cause of the problem.

In one of our previous articles Are Your Tight Hips The Cause Of Your Back Pain Or Knee Pain? I discussed in great detail how hips are often to blame for many of the injuries we see. Our sedentary lifestyle leading us to sit too much contributes to developing tight hips that can then force the spine to flex on itself, in turn, creating spinal injuries like a disc bulge.

The picture below shows an example of a good bending action with the hips on the left versus bending of the spine on the two pictures to the right. Both of these actions will inevitably lead to back pain and a bulging disc.

Poor hip mobility will also limit movement that requires strong gluteal activation. The stiffness in the hips will inhibit the gluteal muscles from functioning correctly, in turn winding up the piriformis muscle to compensate and pick up the workload. In both injuries here tight "STIFF" hips were the cause of the problem. Note that the pain was not in the hips itself, but instead in the lumbar spine for a disc bulge, and in the buttocks for piriformis syndrome. Treating these areas without addressing the hips is a waste of time.

Not all times is the hip stiff and tight from short tight muscles needing mobility. Some cases it is the exact opposite, too loose and unstable. The instability creates a new strategy of stabilizing by the body in order to protect the hip from dislocation. This is where movement patterns are altered creating a false stiffness on that leads to excessive movement again in the spine or in the lower limbs that force compensation at muscles like piriformis.

Again you need to know what type of hip problem you may have in order to use the correct approach. For if you start loosening a hip that is too unstable, you will create more problems and more pain. Here is how we would do this.

You Must Assess Your Joints & Movements

There are a lot of assessments and tests that I may use to be 100% certain on what approach I am going to use and guide me on exercise selection.

It is very difficult here to give you a black and white "do this, do that" approach, and to keep this article relatively short I have removed a lot of these tests, so instead I will give you some of our easiest and most effective ideas on what to look for. To see the complete assessments with detailed instructions of each test, exercises, stretches and step by step programs if you have sciatica are covered in our Back Pain Secrets Program, and all the tests and assessments, exercises, stretches and programs for Piriformis Syndrome are covered in our Piriformis Syndrome program.

Click here to go straight to the shop to find out more or on the image below of what program is relevant to you right now.

Simple assessments for hip mobility involve looking at both flexibility and movements. You cannot just rely on flexibility assessments alone for they will not show instability or weakness when you stand up. In the book Vital Glutes by John Gibbons he makes a great quote -"Tight muscles show themselves lying down, whereas weak muscles show themselves standing up".

This is something we keep in mind when completing the assessment to not get fooled by what might look as good flexibility when doing the simple stretch assessments. Below is 5 simple assessments that will guide me on where to start.

Test 1 - Hip Mobility & Flexibility

There are many different tests I might look at here but sometimes it is the most simple assessments that can tell you a lot.

The 90/90 hip stretch is a great exercise to use for the person lacking a lot of mobility in the posterior muscles of the glutes. It is a great choice to begin with for it is much easier to get into position and does not cause as many problems as some of the more aggressive glute stretches do. This stretch is great to use as a test and also as an exercise to correct your mobility problems.

Other assessments I might use to dig deeper include the following.

Thomas Test

This is a classic test to use for testing the length tension relationship of the anterior hip muscles. It is quite easy to do and can help confirm if there is a loss of hip flexibility causing excessive anterior pelvic tilt. It is not good as an exercise to use for correcting it however.

How to Do the Test

1. Lie down on your back, at the very edge of the table, with both legs hanging freely.
2. Flex the knee and pull it back to the chest as close as you can, using both arms while doing so. The other leg can hang down.
3. The lumbar spine must remain flat and in contact with the table during the test.

The test is positive when:

• You are unable to maintain their lower back and sacrum against the table
• Hip has a large posterior tilt or hip extension greater than 15°
• Knee unable to meet more than 80° flexion

Hip Internal & External Rotation Tests

These tests are usually performed by therapists with you lying flat on the table, but as you are completing this test by yourself this is the way I would do this. This will help to identify any loss of hip motion in a non-weight bearing position that may cause problems when you attempt to complete functional movements in a standing position. If you do have a friend with you, you could get them to use a goniometer to measure the angles of the following tests but this is not essential.

How to Do the Hip INTERNAL Rotation Test

1. You need to sit on a bench with knees and feet together with your body in an upright posture and a neutral lumbar curve.
2. Try to rotate the hip internally while keeping the knee flexed and once the furthest point is reached estimate make note of the angle you have achieved.
3. Complete the same test with the other leg to compare.

Normal = 30 Degrees of internal rotation with no pain.

If you have a friend with you get them to observe if you have to hike your pelvis to achieve this range of motion.

How to Do the Hip EXTERNAL Rotation Test

1. You need to sit on a bench with knees and feet together with your body in an upright posture and a neutral lumbar curve.
2. Try to rotate the hip externally while keeping the knee flexed and once the furthest point is reached estimate make note of the angle you have achieved.
3. Complete the same test with the other leg to compare.

Normal = 40 Degrees of internal rotation with no pain.

You will find a ton of additional information about hip mobility and stretching assessments in the articles below.

• 10 ways to improve your hip mobility
• How to complete a mobility assessment by yourself

Test 2 - Core Activation

Pelvic stability becomes much harder when hip stiffness is present and compensation is inevitable. Instead of providing mobility for the legs to lower to the floor the hips do the exact opposite, they contract and stiffen. Every time the hips try to fire up to create the stiffness in the spine they move the pelvis into anterior tilt and as a result of this you lose your lumbar spine stability. Lack of stability of the pelvis will make it extremely difficult for the glutes to perform their role as they need the assistance of the pelvic stabilizers to position the hips in the right place in order to fire.

Stabilizers react quicker than any other muscle group, to prepare the body for movement. The stabilizer muscles are smaller and much weaker than the larger moving muscles, and the only way they can work effectively and influence the integrity of movement is to fire first.

The TVA for example fires before you even move, it actually anticipates your movement and contracts to support and stabilize your spine prior to anything being done. It has been found with back pain patients it fires too late, or not at all, leaving their spine unsupported and requiring the assistance of large prime mover muscles to do the job. This is where exercises to target the TVA are used to reprogram this faulty timing and correct the compensation of using other muscles trying to do the job.

Test 3 - Glute Function

Now we are up to looking more at strengthening and stabilizing.

And we have to look at the glutes very closely for in both cases of sciatica and piriformis syndrome there is always some gluteal dysfunction present that exacerbates the muscle imbalance and motion compensation. The longer this remains the worse things will get. The tight hips you are trying to loosen from the previous tests will just tighten right up again if the glutes do not do their job. You have to find out if you have adequate activation and put a plan in place to correct this.

There are many different ways to test this, but I find the glute test in the video below to be one of the easiest to do that does not give pain.

1. Lie on your stomach and bending one knee to 90 degrees, lift the thigh a little off the floor.
2. You should be able to get a strong contraction of the gluteal muscle to do this and be able to hold the static contraction for 60 seconds.
3. If this position places too much strain on the hamstring or lower back, or the leg starts shaking, then this is a sign you are unable to recruit the gluteal muscles sufficiently to hold this position.

The other test I like to use is the Bridge. It is common for the gluteal muscles to become lengthened (chronically stretched), reducing the tension in the range around hip extension. The bridge or hip extension exercises target your butt muscles very well in this position.

How To Do The Bridge

1. Lie on your back with knees bent, feet and knees hip-width apart
2. Squeeze the gluteal muscles and lift hips until you have a straight line running through knees and hips to the mid-back. Leave the shoulder blades on the floor
3. Hold the position, focusing on using the gluteal muscles, for 10 seconds in total.
   
4. Place the hips back down, maintaining neutral spine build up the length of hold gradually to 30 secs, and three repeats (sets)

I would also encourage you to read our article on How To Strengthen Your Glutes to see more detailed tests and exercises to enhance this function. The bridge

Make sure you get a copy of our FREE Glute Checklist below by clicking the image to download. This will provide you with all the steps in order of how to do this as this process can be very tricky. Weak glutes is common to both injuries so getting this right is critical.

Test 4 - Bending

Now, this test is CRITICAL if you suspect you have a herniated disc injury causing sciatica.

It can be very difficult for the piriformis sufferer too as there is a significant hip range of motion required. It is usually in this pattern of movement that a back injury was created in the first place and as a result and repeated poor movement of this and the pain symptoms can be amplified. This is also a hamstring range of motion test and any nerve impingement may give a fake reading of tight hamstrings, so you may want to test the hamstrings in a lying position to rule this out. The unique thing with standing up tests are that they are testing more than just mobility for this is also a stability assessment.

This is where we can see the person who passed all the flexibility tests with flying colours appear extremely stiff and tight due to their failure to correctly stabilize the lumbar spine or pelvis during movement. This one movement pattern can correct all the things we have been doing individually so far if you can execute perfectly and be able to progress with loads and to single leg stance. In the gym world, this movement is known as the deadlift and is the king of all gluteal and postural corrective exercises. It is also the one that can absolutely ruin your back if you get it wrong.

You MUST learn how to do this and you must learn how to do this with load or you are only ever a short step away from going back to pain. 

How To Do The Bending Test

1. Standing with feet parallel and shoulder width apart, stick your bottom out (arching your lower back) and reach behind you to hold a piece of your skin in the middle of your lower back.
2. Bend forward from the hips while maintaining the arch in your low back and skin between your fingers until you feel a comfortable stretch in your hamstrings.
3. If you bend too far and round out your back, you will lose the curve in your low back.

Normal: Able to maintain neutral spinal curve and approximately 45deg flexion at the hip. Struggling to do this indicates you move too much through the spine and not through the hips and just about any day to day task that involves you bending over is a potential risk until you correct this. Tying your shoelaces, vacuuming the carpet, picking the shopping bags up are all potentially going to aggravate your injury and the sciatic nerve.

Below is a video of exactly what we look for in a bending actions

Test 5 - Single Leg Squat

This last test we see massive problems in Piriformis Syndrome sufferers.

If the bending action is the risky movement for a herniated disc then single leg exercises are the risky movement with piriformis people. This exercise demands the hip to act as a hip rotator and stabilizer at the same time. It needs to lock the head of the femur into the socket, creating a very tight and stable hip joint during gait. This prevents the ball and socket joint from rattling around during walking and running, but maintain adequate mobility for the leg to swing through.

The reason this is risky for most is that their lack of glute strength and stability of the hip itself is so faulty that the piriformis muscle has no choice but to work excessively hard to prevent hip dislocation and even begins to take over movements of the glutes. If you think about how often we need to stand on one leg, walking, for instance, you will see how easily this pain can escalate from mild to extreme very quickly. Again this is so much more than a simple one joint strength or stability test. Multiple joints and muscles are on the job and this movement requires perfect timing and alignment for it to be completed pain-free.

Watch the videos below to see what we look for when assessing this movement. As with the bending movement, I would rate this as a much more useful exercise to end up using. If you can master this and be able to do this with loads or at high speed the chance of injury is very small. You just cannot beat learning to move.

Read our article on Single Leg Squats to see more detail about this extraordinary exercise.

What Is Next?

Well as you can see the test results can take you in many directions.

1. If you found you were very stiff and tight you need to start working on flexibility and mobility drills to improve your joints range of motion.
2. If you found that your problem was with bending or single leg stance then your problem is much more stability and movement based.
3. Pain with bending indicates back related problems
4. Pain in the butt region indicates more piriformis related problems.

You could also fail all of these tests and be either piriformis or sciatica patient. Are you confused now? I hope not, but you can see how it is so easy to misdiagnose this problem, and also mistreat the problem. You must assess what your body needs and use strategies to improve it. You cannot rely on a therapist or a doctor to do this for you, you MUST find what exercises you need to do and you must start doing them. These injuries can be corrected and they definitely can be prevented.

You will find many great ideas in the articles below

• 4 Best Exercises For Piriformis Syndrome
• Bulging Disc Exercises & Effective Long Term Solutions

Conclusion

Chronic pain can take a real toll on someone's life both physically and mentally. And both sciatica and piriformis syndrome can wreak havoc on daily activities and escalate into crippling injuries. The days of treating symptoms and just trying to get rid of pain are over. We must be smarter in how we approach injuries like these and provide people with proven programs and methods that not only remove the pain, but remove the underlying cause of the injury. The information in this article gives you great insight as to how injuries like these are born and why we must consider other joints like the hip in their role of forcing compensation and pain into other areas.

For more ideas and information on specific topics I may not have covered in detail be sure to check out our INDEX PAGE on the website that has over 300 of our best articles. These are all sorted into categories for quick reference so you can find what you are after more easily. You can also subscribe to our FREE fortnightly newsletter by clicking here.

And if you live in Melbourne you can request a free consultation by clicking the image below.

About The Author

Nick Jack is owner of No Regrets Personal Training and has over 15 years’ experience as a qualified Personal Trainer, Level 2 Rehabilitation trainer, CHEK practitioner, and Level 2 Sports conditioning Coach. Based in Melbourne Australia he specializes in providing solutions to injury and health problems for people of all ages using the latest methods of assessing movement and corrective exercise.

References:

• Movement - By Gray Cook
• Corrective Exercise Solutions for the Hip & Shoulder - by Evan Osar
• The Psoas Solution - by Evan Osar
• Diagnosis & Treatment Of Movement Impairment Syndromes - By Shirley Sahrman
• Low Back Disorders - by Stuart McGill
• Knee Injuries In Athletes - by Sports Injury Bulletin
• The ACL Solution - by Robert G Marx
• Understanding & Preventing Non-Contact ACL Injuries - American Orthopaedic Society For Sports Medicine
• Anatomy Trains - by Thomas Meyers
• Motor Learning and Performance - By Richard A Schmidt and Timothy D Lee
• Assessment & Treatment Of Muscle Imbalance - By Vladimir Janda
• How To Eat, Move & Be Healthy by Paul Chek
• Scientific Core Conditioning Correspondence Course - By Paul Chek
• Advanced Program Design - By Paul Chek