If you've been told you have piriformis syndrome or sciatica, there's a significant chance your actual problem lies somewhere else entirely. A new clinical study registered with India's Clinical Trial Registry reveals that the vast majority of buttock pain cases labeled as piriformis syndrome are actually secondary conditions rooted in deeper spinal or joint issues.

What Is Piriformis Syndrome, and Why Is It So Often Misdiagnosed?

Piriformis syndrome occurs when the sciatic nerve becomes irritated or compressed near the piriformis muscle, a deep muscle in the buttock region. The condition typically causes deep buttock pain, pain radiating down the thigh or leg, and discomfort while sitting for long periods. Because these symptoms closely resemble lumbar disc prolapse, sciatica, sacroiliac joint pain, and spinal stenosis, piriformis syndrome is frequently misdiagnosed.

The problem is straightforward: many patients with buttock pain are told they have a simple muscle spasm without undergoing proper clinical evaluation. This incomplete diagnosis can lead to ineffective treatment that addresses the symptom location rather than the actual pain source.

What Did the Study Actually Find About Buttock Pain?

Researchers at Daradia, a pain clinic in Kolkata, conducted a retrospective analysis of 578 patients presenting with hip and buttock pain. The study, published in the Journal on Musculoskeletal Ultrasound and Pain Medicine and registered with the Clinical Trial Registry of India (CTRI/2022/07/044438), revealed a striking pattern.

Among the 578 patients screened, 99 patients (17.13%) were diagnosed with piriformis syndrome. However, the majority of these cases were not primary piriformis syndrome (a muscle-only problem). Instead, 83 patients (83.87% of the piriformis syndrome group) had secondary piriformis syndrome, meaning their buttock pain was associated with another underlying condition entirely.

This distinction is critical. Primary piriformis syndrome, caused by local anatomical variations in the muscle or nerve, accounted for only 16.26% of cases. Secondary piriformis syndrome, where the real pain generator lies elsewhere, was far more common.

What Are the Hidden Causes Behind Buttock Pain?

The study identified several underlying conditions driving secondary piriformis syndrome. Among patients with secondary piriformis syndrome, the most common associated causes were:

• Lumbo-sacral pathology: Present in 37.23% of secondary cases, including disc problems at the L5-S1 and L4-L5 levels
• Spondyloarthropathy: Found in 27.66% of cases, referring to inflammatory conditions affecting the spine and joints
• Degenerative arthropathy: Identified in 14.89% of cases, involving wear-and-tear changes in joints
• Fibromyalgia and other widespread pain syndromes: Contributing to the remaining cases

When researchers examined the lumbo-sacral findings specifically, they found that disc problems dominated the picture. Among patients with lumbo-sacral pathology, the most frequent findings were L5-S1 intervertebral disc herniation (40.00%), L4-L5 disc herniation (28.57%), and lumbar canal stenosis (22.86%).

This means that in many patients, what feels like piriformis muscle pain is actually the result of a herniated disc pressing on a nerve, a narrowed spinal canal, or inflammatory joint disease. The piriformis muscle itself may be tender or irritated, but it's not the root cause.

How Does SI Joint Dysfunction Create Similar Symptoms?

Beyond piriformis syndrome, another frequently misdiagnosed source of buttock and lower back pain is sacroiliac (SI) joint dysfunction. The SI joint is the strong, weight-bearing connection where the bottom of your spine meets your pelvis. Research suggests that 15 to 30 percent of chronic lower back pain actually originates in the SI joint, yet it remains one of the most under-diagnosed sources of back pain.

SI joint dysfunction causes pain in the lower back, buttock, hip, or occasionally the groin or upper thigh, usually on one side. Patients often report a sensation that their lower back is "locked" or "giving way" when bearing weight, and pain that worsens with prolonged sitting, climbing stairs, or rolling over in bed. Because these symptoms mimic lumbar disc pain and sciatica, SI joint dysfunction frequently goes untreated for years.

How to Get an Accurate Diagnosis for Buttock and Lower Back Pain

If you're experiencing persistent buttock pain or sciatica-like symptoms, a thorough evaluation should include several steps:

• Detailed history and pain mapping: Your provider should ask exactly where the pain is located, what triggered it, what makes it worse, and whether you have a history of pregnancy, prior spine surgery, or trauma. A useful clinical clue is the "Fortin finger sign," where patients place a single finger over the exact spot where pain is worst
• Provocative physical exam tests: Multiple tests can help identify the pain source, including the FABER test, thigh-thrust test, distraction and compression tests, and Gaenslen test. Three or more positive tests significantly increase diagnostic confidence for SI joint involvement
• Imaging to rule out other causes: X-rays and MRI scans are used not to diagnose piriformis syndrome directly (the muscle often looks normal on standard imaging) but to rule out lumbar disc herniation, spinal stenosis, hip arthritis, and other conditions that mimic piriformis or SI joint pain
• Diagnostic injection testing: The most reliable way to confirm SI joint dysfunction is a fluoroscopy-guided injection of local anesthetic directly into the joint. If your typical pain is dramatically reduced or eliminated while the anesthetic is active, the SI joint is confirmed as the source

This multi-step approach prevents the common mistake of treating only the location where pain is felt, rather than identifying the actual pain generator.

Why Does This Matter for Your Treatment?

The implications of the Daradia study are significant for both patients and physicians. Treating only the piriformis muscle through stretching, massage, or targeted injections may provide temporary relief but will not address the underlying lumbar disc disease, spinal stenosis, or sacroiliac joint involvement that's actually driving the pain.

A narrow diagnosis can lead to partial or ineffective treatment. A broader clinical approach that considers lumbar radiculopathy, disc prolapse, sacroiliac joint pain, facet arthropathy, spondyloarthropathy, and spinal canal stenosis can help identify the true driver of pain and improve long-term outcomes.

"A patient may have piriformis tenderness, positive FAIR test, or sciatica-like symptoms, but that does not always mean the piriformis muscle is the only pathology," the Daradia study noted.

Daradia Pain Clinic, Kolkata

When a patient presents with buttock pain or sciatica-like symptoms, the evaluation should include assessment of the piriformis muscle, but it should not stop there. Physicians should also consider whether the pain originates from L5-S1 or L4-L5 disc pathology, sacroiliac joint involvement, spondyloarthropathy, lumbar canal stenosis, or a wider musculoskeletal or pain condition.

When Should You Seek Professional Evaluation?

You should consider consulting a pain physician or spine specialist if you experience persistent buttock pain, sciatica-like pain going down the leg, pain while sitting, pain that doesn't improve with routine medications, pain that returns after physical therapy, low back pain with buttock radiation, or suspected piriformis syndrome or sacroiliac joint pain.

The key takeaway from this research is simple: buttock pain deserves proper diagnosis. What feels like a muscle problem may actually be a disc issue, a narrowed spinal canal, or sacroiliac joint dysfunction. A thorough evaluation by a fellowship-trained spine team is the most reliable way to identify everything contributing to your pain and guide effective treatment.