Sciatica vs. Piriformis Syndrome: How to Tell the Difference

The term “sciatica” gets used loosely — often to describe any pain that travels from the lower back or buttock down the leg. But sciatica is a symptom, not a diagnosis. It tells you the sciatic nerve is being irritated somewhere along its path. It tells you nothing about where.

The two most common sources are lumbar disc herniation — where the nerve root is compressed at the spine — and piriformis syndrome, where the sciatic nerve is compressed or irritated by the piriformis muscle deep in the gluteal region. These two conditions produce similar symptoms. They require different treatment. And confusing them is one of the most common reasons patients don’t get better.

Where the pain comes from matters

In lumbar disc herniation, the compression happens at the nerve root — typically L4–L5 or L5–S1. The pain usually starts in the lower back, radiates through the buttock, and travels down the back of the leg, sometimes into the calf or foot. It’s often worsened by sitting, forward bending, or anything that increases intradiscal pressure. Coughing or sneezing can reproduce it sharply.

In piriformis syndrome, there is no disc involvement. The sciatic nerve exits the pelvis near or through the piriformis muscle. When that muscle is tight, hypertrophied, or in spasm, it compresses the nerve from the outside. The pain is typically deeper in the buttock, may radiate down the leg, but usually doesn’t involve the lower back the same way. It’s often worse after prolonged sitting, hip external rotation, or direct pressure on the piriformis.

How we tell them apart

Clinical testing differentiates them. The straight leg raise test (SLR) is positive in lumbar nerve root compression — elevating the leg reproduces the radiating pain by tensioning the nerve root. The FAIR test (hip flexion, adduction, and internal rotation) is specific for piriformis syndrome — it stretches the piriformis across the sciatic nerve and reproduces the buttock and leg pain if that’s the source.

Palpation of the piriformis — deep in the gluteal region — will often reproduce symptoms directly in piriformis syndrome. The lower back exam is typically unremarkable. In lumbar disc cases, motion palpation of the lumbar spine and segmental provocation will reproduce or worsen symptoms.

Why it matters for treatment

Lumbar disc cases are treated with decompressive lumbar adjustment, McKenzie-style positioning, and management of the disc pressure mechanics. Piriformis cases are treated with direct soft tissue work to the piriformis and hip external rotators, combined with sacroiliac and lumbopelvic adjustment to address the mechanical loading that’s driving the piriformis tension.

If you’ve been told you have sciatica and you’re not getting better, it’s worth asking whether the source has actually been confirmed — or assumed. A thorough clinical assessment takes about 15 minutes and gives you a clear answer.