Eur Spine J (2010) 19:2095–2109

DOI 10.1007/s00586-010-1504-9

REVIEW ARTICLE

The clinical features of the piriformis syndrome:

a systematic review
Kevork Hopayian • Fujian Song • Ricardo Riera •

Sidha Sambandan

Received: 17 January 2010 / Revised: 14 April 2010 / Accepted: 16 June 2010 / Published online: 3 July 2010
Ó Springer-Verlag 2010

Abstract Piriformis syndrome, sciatica caused by com- Keywords Piriformis
Sciatica
Diagnosis

pression of the sciatic nerve by the piriformis muscle, has Systematic review
been described for over 70 years; yet, it remains contro-
versial. The literature consists mainly of case series and
narrative reviews. The objectives of the study were: first, to Introduction
make the best use of existing evidence to estimate the
frequencies of clinical features in patients reported to have Sciatica is musculoskeletal pain felt in the leg [29] along
PS; second, to identify future research questions. A sys- the distribution of the sciatic nerve and sometimes
tematic review was conducted of any study type that accompanied by low back pain. Following Mixter and
reported extractable data relevant to diagnosis. The search Barr’s work correlating clinical features with operative and
included all studies up to 1 March 2008 in four databases: histological findings [75], the dominant opinion for dec-
AMED, CINAHL, Embase and Medline. Screening, data ades on the cause of sciatica was nerve root compression
extraction and analysis were all performed independently by a herniated intervertebral disc (HIVD) [117]. An alter-
by two reviewers. A total of 55 studies were included: 51 native cause, compression of the nerve trunk by the piri-
individual and 3 aggregated data studies, and 1 combined formis muscle (PM), was proposed by Freiberg and Vinke
study. The most common features found were: buttock [42] and developed by Robinson [91], who is credited with
pain, external tenderness over the greater sciatic notch, coining the term piriformis syndrome (PS). The relations
aggravation of the pain through sitting and augmentation of between the PM and the sciatic nerve are described in
the pain with manoeuvres that increase piriformis muscle Appendix 1 and illustrated in Fig. 1. Sciatica can arise
tension. Future research could start with comparing the from other sites too: the lumbar canal (through stenosis),
frequencies of these features in sciatica patients with and the pelvis (without PM involvement) and along the extra-
without disc herniation or spinal stenosis. pelvic journey of the nerve [2].
The existence of PS remains controversial. Only 21 out
of 29 physical medicine and rehabilitation specialists sur-
veyed in the USA believed that the condition exists [96]. It
has been argued that the syndrome is overdiagnosed [105]
K. Hopayian
F. Song
S. Sambandan and underdiagnosed [30,39]. Fishman et al. [37] attempted
School of Medicine, Health Policy and Practice, to set an operational definition of PS by demonstrating
University of East Anglia, Norwich NR4 7TJ, UK
objective electromyography (EMG) findings with symp-
R. Riera toms. They found a delay in the H reflex on EMG in the
Department of the Medicine, Universidad Carabobo, FAIR position (described below) in patients with PS
Valencia, Venezuela compared to asymptomatic controls. An impressively large
number of patients, 918, were studied. However, the study
K. Hopayian (&)
Seahills, Leiston Rd, Aldeburgh IP15 5PL, UK did not establish the accuracy of the H reflex because it
e-mail: [email protected] lacked symptomatic controls (patients with sciatica, but not

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nerve compression by congenital variations of the sciatic

nerve or PM, in which the sciatic nerve or its divisions pass
through the belly or tendinous portions of a normal muscle
or the bellies of a bifid muscle [20, 85, 95]; overuse and
hypertrophy [10, 21, 84, 112]. Some authors use PS for any
sciatica arising from nerve trunk compression, regardless
of PM involvement, for example by osteophytes [66], ha-
ematomas [104], pseudo-aneurysms [73, 82], endometriotic
cysts in the pelvis [28] and prolonged external pressure
[23]. Fractures of the femoral neck and of the ischial
tuberosity and hip arthroplasty too can cause sciatica
[74,123]. Such cases were called secondary PS by Foster
[40] and pseudosciatica by others [94].
A systematic review of general population surveys of
Fig. 1 Diagram showing the relations of PM to the sciatic nerve sciatica found a lifetime prevalence of 12.2–27%, annual
2.2–19.5% and point 1.6–4.8% [62]. The proportion due to
HIVD remains uncertain. In a series of 160 sciatica
PS). Fishman et al. also claimed that response to conser- patients, only 131 (82%) had a corresponding HIVD on
vative therapy was greater in patients with a positive test, MRI [58]. Estimates of the ratio of PS to disc herniation
but scrutiny of their results shows that they did not reach come from secondary or tertiary care and vary according to
statistical significance. Furthermore, the study design and the definitions and selection methods used: \1% [8], 6%
report did not meet the STARD criteria for a study of [79] and approximately 15% [6]. Those based on contem-
diagnostic accuracy [9]. Filler claimed that ‘‘large scale poraneous coding of diagnoses [8] are less open to selec-
formal class A study design’’ publications, one of which tion bias than those based on retrospective reviews of
was the study by Fishman et al., had proven the existence records [6] or recall [79].
of the syndrome [36]. Another of these studies was the one Signs specific to PS that have been reported include
by Filler et al. [36] in which patients with sciatica who tenderness of the PM found on external palpation over the
responded to local anaesthetic and steroid injections into greater sciatic notch or on internal palpation per vagina or
the PM were classed as confirmed muscle-based PS and rectum [30, 91, 120] and tonic external rotation of the hip
those who improved with surgery as surgically confirmed [99]. Several tests are said to reproduce sciatica by aug-
muscle-based PS. MRI neurography in confirmed and menting PM tension, either by passively stretching the
surgically confirmed PS patients was reported to have an muscle, the Freiberg [42] and FAIR tests [121], or by
important predictive value. However, neither of these two resisted muscle contraction, the Pace [79] and Beatty tests
studies was actually ‘‘class A’’. By class A, Filler meant [4] (Table 1).
‘‘grade A’’ studies described by Kent et al. [59]. Both the
Fishman and Filler studies failed to meet two of the criteria
for grade A studies: that all clinical features be described Existing reviews
and that an adequate reference standard be used. Indeed,
there is no accepted investigation that can act as the ref- The literature on PS consists largely of reviews and case
erence standard for PS. Candidates for the role include: studies. Most reviews of PS have been either narrative
reviews [13,46,80,88,89,92], sometimes with illustrative
1. nerve conduction studies (NCS) with the hip flexed,
case reports [79,120], or case studies accompanied by a
abducted and internally rotated, termed FAIR [38, 97];
review to place them in context.
2. NCS with magnetic stimulation [17];
Silver and Leadbetter [96], identifying 26 cases in 12
3. variations on magnetic resonance imaging such as
studies [1,3,4,11,19,43,53,56,81,95,116,120], calculated
neurography to enhance images of the sciatic nerve
frequencies for only three clinical features: ‘neurologic
[36,68].
deficit’, the Freiberg sign and the Pace sign. The only
However, the validity of these techniques has been systematic review of PS available at the time of our search
vigorously disputed [111]. Hulbert and Doyle [50] and was confined to non-surgical interventions [26]. Its two
Kirschner et al. [60] have summarised and compared the trials with positive outcomes were excluded from our
investigations available. review because they did not describe the clinical features
Proposed mechanisms for PS include: contracture or sufficiently. Two more reviews have been published since.
spasm of the PM from trauma [42,91]; predisposition to Hulbert and Deyle highlighted the paucity of evidence for

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Table 1 Specific tests for sciatica

Name of test Date first Description Attributed to
described

Freiberg 1934 Passive internal rotation of the hip in extension reproduces pain Freiberg and Vinke [42]
Pace 1976 The clinician provides resistance to hip abduction by holding Pace and Nagle [79]
the sitting patient’s knee; reproduces pain
Tonic external rotation of hip 1981 Visible sign in patient at rest Solheim [99]
FAIR = flexion, abduction and 1981 Maintaining the hip in flexion abduction and internal rotation Solheim [99]
internal rotation of the hip reproduces pain
Beatty 1994 The patient holds the flexed hip in abduction against gravity Beatty [4]
whilst lying on the unaffected side; reproduces pain

differential diagnosis and treatment [50], but did not literature, what was the frequency of the symptoms, signs
identify specific research questions. Kirschner et al. [60] specific to PS and signs looked for in sciatica in general?
provided a narrative review of botulinum toxin therapy. The second aim was to identify future research questions.
Research has reached an impasse. Controlled trials of We used any study types that reported data relevant to
therapy are unlikely to proceed until two conditions are diagnosis.
met: a sufficiently high prevalence and a reliable method of
diagnosis. Research into prevalence cannot proceed with-
out established diagnostic features. Studies of diagnostic Methods
accuracy cannot proceed without a systematic description
of the syndrome and a reference standard. Therefore, much The methods were in accord with the PRISMA statement
research is needed with several study types to evaluate PS. on the conduct of systematic reviews [69].
A better understanding of the purported clinical features of
PS is the first step. A systematic review of the clinical Search
features of PS is such a step.
Knowledge gained from case studies has limitations. The search included all studies up to 1 March 2008. The
Generalising from particular cases has its dangers and the Thomson Dialog NHS facility was used to search four
absence of a comparison group prevents hypothesis testing. databases: Allied and Complementary Medicine (AMED),
Those who promote the concept of levels of evidence Cumulative Index to Nursing and Allied Health Literature
allocate case studies next to the bottom level in the hier- (CINAHL), Embase and Medline. The following search
archy of evidence [15]. However, case studies have strings were used:
important roles [115]. Discovery begins with finding the
#1 (PIRIFORMIS OR PYRIFORMIS) ADJ SYN-
unexpected and the stimulation of further research [115].
DROME.TI, AB
Evidence of cases and their occurrence is needed before
#2 (PIRIFORMIS OR PYRIFORMIS) AND SCI-
evidence of aetiology or treatment effectiveness can be
ATIC$.TI, AB
established [54]. Case reporting can, therefore, lead to
#3 1 OR 2
more advanced research.
Case studies provide suitable material for systematic (ADJ = adjacent. The Thomson Dialog NHS facility is no
reviews, both of the descriptive type [32–35] and meta- longer available). Additional studies were sought from the
analysis. Meta-analyses have covered intervention [25], references of all retrieved articles.
complication rates of surgery [70, 87,119] and the char-
acteristics and prognosis of tumours [98]. Inclusion/exclusion

All titles and abstracts were screened independently by two

Aims reviewers. Studies were excluded if: they were not about
PS; the language was not English, French, Chinese or
We had two aims. The first aim was to make the best use Spanish; the publication was not a print or Internet bio-
of existing evidence to estimate the frequencies of clinical medical journal; the condition was a complication of hip
features in patients reported to have PS. Our main surgery or fracture. When a disagreement occurred, the
research question was, in cases of PS reported in report was retrieved.

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Retrieved full text articles were screened independently recorded as free text comment. All comments were then
by two reviewers. Studies were included if they satisfied scrutinised and compared to create categories of corrob-
all three criteria: first, the study had to be a case studies orating evidence.
report, a narrative review including a case studies report,
a study of diagnostic test accuracy or a study of a ther- Calculating frequencies
apeutic intervention that described clinical features; sec-
ond, the cases matched the study definition of PS; third, Choosing the denominator to calculate frequencies from
clinical features were described sufficiently for data case studies is problematic. Brief clinical records are not
extraction. written with future publications in mind [54]. The non-
reporting of a feature could mean several things: the feature
Data extraction was not sought; the feature was sought, but not recorded;
the feature was sought and recorded but not reported. A
Data was extracted independently by two reviewers. denominator that includes all cases might underestimate
Studies were divided into ‘individual data studies’ (case the frequency if a feature had been present but not sought.
reports and case series reporting data for each patient) and A denominator that is confined only to studies where a
‘aggregated data studies’ (case series reporting data feature was reported, as present or absent, might overesti-
aggregated for all patients). Articles were scrutinised for mate the frequency if the authors, believing it to be
pre-specified features (Appendix 2) chosen from prior pathognomonic, selectively report positive cases.
knowledge of literature. Two more features (tonic external Another potential source of bias is the use of a clinical
rotation and tenderness on rectal examination) were added feature as a criterion for patient selection. This would tend
after reading retrieved articles. Several reports of PS have to return a 100% frequency for the feature. Evidence for
differentiated between buttock pain and low back pain this bias was found in the aggregated data studies included
[1,3,4,47,61,77,95,100,112]. Recent European guidelines in the review. Evidence was also found in two individual
define low back pain as localised below the ribs and above data studies, but both were excluded on other grounds
the inferior gluteal folds [114], which includes the buttock. [7,97]. We decided to calculate frequencies in four ways:
For this review, we used only those terms in the PS liter- all cases; only corroborated cases; only reported cases (i.e.
ature, namely, sciatica for pain felt in the leg, buttock pain feature explicitly reported as present or absent); only cor-
for pain felt in the buttock itself, and low back pain to mean roborated and reported cases. A feature recorded as
pain felt in the back but above the buttock. uncertain was treated as absent in the analysis. Denomi-
The rules for data extraction were: nators were calculated using only the sample relevant to a
feature: only women for dyspareunia and only cases pub-
1. Features stated as present or absent were recorded as
lished after the first description of PS-specific tests
positive or negative, respectively.
(Table 1).
2. If the absence of a feature was not explicitly stated, it
Numerators were calculated by adding the number of
was recorded as ‘not reported’.
patients with positive features. Since the point estimates of
3. Ambiguous reports, arising from vague or summary
percentages were often close to 100, 95% confidence
phrases, for example, ‘no signs of radiculopathy’, were
intervals were calculated by first transforming percentages
recorded as ‘uncertain’.
to log odds [106].

Analysis: individual data studies Analysis: aggregated data studies

Corroboration Frequencies for diagnostic features were calculated for

each study with the intention to pool data if appropriate.
The absence of a reference standard test means uncertainty
over whether cases truly represent the condition. However, Analysis: quality assessments
certainty is based on a continuum. Some authors proffer
evidence to support their diagnosis, such as response to There is no accepted tool for evaluating the quality of case
surgery after a long duration of pain. Such evidence reports in diagnosis. Neither the Centre for Reviews and
cannot be accepted uncritically, but should be weighed Dissemination’s guidance on systematic reviews [16] nor
and judged like all evidence. Evidence that supports a the US Agency for Healthcare Research and Quality’s
plausible cause and effect has been termed as corrobo- review of rating systems [118] mention case studies. The
rating evidence, without implying an incontrovertible case only grading system discovered was one specific to therapy
definition. Any potential corroborating evidence was [122]. We therefore adapted recommendations for case

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study reports from several sources [14,52,54,109]. Our tool of frequencies. Two reviewers independently assessed
for assessing quality was specific to case reports of PS and study quality.
diagnosis taking account of (1) completeness of reporting
and (2) minimisation of bias (Appendix 3). Search results
Age and sex are vital data. We included the basic
components of a pain history (Appendix 3). Studies were The flow of records is shown in Fig. 2. Studies entered
categorised according to the number of items reported in into the synthesis comprised 51 individual data studies
the history: good, if two or fewer items were missing; (Table 2), 3 aggregated data studies [30,51,71] and 1
satisfactory, if three or four items were missing; and poor if combined [30]. Of the individual data studies, 31 were case
more than four were missing. For case series, the poorest reports (single case) and 24 case series (two or more cases).
report was used to categorise the study. History reporting
was so poor in aggregated data studies that categorisation
was not attempted. Two sets of examinations can reason- Results: quality assessments
ably be expected: routine tests for sciatica, such as limited
straight leg raising (SLR); and specific tests for PS. The Individual data studies
number of routine tests in each study was counted. For case
series, the case with the lowest number of reports was taken All studies met the criteria of reporting age and sex. The
to represent the study. For PS-specific tests, the presence of quality of history reporting was good in only 24 studies
at least one specific sign was sought rather than the number (Table 3). Commonly missed items were onset of pain,
because they have changed over time. For case series, it is past medical history and evolution of the symptoms.
important that the method of selecting cases be described to Table 3 also shows that reporting of signs was incomplete
minimise bias, for example, by including consecutive with only 40 studies reporting both routine sciatica and PS-
cases. We decided against assigning quality scores to specific signs. It is surprising that six studies did not report
perform sensitivity analysis because of the overlap of a single sign specific to PS, despite reporting purported
certain items in the quality assessment and the calculation cases. The maximum quality achievable was a good history

Fig. 2 Flow of records Records identified through

database search
AMED 37
Idenfication CINAHL 54
Embase 146
Medline 153
Total 390

Records after removal of

duplicates and deletions 181
Records excluded
Language 15
Not obtainable 9
Not case study or review 9
Records with additions from Not medical publication 3
Screening search of reference lists 231 Not about PS 22
Total 58

Records excluded
Full text articles assessed Not obtainable 2
Eligibility No cases 49
for eligibility 173
Not about PS 27
Clinical features not
described 40
Total 118
Studies included in synthesis
Individual case studies 51
Included
Aggregated case studies 3
Individual and aggregated 1
Total 55

Numbers refer to number of studies.

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Table 2 Included studies with individual data

Study: first author and year No. in study No. included No. of routine If signs specific to Selection
(language if not English) in review sciatica signs reported PS reported method

Adams 1980 [1] 4 4 4 Yes Not described

Barton 1991 [3] 4 4 Uncertain Yes Not described
Beatty 1994 [4] 3 3 0 Yes Not described
Beauchesne 1997 [5] 1 1 4 No Not applicable
Brown 1988 [11] 1 1 3 Yes Not applicable
Bustamante 2001 [12] 2 1 3 Yes Not described
Chantraine 1990 (French) [18] 2 1 0 Yes Not described
Chen and Wan 1992 [21] 2 2 4 Yes Not applicable
Chen 1992 [19] 1 1 4 Yes Not applicable
Chen 1994 [20] 1 1 4 Yes Not applicable
Chong 2004 [22] 1 1 3 Yes Not applicable
Colmegna 2007 [24] 1 1 1 Yes Not applicable
Dalmau 2005 [27] 1 1 0 Yes Not applicable
Durrani and Winnie 1991 [30] 1 1 4 Yes Not applicable
El-Rubaidi 2003 (Spanish) [31] 1 1 2 No Not described
Foster 2002 [41] 7 7 0 Yes Not described
Freiberg 1937 [43] 2 2 1 Yes Not described
Gandhavadi 1990 [44] 1 1 1 Yes Not applicable
Guyomarc’h 2004 (French) [45] 3 3 Uncertain Yes Not described
Hanania 1998 [47] 6 6 0 No Not described
Hopayian 1999 [48] 3 1 2 Yes Not described
Hughes 1992 [49] 5 5 1 Yes Not applicable
Jankiewicz 1991 [53] 1 1 1 Yes Not applicable
Jroundi 2003 (French) [55] 1 1 0 Yes Not applicable
Julsrud 1989 [56] 1 1 Uncertain Yes Not applicable
Karl 1985 [57] 1 1 1 Yes Not described
Kobbe 2008 [61] 2 2 1 Yes Not described
Kosukegawa 2006 [63] 1 1 4 No Not applicable
Kouvalchouk 1996 (French) [64] 4 4 Uncertain Yes Not described
Ku 1995 [65] 1 1 4 Yes Not applicable
Lee 2004 [67] 1 1 Uncertain Yes Not applicable
Lewis 2006 [68] 14 14 3 No Not described
Mayrand 2006 [72] 1 1 3 Yes Not applicable
Molina 2003 [76] 1 1 4 Yes Not applicable
Nakamura 2003 [77] 2 2 0 Yes Not described
Ozaki [78] 1 1 4 Yes Not applicable
Papadopoulos 1990 [81] 1 1 4 Yes Not applicable
Park 1991 [83] 1 1 3 Yes Not applicable
Richardson 1992 [90] 1 1 1 Yes Not applicable
Robinson 1947 [91] 2 2 4 Yes Not applicable
Rossi 2001 [93] 1 1 1 Yes Not described
Sayson 1994 [95] 1 1 3 Yes Not applicable
Solheim 1981 [99] 2 2 2 Yes Not applicable
Spinner 2001 [100] 1 1 3 Yes Not described
Stegbauer 1997 [101] 1 1 4 Yes Not applicable
Stein 1983 [102] 2 1 4 Yes Not described
Synek 1987 [108] 1 1 3 Yes Not applicable

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Table 2 continued
Study: first author and year No. in study No. included No. of routine If signs specific to Selection
(language if not English) in review sciatica signs reported PS reported method

Synek 1987 [107] 4 1 4 No Not described

Turtas 2006 [112] 1 1 3 Yes Not applicable
Vallejo 2004 [113] 1 1 1 Yes Not applicable
Vandertop 1991 [116] 1 1 4 Yes Not applicable
Wyant 1979 [120] 2 2 4 Yes Not applicable

Table 3 Summary of history and reported signs in studies with All studies reported at least one sign specific to PS and
individual data one sign in the routine examination for sciatica.
Signs Historya
Poor Satisfactory Good
Results: frequencies
None 1 0 0
Routine sciatica signs only 2 1 2 Data were usable from a total of 126 patients, 100 in indi-
PS signs only 2 4 0 vidual data studies and 26 from Durrani and Winnie [30].
Sciatica and PS signs 8 10 22
a Individual data studies
The quality of history is graded according to the number of items
missing in the report: good B2; satisfactory = 3 or 4; poor C5. The
overall quality is represented by values (history and signs) ranging There were 52 women and 48 men with a mean age of
from poor to maximum achievable (shown in underline, italic, bold, 43 years (95% CI 14, 72). Figure 3 shows the frequencies
bold italic)
of the clinical features (with 95% CI) for each of the four
denominators. Frequencies calculated from all cases (first
and a report of both sets of signs. Only 22 studies achieved plot on left) and corroborated cases (second plot from left)
this. were similar (Fig. 3). However, frequencies calculated
from reported studies (third plot from the left) were higher
Selection than in all studies and corroborated studies. Frequencies
calculated from reported studies and reported corroborated
Of the 20 case series, only 1 reported its inclusion criteria studies (plot on furthest right) were similar. Corroboration
[68]. It described a retrospective study of the records of made little difference to frequency estimates, whereas
patients with a mismatch between spinal MRI and their reporting made a big difference.
clinical condition referred for MRI neurography, but failed
to report how they were selected from such referrals. Symptoms

Studies with aggregated patient data Buttock pain was common and more common than low back
pain for all denominators used. The estimates for buttock
Many items in history and examination were missed pain ranged from 50% (corroborated) to 95% (reported) and
(Table 4). Only Durrani and Winnie reported how patients for low back pain from 14% (corroborated) to 63% (repor-
were selected, how data were collected, the sex distribu- ted). Aggravation of sciatica through sitting was as common
tion, the mean age and age range and several features [30]. as buttock pain, with estimates ranging from 39% (all) to
It was a prospective study of consecutive cases seen in a 97% (corroborated and reported). Dyspareunia showed the
single clinic. Lu et al. [71] reported only the range of ages greatest discrepancy between all cases and reported cases
and Indrekvam and Sudmann [51] reported only the mean (13–100%, respectively), reflecting the very large propor-
age. tion of under-reporting in the all cases studies. Therefore,
Filler et al. [36] recruited from 239 patients with either none of the estimates for dyspareunia are reliable.
failed disc surgery or no diagnosis after imaging, selecting
those who obtained relief from MRI-guided injection of PS-specific signs
steroid and local anaesthetic into the PM. They did not
describe the sex and age distribution of the selected cases Frequencies were similar for the Freiberg sign, range 32%
and reported only a few features. (all studies) to 63% (reported studies), and the Pace sign,

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Table 4 Clinical features in aggregated data studies, number (%)

Study: first author and year Lu et a 1985 Durrani and Indrekvam and Filler et al.
(language if other than English) (Chinese) [71] Winnie 91 [30] Sudmann 02 [51] 2005 [36]

No. of cases 60 26 19 162

Female 21 (35) 11 (42) 15 (79) Not reported
Age range 17–70 25–62 Not reported Not reported
Age mean Not reported 35.5 43 Not reported
Buttock pain 60 (100) 26 (100) 19 (100) (100)
Low back pain Not reported 13 (50) Not reported (42.4)
Pain on sitting Not reported 15 (58) Not reported Not reported
Dyspareunia Not reported 6 (23) Not reported Not reported
External tenderness 54 (90) 24 (92) 19 (100) (70.8)
Internal tenderness Not reported 26 (100) Not reported Not reported
Freiberg sign positive 60 (100) 9 (35) 19 (100) Not reported
Pace sign positive Not reported 8 (31) 19 (100) Not reported
Beatty sign positive Not reported Not reported Not reported Not reported
Tonic external rotation of hip Not reported 10 (38) Not reported Not reported
FAIR sign positive Not reported Not reported Not reported Not reported
SLR limited Not reported 12 (46) 5 (23) (40.7)
Reflexes diminished Not reported Not reported Not reported Not reported
Sensation diminished 24 (40) Not reported 10 (53) Not reported
Power diminished Not reported Not reported 3 (16) Not reported

30% (corroborated) to 74% (reported). The numbers Aggregated data studies

reported for tonic external rotation, FAIR and Beatty signs
were small and the proportions of unreported cases high; so In three studies, women comprised 35–79% of the series.
estimates are not reliable. External tenderness was com- All four reported 100% frequency for buttock pain, sug-
mon, with a range of 59% (corroborated) to 92% (corrob- gesting this was part of their case definition (Table 4). Two
orated and reported). Internal tenderness was frequently reported very few features [51,71], whose frequencies were
unreported, probably because this examination was seldom close to or equal to 100%, suggesting case selection on the
performed in orthopaedic or neurological practice. The basis of these features. Filler [36] reported only frequencies
range of estimates was 24% (corroborated studies) to 83% rather than raw data. Pooling was therefore considered
(reported). inappropriate. Only Durrani and Winnie reported several
features (Table 4).
Routine signs in sciatica In Durrani and Winnie’s series, the features present in
half or more than half the cases were: buttock pain, low
Limited SLR appeared to be the commonest finding, range back pain, pain aggravated by sitting, external tenderness
42% (all) to 62% (corroborated and reported), with and internal tenderness. Two further specific signs were
diminished reflex, sensation and power reaching a maxi- tested: Pace and tonic external rotation, which were about
mum of 26, 39 and 37%, respectively. as frequent as limited SLR.

Combinations of features
Results: corroborating evidence
The commonest features were further analysed. Three
features, pain in the buttock, pain aggravated by sitting and Of the case studies with individual data, 79 cases had one
external tenderness were reported together in 22 cases, a or other form of corroborating evidence. The categories of
frequency of 22% (CI 15–31) for all cases and 31% (CI 21– corroborating data are shown in Table 5 with examples.
42) for reported cases. Of these 22, 12 were positive for at The types are not mutually exclusive so that many cases
least one manoeuvre increasing PM tension. had more than one item of corroboration, illustrated

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Fig. 3 Frequencies of clinical features from individual data studies

by multiple entries in the examples column. There were most comprehensive review of diagnosis, incorporating
reports of congenital anomalies of the PM and/or sciatic data from 100 individual cases and aggregated data from
nerve, acquired abnormalities of the PM and/or sciatic another 26. We have extracted data according to pre-
nerve, but also of normal morphology with response to specified criteria to cover three important diagnostic areas:
surgical division of the PM, for example, Barton, case 4 symptoms, physical signs specific to PS and signs routinely
[3]. tested in sciatica.
Incomplete reporting of corroborative data was The limitations of the study arise from the nature of the
encountered, for example, omission of the duration of the literature reviewed. A synthesis of case studies may suffer
symptoms [77], operative findings [43] or period of follow- from either under-reporting, especially of the absence of
up [5]. Even case series did not report a consistent set of signs, or over-reporting of the presence of signs. Over-
data for all cases in a series [61, 64]. reporting may be a particular problem when signs are being
proposed by the author as pathognomonic. We have tackled
this problem by calculating frequencies in four ways to
Discussion provide a range of estimates. This enables comparison of
the features with each other. The absence of a reference
Strengths and limitations standard does not diminish the value of these ranges since
we found them to be similar in both corroborated and non-
The main strength of this study is that it is the first sys- corroborated studies. Of the aggregated data studies, the
tematic review of the diagnostic features of PS. It is the one with the highest quality, Durrani and Winnie, reported

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Table 5 Types of corroborating data with examples

Corroborating item Examples: description and study (first author and year)

Nerve conduction studies or electromyography show EMG findings suggestive of involvement of the inferior gluteal and peroneal
extraspinal delay branches of the sciatic nerve; case 3. Hughes et al. 1992 [49]
Delayed responses when hip was held in FAIR position; two out of two cases.
Nakamura 2003 [77]
Imaging shows structural abnormality: Hypertrophy of PM; two cases out of two. Chen and Wan 1992 [21]
Hypertrophy of PM. Jankiewicz et al. 1991 [53]
T2 hypersignal at the level of PM and sciatic nerve. Jroundi et al. 2003 [55]
Abnormal MRI neurography, suggesting entrapment at the level of the PM;
12 out of 14 cases. Lewis et al. 2006 [68]
Operative findings of abnormalities of PM and/or of Calcified PM. Beauchesne and Schutzer 1997 [5]
sciatic nerve and/or of sciatic nerve impingement Sciatic nerve impinged between PM and short external rotators; case number 1
out of 2. Chen and Wan 1992 [21]
Tendinous band of PM indenting peroneal branch of the sciatic nerve; case
number 3 out of 5. Hughes et al. 1992 [49]
Impingement of the sciatic nerve by the PM; six out of seven cases. Foster 2002
[41]
Impingement by the PM or by an associated fibrous band; all four cases that had
surgery. Lewis et al. 2006 [68]
Anomalous division of the sciatic nerve with its superior branch passing through
the PM; case number 2 out of 4. Kouvalchouk 1996 [64]
Bifurcated sciatic nerve with posterior cutaneous femoral nerve squeezed
between the PM and the greater sciatic notch. Ozaki and Muro 1999 [78]
Relief following surgery (long term follow up not Pain increasing for 9 weeks after fall, relief following excision of calcified
reported) muscle. Beauchesne and Schutzer 1997 [5]
Seven cases, average duration of pain of 2 years, immediate improvement after
division of PM and return to work, and relieved of symptoms at 3–6 months.
Foster 2002 [41]
Three cases out of four had surgery. Lewis et al. 2006 [68]
Prolonged post-operative relief (over one year) Both cases out of two. Chen and Wan 1992 [21]
All four cases. Kouvalchouk et al. 1996 [64]
Case 1. Nakamura 2003 [77]
Relief following X-ray guided injection of local Pain for 7 months, free of pain at the 3-month follow-up after two injections.
anaesthetic and corticosteroid into PM (long term Bustamente [12]
follow up not reported)

frequencies close to those calculated from individual data claim is variable. For example, does response to local
studies, adding credibility to the findings. anaesthetic and steroid into the PM count as evidence of
The majority of cases were reported from secondary and PS or can it, as Tiel [111] has argued, also be expected in
tertiary centres, which are more likely to encounter severe cases of more distal nerve impingement? There are
or more chronic cases. Therefore, the generalisability to instances where evidence even in the absence of a com-
primary care is limited. parison group makes cause and effect seem so probable
Case studies typically present the outcome of treatment that a causal relationship is credible [42]. For example,
as implicit evidence of proof of the diagnosis. However, Lewis et al. [68] reported several cases where the results
there are alternative explanations for such improvement, of MRI were supported by findings at operation, followed
such as natural history, placebo response and observer by relief of symptoms. What such cases cannot do is
bias. One strength of our review is that we have made the settle the controversy over the status of PS, but synthes-
process explicit and assigned a lesser weight of evidence, ising and making transparent the data does enable
support rather than proof, which we have termed cor- judgement on how much weight must be given to them
roboration. However, what counts as corroboration itself when considering the implications for practice and
is open to interpretation and the degree of certainty it can research.

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Implications for practice The significant minority of people with sciatica but no
spinal cause (whether HIVD or spinal stenosis) points to
The concurrence of several clinical features and the the need for research on extraspinal causes of sciatica.
numerous cases with corroborating data add support to the Our review raises three questions for research that would
arguments for the existence of the syndrome. Practitioners progress our understanding of the role of PS in these
may consider entertaining the diagnosis in patients with cases. The first is with respect to whether the features
atypical histories [48] or a ‘‘negative MRI’’. Patients identified here occur significantly more often in patients
without a diagnosis after imaging still deserve an expla- without a spinal cause than in patients with a proven
nation for their symptoms and hope for their relief. Dis- spinal cause. This would provide stronger evidence that
cussing the possibility of PS with patients in these these features represent a condition distinct from sciatica
situations is an option. from spinal causes. Unfortunately, data for their fre-
Four features appear to be most common: buttock pain, quency in sciatica in general and in HIVD or spinal
aggravation of sciatica through sitting, external tenderness stenosis in particular are not available because these tests
over the greater sciatic notch and augmentation of the pain are not routinely conducted. The second question is
with manoeuvres that increase PM tension. These tests are whether the quartet of buttock pain, pain on sitting,
easy to perform within the usual clinical examination. Most external tenderness and pain with increased PM tension
practitioners, however, may be less inclined to perform occur significantly together and significantly more com-
routine internal examination without stronger proof of its monly in patients without spinal causes than in patients
accuracy. with spinal causes. The third is whether the quartet is
This synthesis provides empirical data, which challenge accompanied by objective tests of nerve trunk compres-
the received wisdom that neurologic deficits and limited sion, such as imaging or NCS. These three questions are
SLR are rare [79,103]. It also challenges the belief that the best answered by cross-sectional studies of patients with
prevalence in women is very much greater [79,91]. sciatica.
It could be argued that there is no value in making a Further single case reports or small series are unlikely to
diagnosis where there is no proven treatment. However, the improve our understanding of PS unless they reveal pre-
paucity of effective treatment is true of low back pain and viously undiscovered aspects of the condition. But, future
sciatica in general. The relief of pain with surgery in case studies as well as cross-sectional studies must be more
carefully selected cases of PS identified in this review has informative. The quality of most case studies reviewed was
its parallel in the early history of disc decompression by disappointing. Future studies should report clinical features
Mixter and Barr. Nevertheless, the high success rates for both comprehensively and explicitly. The items we used
surgery have been reported only in a small series for quality assessment provide a framework for such
[41,68,84]. There is limited evidence for non-surgical reporting.
therapy [26]. Whilst uncertainty about therapy remains,
what is certain is that research into therapy is more likely to Acknowledgments We thank Mrs Wendy Marsh, Head of Knowl-
edge Services, Ipswich PCT for assistance with retrieval, and Prof.
proceed when the syndrome has been systematically
Milos Jenicek and Prof. Paul Glasziou for comments on the assess-
studied. ment of case studies. The study was partly funded by a grant from the
Scientific Foundation Board of the Royal College of General Practi-
Implications for research tioners. The authors are independent of the funding body.

Conflicts of interest statement None.

Filler marshalled imaging and outcome data to argue for
PS [36]. Whilst the volume of empirical data he pre-
sented deserves attention, we have argued that it does not
amount to the highest level of evidence that he claims. Appendix 1: Anatomy of the PM
Tiel has argued that there are alternative explanations for
Filler’s observations: that MR neurography changes are The PM originates from the pelvic surface of the sacral
artefactual, that PM injections act by non-specific means segments S2–S4, the sacro-iliac joint, the anterior sacro-
and that placebo response may explain treatment success spinous ligament and the sacro-tuberous ligament. It passes
[110]. However, in many case series, patients had not through the greater sciatic notch to insert onto the greater
had a placebo response to previous therapies, including trochanter of the femur. The sciatic nerve exits the pelvis
disc surgery, before undergoing PM resection. This study below the belly of the muscle. Many congenital variations
will not settle the debate on the existence or rarity of PS, exist: the nerve may divide proximally, the nerve or a
but does permit the formulation of specific research division of the nerve may pass through the belly of the
questions. muscle through its tendons or between the part of a

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congenitally bifid muscle [85, 86]. The PM externally Case definition

rotates, abducts and partially extends into the hip.
5. Was there corroborating evidence?
Selection
Appendix 2: Data extraction form for individual patient
6. Applies only for case series
data
Was the method of selection free of bias, for example,
Citation through recruitment of consecutive cases?
Type of study
Patient identification number
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