Acupuncture for Piriformis Trigger Points
A person with piriformis pain
About the piriformis muscle
The piriformis is one of the six lateral hip rotators that is located in the deep gluteal area of the hip. It lies deep to the gluteus maximus muscle and usually superficial to the sciatic nerve in the middle portion of the gluteal region. The piriformis muscle passes through the greater sciatic foramen to exit the pelvis and attach onto the greater trochanter. The location of the piriformis muscle makes it prone to nerve entrapment of the sciatic nerve and other nerves. Because of that it can cause piriformis syndrome and sciatica pain.
The piriformis muscle is an important muscle for lateral rotation of the hip. It helps keep the thigh from medially rotating too much during the early stance phase of running or walking. It also helps to stabilize the ball and socket of the hip joint. Tightness in the piriformis is common in hip labrum tear cases since it can tug on the femur and affect the angle at which the femur goes into the acetabulum.
A tight piriformis can lead to trigger points, myofascial pain in the hip and pelvis, as well as nerve entrapment or Piriformis Syndrome. Trigger points in the piriformis primarily refer pain to the SI joint, the gluteal area, over the posterior hip, and down the posterior thigh.
Piriformis syndrome can also be associated with trigger points in the piriformis muscle and is commonly defined by pain, numbness, and tingling in in the hip, buttock, posterior thigh, and in some cases also the low back, perineum, and rectum (during defecation). As far back as 1976, treatment for piriformis syndrome involves the deactivation of piriformis trigger points.
Piriformis trigger points can mimic sacroiliac joint (SI joint) dysfunction and intervertebral disc herniation due to the referred pain and nerve entrapment that the piriformis muscle can cause.
Identifying piriformis trigger points via palpation and treatment with acupuncture and dry needling can help avoid unnecessary disc surgery in cases where the pain is mistakenly thought to be of disc origin.
Read more to learn about piriformis trigger points and how acupuncture and dry needling can help relieve hip, buttock, thigh, and sciatica pain naturally.
Piriformis (right) and muscles of the posterior hip and thigh (left)
Piriformis origin and insertion
Piriformis origin:
The piriformis origin is on the anterior surface of the sacrum.
Piriformis insertion:
The piriformis insertion is on the superior aspect of the greater trochanter.
Since the piriformis muscle attaches on the sacrum and the greater trochanter, it brings those two structures closer together which makes it a lateral rotator of the hip. Additionally, while the hip is flexed, it brings those two structures closer which results in abduction of the hip.
Piriformis action
Laterally rotate the hip
Abduct the hip (when the hip is flexed)
The piriformis is an important hip rotator and also can abduct the hip if the hip is in a flexed position. The piriformis helps to restrain excessive medial rotation of the thigh during weight-bearing activities.
Synergists and antagonists of the piriformis
Piriformis synergists:
Lateral rotation of the hip: Superior gemellus, inferior gemellus, obturator internus, obturator externus, quadratus femoris, gluteus maximus
Assisted by the biceps femoris (long head), sartorius, gluteus medius (posterior fibers), and gluteus minimus (posterior fibers)
Piriformis antagonists:
Medial rotation of the hip: hamstrings (semitendinosis, semimembranosis), tensor fasciae latae, pectinus, gluteus medius (anterior fibers), gluteus minimus (anterior fibers), adductor longus and magnus
Piriformis Trigger Points
Main complaints related to piriformis trigger points include:
Lateral Thigh & Hip Pain
Pelvic Pain
Buttock Pain
Posterior Thigh Pain
Appendicitis-like Pains
Impotence due to Nerve Entrapments
Painful Intercourse
Stress Incontinence or Anal/Genital/Perineal pain
The piriformis muscle is referred to as the “double devil” by Travell & Simons since it causes pain from its pain referral patterns and from nerve entrapment. Since it can cause pain in a wide range of areas and compress various nerves in the deep gluteal region, it can be difficult to pinpoint piriformis trigger points as the culprit.
Trigger points in the posterior fibers of the gluteus minimus muscle, the gemelli muscles, and the obturator internus muscle are most commonly associated with piriformis trigger points. It is also important to assess other piriformis synergists and antagonists to identify possible satellite or latent trigger points.
Piriformis Trigger Point Locations
Piriformis trigger points can be located along the belly of the muscle. Piriformis muscle pain refers to the sacroiliac area (SI joint), buttock, and posterior hip. In some cases the pain referral from piriformis pain can extend lower over the proximal two-thirds of the back of the thigh and can feel like high hamstring or medial hamstring pain.
Since the piriformis muscle is underneath the gluteal muscles, the best way to release piriformis trigger points is with an acupuncture needle.
Piriformis trigger point locations and pain referral pattern
Signs and symptoms of piriformis trigger points
"Piriformis Syndrome" - pain and paresthesia in low back, hip, buttock, posterior thigh/leg/foot, groin, perineum, and rectum (during defecation)
Pain that is worse with sitting or hip flexion, adduction, or medial rotation
Swelling in limb or sexual dysfunction
What causes piriformis pain and trigger points?
Piriformis Syndrome:
Myofascial pain from trigger points
Nerve entrapment by piriformis
SI joint pain and dysfunction
Unaccustomed muscle overload from things like squatting, falling, twisting sideways while bending, forceful turnout, or sexual positions
Lifting a heavy load
Driving for long periods of time
Leg length discrepancy
Repetitive muscle strain is a common cause of piriformis trigger points. If a muscle has a latent trigger point, keeping it in a shortened position for long periods can activate the trigger point. Piriformis trigger points are especially prone to this. Direct trauma to the muscle or sitting for long periods of time are also common activating factors for trigger points in piriformis muscle.
Trigger points in the gluteus minimus and gluteus medius have similar perpetuating factors so they are often present along with piriformis trigger points in cases of hip, buttock, or low back pain.
Piriformis syndrome treatment
What is piriformis syndrome?
Piriformis syndrome is commonly defined as pain from the piriformis muscle due to compression of nerves (commonly the sciatic nerve) that pass through the greater sciatic foramen along with it. It is a nerve entrapment syndrome that has a different cause than myofascial trigger points in the piriformis - although they can happen together and are often related. It can be a cause of non-disc related sciatica. Piriformis syndrome is thought to account for up to 2.4 million cases of pain each year.
Piriformis syndrome pain primarily occurs in the posterior gluteal area and hip. It can include numbness and tingling, and extend as far down as the back of the thigh, back of the knee, calf, or bottom of the foot. The various pains from piriformis syndrome can seem unrelated since they can span all the way from the low back down to the foot, and include pain in the groin, perineum, and rectum (only during defecation).
In approximately 10 percent of people, the sciatic nerve passes through or above the piriformis muscle. These people are more prone to piriformis syndrome since the muscle can compress the sciatic nerve more easily.
What causes piriformis syndrome?
Piriformis syndrome has three main causes:
Piriformis trigger point pain and muscle tightness
Taut bands from the muscle place tension on the muscle and cause it to bulge
Caused by repetitive muscle strain, excessive sitting, or lack of movement of the hip
Nerve entrapment by the piriformis due to its location and its passing through the greater sciatic foramen
Can be caused by muscle tightness (above), or by anatomical differences in the location of the sciatic nerve (and other nerves) in relation to the piriformis muscle and the greater sciatic foramen
SI joint (sacroiliac) dysfunction that can irritate the piriformis muscle
The piriformis muscle can cause nerve entrapment on any nerves that pass through the greater sciatic foramen with the piriformis muscle. The happens when the muscle tightens or enlarges to fill the space in the foramen and press on the adjacent nerves.
Piriformis syndrome can account for up to 6% of all low back pain cases, so it is important to consider in cases of back pain in addition to hip and gluteal pain.
Possible nerve entrapment (Piriformis Syndrome) from piriformis muscle:
The piriformis muscle can compress a number of nerves because of the muscle’s anatomical location and because it passes through the greater sciatic foramen which a number of nerves also pass through.
Sciatic nerve
Usually between the piriformis and the rim of the greater sciatic foramen
Superior gluteal nerve
Usually between the cephalic (towards the head) portion of the piriformis and the upper rim of the greater sciatic foramen (SI area)
Pudendal nerve
Usually near the lower portion of the piriformis
Inferior gluteal nerve
Passes through greater sciatic foramen with the piriformis
Posterior femoral cutaneous nerve
Passes through greater sciatic foramen with the piriformis
Nerves supplying other hip rotators - gemelli, obturator internus, and quadratus femoris muscles
Piriformis syndrome symptoms are commonly worsened by excessive sitting, excessive running or walking, or by having the hip flexed, adducted, and medially rotated for too long all at once. Symptoms can include sexual dysfunction including impotence in some cases.
Identifying piriformis syndrome and trigger points
Myofascial pain due to piriformis trigger points or piriformis syndrome can be identified by the referral patterns of the muscle, by pain/weakness of resisted abduction of the thigh when the hip is flexed, and by local point tenderness of the piriformis with palpation. In cases of piriformis syndrome there will also be nerve entrapment that causes pain, tingling, or numbness along the trajectory of the affected nerve, as well as pelvic pain and sexual dysfunction in certain cases.
How to treat piriformis syndrome?
A 2021 study highlighted acupuncture and dry needling as effective conservative treatment options for piriformis syndrome. Other treatment options include physical therapy, pain injections, and surgery. Acupuncture and dry needling offer the most direct and best treatment for piriformis syndrome for cases where muscle tightness and trigger points are the cause of nerve compression that is causing the pain.
Piriformis syndrome in pregnancy
Piriformis syndrome and sciatica pain is common during and after pregnancy because the hip and gluteal muscles get stretched and strained to accommodate for the growth and transport of the new baby. Treatment with acupuncture and dry needling is safe and effective both during and after pregnancy for back and pelvic pain, as well as piriformis syndrome and sciatica pain.
Acupuncture for piriformis syndrome
Trigger point acupuncture and dry needling can provide myofascial release in the piriformis by identifying the taut bands of muscle that create pain associated with hip pain buttock pain, sciatica pain, thigh pain, or symptoms of piriformis syndrome. Trigger point therapy with an acupuncture needle helps to relax the muscle to restore function, improve range of motion, and reduce pain.
Acupuncture is an effective treatment for musculoskeletal pain of the extremities and for piriformis syndrome.
Your acupuncturist will palpate for taut bands of muscle to find trigger points in the affected muscle and release them using an acupuncture needle.
Dry needling for piriformis syndrome
Dry needling is an effective treatment for piriformis syndrome. One study found that dry needling reduced piriformis syndrome pain after 3 sessions, and that the pain intensity was significantly reduced.
Another study showed that dry needling the piriformis muscle along with the gluteus maximus, gluteus medius, and gluteus minimus muscles resolved piriformis syndrome pain in three patients in just 10 days. Six months later they were still symptom free.
Over to you
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