Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA

Piriformis Syndrome – Clinical Tests

1. Basic Concept

Piriformis syndrome refers to leg pain or sciatica attributed to compression/irritation of the sciatic nerve at the hip, rather than a lumbar spine pathology.

It can therefore mimic:

• Lumbar disc herniation
• Lumbar radiculopathy
• Sciatica

The diagnosis can be difficult because the symptoms may overlap considerably with lumbar spine disease.

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2. Anatomy

Piriformis muscle

• Origin: Anterolateral/anterior surface of the sacrum
• Insertion: Posterior aspect of the greater trochanter
• Located deep in the buttock.

Pain distribution

Typically:

• Deep buttock pain
• Posterior thigh pain
• May extend into the posterior leg because of sciatic nerve irritation
• Paresthesia/pins and needles may occur

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3. Straight Leg Raising Test

The lecture emphasizes the straight leg raising (SLR) test primarily in the context of lumbar disc herniation.

Technique

• Hip is flexed while the knee is progressively extended.

Positive test

Reproduction of the patient’s sciatic/radicular pain suggests sciatic nerve irritation, and the lecture associates a positive SLR particularly with lumbar disc herniation.

Important distinction

SLR primarily tests neural tension associated with lumbar pathology; it is not the specific test for piriformis syndrome.

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4. Lasègue / Straight Leg Stretch Test

The lecture describes the Lasègue maneuver as a nerve-stretching test.

Technique

• Hip flexed to approximately 90°
• Knee progressively extended

Positive test

• Reproduction of the patient’s pain.

It may also be performed with the patient lying on their side.

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5. FAIR Test — Most Important Piriformis Test

FAIR = Flexion, Adduction, Internal Rotation

This should not be confused with FABER.

FAIR test

The hip is positioned in:

• Flexion
• Adduction
• Internal rotation

Principle

This maneuver stretches the piriformis and can reproduce symptoms if the piriformis is irritating/compressing the sciatic nerve.

Positive FAIR test

• Reproduction of the patient’s typical buttock/sciatic symptoms.

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6. FAIR vs FABER

Test	Position	Main purpose in the lecture
FAIR	Flexion + Adduction + Internal rotation	Piriformis syndrome
FABER	Flexion + Abduction + External rotation	SI/hip pathology

Exam Pearl

FAIR / FABER

FAIR – Piriformis

FABER – SI/hip assessment

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7. Posterior Buttock Pressure

During the FAIR maneuver, the examiner can apply pressure over the posterior buttock/piriformis region.

Positive finding

• Marked tenderness
• Reproduction of the patient’s familiar pain

This supports the possibility that the piriformis region is contributing to the symptoms.

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8. Clinical Differentiation

Feature	Lumbar disc/radiculopathy	Piriformis syndrome
Main source	Lumbar spine	Piriformis/sciatic nerve region
Sciatic symptoms	Common	Can occur
SLR	Important clinical test	May reproduce symptoms but is not specific
FAIR	Not the primary test	Important provocative test
Buttock tenderness	Less characteristic	May be prominent
Posterior buttock pressure	Not diagnostic	May reproduce symptoms

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High-Yield Take-Home Points

• Piriformis syndrome can mimic lumbar sciatica.
• Piriformis originates from the sacrum and inserts on the greater trochanter.
• Pain is typically deep in the buttock, often extending into the posterior thigh/leg.
• SLR/Lasègue – stretches the sciatic nerve and is classically associated with lumbar disc pathology.
• FAIR – piriformis provocative test.
• FAIR = Flexion + Adduction + Internal Rotation.
• FABER is different from FAIR.
• Posterior buttock tenderness during the provocative maneuver supports piriformis-region pathology.
• A positive clinical test does not by itself establish piriformis syndrome, because the condition can overlap clinically with lumbar radiculopathy.