Sciatica vs. piriformis syndrome

True sciatica

True sciatica is irritation of the sciatic nerve where it exits the lumbar spine — usually from a bulging disc, or from arthritic change narrowing the space through which the nerve passes.

The pain starts in the low back and travels down the leg along a specific path. It often comes with numbness, tingling, or occasional weakness, and it typically worsens with forward bending, with sitting, and with coughing or sneezing.

Piriformis syndrome

The piriformis is a small muscle deep in the buttock that rotates the hip outward. The sciatic nerve runs directly beneath it — and in roughly one in six people, runs through it.

When the piriformis becomes chronically tight or inflamed, it can compress the sciatic nerve right there in the buttock. The leg pain that results looks very similar to true sciatica — but the cause is muscular, not spinal, and it sits much lower down.

Piriformis-driven pain usually starts in the buttock rather than the low back, and tends to worsen with prolonged sitting (especially on a hard surface, or with a wallet in the back pocket) and with activities that load the hip rotators: running, cycling, stairs.

Telling them apart

Assessment uses specific movement tests, palpation, and the pattern of the pain itself. The slump test — gradually flexing the spine and extending the leg — loads the whole nerve track and helps locate where the irritation is sitting. The distribution of numbness (if any), which movements provoke the symptoms, and where the pain begins all help place the source.

Often both are present to some degree. There's a pattern called "double-crush" — two mild compressions along the same nerve add up to one big symptom. A lumbar disc issue causes guarding in the piriformis, which adds its own compression on top of the original problem. Treating only the upstream cause misses the piriformis; treating only the piriformis misses the disc.

Calling every leg pain "sciatica" is like calling every headache a migraine — it points you away from the actual problem.

Treatment

For piriformis syndrome, the work is local and upstream at once — releasing the muscle itself (commonly with muscle energy techniques and counterstrain), addressing the hip and pelvic patterns that are keeping it tight, and improving the glide of the sciatic nerve through the surrounding tissue with graded neural-mobilization exercises ("nerve glides").

For true sciatica, treatment focuses on the lumbar spine, the pelvis, and the fascial sleeves along the nerve's full path — giving the nerve more room without trying to force the disc to do something it can't. Sacral and pelvic mechanics matter here too, since pelvic torsion can pre-tension lumbar nerve roots even before the disc is part of the picture.

With either presentation, I trace the nerve's entire pathway during assessment — from the lumbar exit, through the deep buttock, down the back of the thigh — and clear restrictions wherever they're sitting. Postural and ergonomic patterns get checked (sitting setup, wallet pocket, asymmetric hip loading), and when assessment points there, visceral restrictions — a tethered colon or kidney altering pelvic mechanics — get addressed too. Neither presentation is unsolvable. Sometimes the fix is straightforward; sometimes it takes a few layers. What matters is finding the actual driver and working it.

Most people with either presentation see substantial change in two to four sessions. Multi-site (double-crush) cases or longer-standing presentations typically take a longer series — four to eight visits — paired with home neural-mobilization work between visits.

In health, Eli Mead, D.O.M.P.