A reader of this column recently wrote to me with the following question:
“I’m getting Physical Therapy for lower back pain and sciatica that is said to be from ‘piriformis syndrome’. My PT treatment has consisted of various exercises and some massage. Eight sessions in and no change at all. I’m still having pain when sitting or walking a distance. What now? Do I need anultrasound or MRI to see if there is any damage or tear to my piriformis Should I get an injection?”
When I hear something like this, my first thoughts are that either the diagnosis has been missed – or the treatment plan is all wrong– because you absolutely should be seeing some progress and results after 8 sessions of quality physical therapy.
Is it really piriformis syndrome – or is it sciatica?
These two conditions are frequently confused and all too often interchanged. The reality is, piriformis syndrome is far less common than you might think. In fact, research suggests piriformis syndrome is often misdiagnosed and may account for only 6–8% of all cases of sciatica-like symptoms (Boyajian-O’Neill et al., Am Fam Physician, 2008). What’s the more likely reason for your radiating leg pain? That it’s coming from your lower back, not your piriformis.
Sciatica is a symptom – not a diagnosis
Sciatica refers to pain that radiates down the leg along the sciatic nerve. It can stem from a number of causes, but the most common – by far – is a mechanical problem in the lumbar spine. Things like a bulging disc, joint dysfunction, or even a poorly moving vertebra can irritate or compress a nerve root and cause sciatic pain.
Piriformis syndrome, on the other hand, involves the piriformis muscle compressing the sciatic nerve as it passes through the buttock. This canhappen, but true cases are very rare – and diagnosing it correctly requires a process of elimination that most general practitioners and physical therapists don’t have the training to perform correctly.
Why mechanical diagnosis matters
Mechanical diagnosis matters because 80% of all musculoskeletal problems – including sciatica – are due to mechanical causes. And if you don’t take someone through a proper and thorough mechanical exam you will not be able to accurately diagnose the source of your sciatica. This is very likely what happened in this reader’s case.
A mechanical specialist will take you through repeated movements designed to map your symptoms and confirm specific responses to movement. This involves testing how your symptoms respond to specific repeated movements – like bending forward, arching backward, or twisting – and tracking which movements improve or worsen your pain. This is the only way to truly diagnose a mechanical pain issue. MRI’s and X-rays can’t detect mechanical pain problems – which is why they often lead to misleading diagnoses when used too soon.
Without a proper mechanical exam, treatment becomes a guessing game. Massage therapy, stretching, dry needling, and general exercises aimed at loosening your piriformis might feel good temporarily, but they won’t solve the problem if the issue is coming from your spine. Research shows that when mechanical diagnosis and therapy is applied correctly, it’s highly effective atresolving back and leg pain – even in cases that have failed previous treatment (May et al., J Man Manip Ther, 2006).
What to do if physical therapy isn’t working
Let’s say your therapist did perform what they believe to be a thorough mechanical evaluation and still thinks it’s piriformis syndrome. And yet, you’ve gone through 8 sessions and feel no better.
This is a red flag for me.
In my clinic, we expect to see at least some change by session 4 or 5 – even if it’s small. If you’re not seeing meaningful progress by then, it’s time to reassess. That doesn’t necessarily mean it’s time for imaging or surgery. It may simply mean you need a different approach – or a more specialized provider.
A mechanical back pain specialist can help
When it comes to distinguishing between true piriformis syndrome and sciatica caused by a spinal issue, no one is better equipped than a mechanical back pain specialist.
These clinicians are experts at figuring out where your pain is coming from and what movement strategies will actually help you.
They don’t rely on vague diagnoses or cookie-cutter treatments. They use a methodical approach based on how your body responds to specific, repeated movements – and this approach has been shown to be highly effective for resolving back pain and sciatica.
The bottom line?
Piriformis syndrome is real – but very rare. If you’re dealing with leg pain, numbness, or tingling and have been told it’s from your piriformis, there’s a good chance it’s actually sciatica from a mechanical problem in your back.
And that’s good news – because it means there’s often a clear and natural solution.
Find someone who specializes in mechanical diagnosis, and you’ll be one step closer to getting answers – and finally getting some relief.
Consider coming in and talking to a specialist at my clinic.
We’ll help you find a natural and movement-based solution to your problem so that you don’t have to rely on pain pills, never have to consider cortisone shots or surgery, and can spend time doing the things you love instead of hanging out in the doctor’s office.
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About the Author:
Trupti Mehta, PT, MS, OCS is DCs Leading Physical Therapist and Back Pain Specialist.
Trupti graduated with a Master’s degree in Physical Therapy from UNC-Chapel Hill in 2001. She has furthered her studies with numerous post-graduate courses focusing on the Neck, shoulder, knee, and back, with a strong emphasis in manual therapy. Recently completed courses in Maitland-Australian Physiotherapy Seminars (Levels 1- 5), has afforded her an excellent way to relieve pain and help people get moving, active and healthy quickly and effectively. With 18+ years of experience in Physical Therapy, Trupti has practiced in various orthopedic and sports focused clinical settngs, in both the Raleigh-Durham, NC and DC regions. She has been Director of multiple Physical therapy Clinics in DC and also worked with some renowned specialists at Georgetown University Hospital in DC. During her years of service, Trupti has had the privilege of caring for a wide variety of clients: from school-aged children to retirees; from homemakers to business professionals; from weekend warriors to professional athletes.
Trupti is an avid fan of the outdoors, art, traveling and of course the Tar Heels. She enjoys spending time with her lible niece and nephew and working with her clients to improve theirlives.