Abstract
Patients with lumbosacral and buttock pain provide tacit support for recognizing the piriformis muscle as a contributing factor to the pain (piriformis syndrome). One hundred and twelve cadaveric specimens were observed to elucidate the anatomical variations of the piriformis muscle referred to the diagnostic and treatment of the piriformis syndrome. The distance between the musculotendinous junction and the insertion was measured and the piriformis categorized into three types: Type A (71, 63.39%): long upper and short lower muscle belly; Type B (40, 35.71%): short upper and long lower muscle belly; Type C (1, 0.9%): fusion of both muscle bellies at the same level. The diameter of the piriformis tendon at the level of the musculotendinous junction ranged from 3 to 9 mm (mean: 6.3 mm). The piriformis showed the following possible fusions with adjacent tendons. In type one (60, 53.57%) a rounded tendon of the piriformis reached the upper border of the greater trochanter. In type two (33, 29.46%) it first joined into the gemellus superior tendon and at last both fused with the obturator internus tendon and inserted into the medial surface of the greater trochanter. A fusion of the piriformis, obturator internus and gluteus medius tendon with the same insertion area as above was observed in type three (15, 13.39%) and finally in type four (4, 3.57%) the tendon fused with the gluteus medius to reach the upper surface of the greater trochanter. Based on this survey anatomical causes for the piriformis syndrome are rare and a more precise workup is necessary to rule out more common diagnosis.
Similar content being viewed by others
References
Babinski MA, Machado FA, Costa WS (2003) A rare variation in the high division of the sciatic nerve surrounding the superior gemellus muscle. Eur J Morphol 41(1):41–42
Barton PM (1991) Piriformis syndrome: a rational approach to management. Pain 47:345–352
Beaton LE, Anson JB (1937) The relation of the sciatic nerve and of its subdivisions to the piriformis muscle. Anat Rec 70:1–5
Beatty RA (1994) The piriformis muscle syndrome: a simple diagnostic maneuver. Neurosurgery 34(3):512–514
Beauchnese RP, Schutzer SF (1997) Myositis ossificans of the piriformis muscle: an unusual case of piriformis syndrome. A case report. J Bone Joint Surg [Am] 79(6):906–910
Benzon HT, Katz JA, Benzon HA, Iqbal MS (2003) Piriformis syndrome. Anesthesiology 98:1442–1448
Broadhurst NA, Simmons DN, Bond MJ (2004) Piriformis syndrome: correlation of muscle morphology with symptoms and signs. Arch Phys Med Rehabil 85:2036–2039
Brown JA, Braun MA, Namey TC (1988) Piriformis syndrome in a 10-year old boy as a complication of operation with the patient in the sitting position. Neurosurgery 23:117–119
Chen WS (1994) Bipartite piriformis muscle: an unusual cause of sciatic nerve entrapment. Pain 58(2):269–272
Chen WS (1992) Sciatica due to piriformis pyomyositis. J Bone Joint Surg [Am] 74:1546–1548
Fishman LM, Konnoth C, Rozner B (2004) Botulinum neurotoxin type B and physical therapy in the treatment of piriformis syndrome. Am J Phys Med Rehabil 83:42–50
Fishman LM, Zybert PA (1992) Electrophysiologic evidence of piriformis syndrome. Arch Phys Med Rehabil 73(4):359–364
Freiberg AH (1937) Sciatic pain and its relief by operations on muscle and fascia. Arch Surg 34:337–350
Freiberg AH, Vinke TA (1934) Sciatica and the sacroiliac joint. J Bone Joint Surg [Am] 16:126–136
Georgiadis GM, Olexa TA, Ebraheim NA (1996) Entry sites for antegrade femoral nailing. Clin Orthop 330:281–287
Hollinshead H (1964) Anatomy for surgeons, vol 3. Back and Limbs. Holber Medical Division, Harper & Row, New York, pp 690–691
Karl RD Jr, Yedinak MA, Hartshorne MF, Cawthon MA, Baumann JM, Howard WH, Bunker SR (1985) Scintigraphic appearance of the piriformis muscle syndrome. Clin Nucl Med 10(5):361–363
Kim S, Choi JY, Huh YM, Song HT, Lee SA, Kim SM, Suh JS (2006) Role of magnetic resonance imaging in entrapment and compressive neuropathy-what, where, and how to see the peripheral nerves on the musculoskeletal magnetic resonance image: part 1. Overview and lower extremity. Eur Radiol 30 [Epub ahead of print]
Kirkaldy-Willis WH, Hill RJ (1979) A more precise diagnosis for low-back pain. Spine 4(2):102–109
Meknas K, Christensen A, Johansen O (2003) The internal obturator muscle may cause sciatic pain. Pain 104:375–380
Moore KL, Persaud TVN (1993) The developing human. Clinically oriented embryology. WB Saunders Company, Philadelphia, London, pp 376–382
Pace JB, Nagele D (1976) Piriform syndrome. West J Med 124:435–439
Papadakis SA, Shepherd L, Babourda EC, Papadakis S (2005) Piriform and trochanteric fossae. A drawing mismatch or a terminology error? A review. Surg Radiol Anat 27:223–226
Papadopoulos EC, Khan SN (2004) Piriformis syndrome and low back pain: a new classification and review of the literature. Orthop Clin North Am 35(1):65–71
Parziale JR, Hudgins TH, Fishman LM (1996) The Piriformis syndrome. Am J Orthop 25(12):819–823
Pokorný D, Jahoda D, Veigl D, Pinskerová V, Sosna A (2006) Topographic variations of the relationship of the sciatic nerve and the piriformis muscle and its relevance to palsy after total hip arthroplasty. Surg Radiol Anat 28:88–91
Porta M (2000) A comparative trial of botulinum toxin type A and methylprednisolone for the treatment of myofascial pain syndrome and pain from chronic muscle spasm. Pain 85:101–105
Rask MR (1980) Superior gluteal nerve entrapment syndrome. Muscle Nerve 3(4):304–307
Robinson DR (1947) Piriformis syndrome in relation to sciatic pain. Am J Surg 73:355–358
Sayson SC, Ducey JP, Maybrey JB, Wesley RL, Vermilion D (1994) Sciatic entrapment neuropathy associated with an anomalous piriformis muscle. Pain 59(1):149–152
Silver JK, Leadbetter WB (1998) Piriformis syndrome: assessment of current practice and literature review. Orthopedics 21(10):1133–1135
Solheim LF, Siewers P, Paus B (1981) The piriformis muscle syndrome. Acta Orthop Scand 52(1):73–75
Sosna A, Pokorny D, Jahoda D (2005) Sciatic nerve palsy after total hip replacement. J Bone Joint Surg [Br] 87-B:1140–1141
Souza TA (2005) Differential diagnosis and management for the chiropractor: protocols and algorithms, 3rd edn. Jone and Bartlett Pub., Sudbury
Spratt JD, Stanley AJ, Grainger AJ, Hide IG, Campbell RS (2002) The role of diagnostic radiology in compressive and entrapment neuropathies. Eur Radiol 12:2352–2364
Steiner C, Staubs C, Ganon M, Buhlinger C (1987) Piriformis syndrome: pathogenesis, diagnosis, treatment. J Am Osteopath Assoc 87(4):318–323
Thiel W (1992) Die Konservierung ganzer Leichen in natürlichen Farben. [The preservation of the whole corps with natural color]. Ann Anat 174:185–195
Thiele GH (1937) Coccydynia and pain in the superior gluteal region. JAMA 109:1271–1275
Travell JG, Simons DG (2000) Handbuch der Muskel- Triggerpunkte. Untere Extremität. Urban & Fischer, München, Jena, pp 214–228
Williams PL (1999) Gray’s anatomy 38th Eng. Ed Churchill Livingstone, London, pp 876–877
Yeoman W (1928) The relation of arthritis of the sacroiliac joint to sciatica. Lancet 2:1119–1122
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Windisch, G., Braun, E.M. & Anderhuber, F. Piriformis muscle: clinical anatomy and consideration of the piriformis Syndrome. Surg Radiol Anat 29, 37–45 (2007). https://doi.org/10.1007/s00276-006-0169-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00276-006-0169-x