ORIGINAL ARTICLE

Prevalence of Piriformis Syndrome in Chronic

Low Back Pain Patients. A Clinical Diagnosis
with Modified FAIR Test
Chee Kean Chen, MD, MMed*; Abd J. Nizar, MD, MMed *Department of
Anesthesiology and Intensive Care, Sarawak General Hospital, Kuching, Sarawak;
Department of Anesthesiology and Intensive Care, University Science of Malaysia,
Kubang Kerian, Kelantan, Malaysia
n Abstract
Purpose: Piriformis syndrome is a collection of symptoms and signs of pain from piriformis muscle and is characterized by pain in buttock with variable involvement of sciatic nerve. This syndrome is often overlooked in clinical
practice because its presentation has similarities with other spine pathologies. A major problem with the clinical
diagnosis of piriformis syndrome is the lack of consistent objective find- ings and an absence of single test that is
specific for pirifor- mis syndrome. Therefore, a precise and reliable clinical method of diagnosing piriformis syndrome
should be devel- oped by clinicians. Methods: This is a prospective observational study involving 93 consecutive
patients who attended the Pain Management Unit for chronic low back pain. The diagnosis of piriformis syndrome
was made using the modified Flexion Adduction Internal Rotation (FAIR) test, which is a combination of Lase`gue sign and FAIR test. Prevalence of piriformis syndrome based on this technique was compared with the previous
data using other techniques. Chi square (v2) analysis was per- formed to detect the relationship between piriformis
syn- drome and the potential risk factors. Results: On the basics of our diagnostic criteria, the preva- lence of
piriformis syndrome was 17.2% among low back pain patients. All the patients diagnosed with piriformis syndrome
responded well with piriformis muscle injections. No significant associations were detected between pirifor- mis
syndrome and spine disorders. Conclusions: Piriformis syndrome is a painful condition that is often overlooked in the
differential diagnosis of chronic buttock or low back pain. The modified FAIR test together with piriformis muscle
injection is potentially a reliable method for the clinical diagnosis of piriformis syndrome.n
Key Words: lower back pain, myofacial pain syndromes,
Address correspondence and reprint requests to: Chee Kean Chen,
sciatica MD, MMed, Department of Anaesthesiology
and Intensive Care, Sarawak General Hospital, Jalan Hospital, 93586 Kuching, Sarawak, Malaysia. E-mail:
leshally@hotmail.com.
Disclosure: This study was done with no financial support or sponsor- ship. There is no conflict of interest related
to this study.
Submitted: March 17, 2012; Revision accepted: May 23, 2012

INTRODUCTION
DOI. 10.1111/j.1533-2500.2012.00585.x
Piriformis syndrome is defined as collection of symp- toms and signs of pain arises from piriformis muscle, 2012
The Authors Pain Practice 2012 World Institute of Pain, 1530-7085/12/$15.00 Pain Practice, Volume , Issue ,
2012

with or without sciatic nerve entrapment.1 It has been documented as a contributory cause for sciatica,

buttock, and low back pain.2,3 This syndrome presents as pain and localized tenderness around the gluteal region at
the area of piriformis muscle and is usually described as a deep, aching type of pain with or with- out signs and
symptoms of sciatica.4,5 Piriformis syn- drome usually manifests as myofascial pain syndrome, where either pain
originates from the muscle itself, as nerve entrapment syndrome, or both.6 This syndrome occurs most frequently
among populations in their fourth and fifth decade of life and affects individuals regardless of type of occupations
and level of activity. The reported prevalence of piriformis syndrome among chronic low back pain patients varies
widely, between 5% and 36%.79
Piriformis syndrome is often underscored in the dif- ferential diagnosis of chronic hip, buttock, and low back pain
as it is frequently unrecognized or is misdi- agnosed in clinical settings.2,10 Controversies exist as to whether the
current clinical diagnosis reflects the true figure on the prevalence of piriformis syndrome, as it is frequently
confused with various low back pain disorders.4 Piriformis syndrome can have similar pre- sentations as other
somatic pain disorders, such as intervertebral disc pathology, lumbo-sacral radiculopa- thy (sciatica), sacro-iliac
disorders, and trochanteric pathology.2,4,11 In extreme cases, misdiagnosis of piri- formis syndrome-related back
pain with sciatica as prolapsed intervetebral disc may lead to unnecessary surgery.10 Delay in the recognition and
hence treat- ment for piriformis syndrome may progress to patho- logic conditions of the sciatic nerve and chronic
dysfunction of musculoskeletal system because of com- pensatory changes, resulting in pain, paresthesia,
hyperesthesia, and muscle weakness.4,12
The main concern with the diagnosis of piriformis syndrome is the lack of consistent objective findings, which
leads in many cases to unnecessary imaging studies and to time loss in searching for etiology of buttock or low back
pain. Of the many diagnostic techniques, the Flexion Adduction Internal Rotation (FAIR) technique had shown high
specificity and sensitivity when used in combination with functional electromyography examination.13,14
Tenderness at the gluteal region around the piriformis muscle (Lase`gue sign) has been noted to be the most
consistent clinical finding in piriformis syndrome.2 We evaluated the prevalence of piriformis syndrome among
patients with chronic buttock and low back pain using a com- bination of FAIR and Lase`gue sign (modified FAIR
test), together with piriformis muscle injection.
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CHEN AND NIZAR

METHODS
After obtaining approval by the Ethics Committee of University Science Malaysia, 93 consecutive patients who
attended the Pain Management Unit at Hospital University Science Malaysia, Kelantan, in 2010 for chronic buttock
and low back pain (ie, lasting more than 6 months) were enrolled in this prospective obser- vational study. All
patients who presented with but- tock and low back pain with or without sciatica regardless underlying pathology
were included in the study. Low back pain is defined as back pain arising from the area between the subcostal
margin and glu- teal region. Sciatica is defined as symptoms of pain, numbness, electric current, or needle prick
sensation in the distribution of sciatic nerve as a result of sciatic nerve irritation, for example, injury to or
compression on the nerve. Demographic data of the patients, chro- nicity of back and buttock pain and primary
diagnosis were collected and examined.
Piriformis syndrome was diagnosed among chronic buttock and low back pain patients by using the modi- fied
FAIR test. The FAIR test was performed on the patient in supine position, with the affected hip flexed at 60 and the
knee flexed at 90. With the hip being stabilized, a single examiner will internally rotate and adduct the hip by
applying downward pressure onto the knee (Figure 1). Modified FAIR test was carried out by applying digital
pressure over the piriformis
Figure 1. Flexion Adduction Internal Rotation test.

muscle during the FAIR test maneuver (Figure 2). This technique is therefore a combination of FAIR test and
Lase`gue sign. Modified FAIR test is considered positive if there is localized tenderness over the piriformis mus- cle
during deep pressure application with reproduction of sciatic symptoms. Patients with positive modified FAIR test
were then further confirmed with piriformis muscle injection. Piriformis muscle injection was done in an aseptic
technique under real-time fluoroscopic guidance. The area of maximum tenderness was viewed under fluoroscopy to
provide a guide to the point of needle insertion. After performing piriformis myogram with 0.5 mL of contrast,
which showed a band of contrast across the location of piriformis muscle from sacrum to greater trochanter of femur
(Figure 3), an injectate of 1.5 mL of lignocaine 2.0% and 0.5mL triamcinolone acetonide 20mg was injected.
Reduction in visual analogue score (VAS) of > 50% after the injection was considered as fulfillment of diagnostic
criteria for piriformis syndrome. The patients with positive modified FAIR test were then tabulated according to
socio-demographic data, associ- ated spine disease or medical disorders and the various variables of piriformis
syndrome presentation. Data collected were then analyzed using the SPSS software version 16.0 (SPSS Inc.,
Chicago, IL, USA). Chi square (v2) analysis was performed to detect the association between the clinical diagnosis
of piriformis and the potential risk factors.
Figure 2. Modified Flexion Adduction Internal Rotation test.

Diagnosis of Piriformis Syndrome with Modified FAIR 3

RESULTS
Ninety-three patients with chronic low back and but- tock pain caused by various etiologies were enrolled into this
study. Sixteen patients (17.2%) were diagnosed to have piriformis syndrome with modified FAIR test, and all 16
patients (100%) had > 50% reduction in VAS after piriformis injection. Majority of the patients (82.8%) with
piriformis syndrome presented with sciat- ica. Women constituted 62.5% of the total number of
Figure 3. Piriformis myogram.
Table 1. Demographic Characteristics of Respondent
Sample Population N = 93 n (%)
Patients with PS N = 16 n (%)
Gender
Male 36 (38.7) 6 (37.5) Female 57 (61.3) 10 (62.5) Age group (years)
< 30 11 (11.8) 2 (12.5) 31 to 40 15 (16.1) 2 (12.5) 41 to 50 28 (30.1) 5 (31.2) 51 to 60 14 (15.1) 4 (25.0) > 60 25
(24.9) 3 (18.8) Body mass index
Underweight (< 18.5) 1 (1.1) 0 (0.0) Normal (18.5 to 24.9) 37 (39.7) 6 (37.4) Overweight (25.0 to 29.9) 30 (32.3) 5
(31.3) Obese (> 30.0) 25 (26.9) 5 (31.3) Duration of back pain
< 1 year 16 (17.2) 4 (25.0) 1 year 18 (19.4) 2 (12.5) 2 years 19 (20.4) 2 (12.5) 3 years 19 (20.4) 4 (25.0) > 3 years 21
(22.6) 4 (25.0)
PS, piriformis syndrome.

patients with piriformis syndrome. Age, gender, BMI, and duration of pain had no significant associations with the
development of piriformis syndrome (Table 1). Baseline pain score (VAS) was found to be moderate (VAS 40 to 60
mm) in 25% of the piriformis syndrome patients, and the remaining 75% of them reported severe pain (VAS > 60
mm). Baseline Oswestry Disabil- ity Index (ODI) among patients with piriformis syn- drome was found to be
moderate in 43.8% of patients (ODI 20 to 40), and severe disability was recorded in 50% of them (ODI > 40) (Table
2). A large proportion of patients who presented with sacroiliac joint syn- drome, facet joint arthropathy, spinal
stenosis, and pro- lapsed intervertebral disc were diagnosed to have piriformis syndrome based on the modified
FAIR test. However, all the spine conditions mentioned were found to have no statically significant association with
the clin- ical diagnosis of piriformis syndrome (Table 3).
DISCUSSION
Piriformis syndrome is a collection of symptoms and signs of pain from piriformis muscle and is character- ized by
pain in buttock with variable involvement of sciatic nerve. The reported prevalence of piriformis syndrome varies
widely, between 6% and 36%, depending on the diagnostic criteria used and the char- acteristics of the sample
population.1,79 In 1976, Pace and Nagle8 reported that 6% of 750 patients who were admitted through the hospital
for problem back service, had piriformis syndrome, diagnosed using Freiberg test and Pace test. In a study of 93
patients with sciatica by Benson and Schutzer,9 15% were
Table 2. Characteristics of Piriformis Syndrome Among Chronic Low Back Pain Patients
Character of Piriformis Syndrome Frequency (n) Percentage
Type of respondent
With piriformis syndrome 16 17.2 Without piriformis syndrome 77 82.8 Piriformis syndrome with sciatica
Yes 13 81.3 No 3 18.7 Visual analogue score (0 to 100 mm)
< 40 0 0 40 to 60 4 25.0 > 60 12 75.0 Oswestry Disability Index
Mild (0 to 20) 1 6.2 Moderate (21 to 40) 7 43.8 Severe (41 to 60) 8 50.0 Response to piriformis muscle injection
Yes 16 100.0 No 0 0

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CHEN AND NIZAR

diagnosed to have piriformis syndrome with FAIR test and palpation of the greater sciatic notch. By using painful
rectal examination and in the absence of other findings, 6% of patients with sciatica were diagnosed to have
piriformis syndrome by Hallin.4
To date, there are no set criteria for the clinical diagno- sis of piriformis syndrome. This is because even until
recently, there is no controlled trial assessing the reliabil- ity of clinical features and determining the efficacy of
treatments for piriformis syndrome.1 The main problem with the clinical diagnosis of piriformis syndrome is lack of
consistent objective findings. Over the years, various different maneuvers, as summarized in Table 4, were
introduced to diagnose piriformis syndrome. However, no single test or sign is reliable and consistent in all
cases.5,19 The major clinical findings in piriformis syn- drome include tenderness over buttock area (Lase`gue
sign), extending from the sacrum to the greater trochanter and piriformis tenderness on rectal or pelvic examination.
Durrani & Winnie reported that the clinical diagnosis of piriformis syndrome can be enhanced by the reproduction
of sciatica in 92% of the piriformis syndrome patients upon deep digital palpation on the gluteal region at one- third
of the distance from the greater trochanter.2 This is because the etiology of piriformis syndrome can be partly due to
myofascial pain syndrome of the piriformis muscle or secondary to various spine and pelvic diseases.6,15 A case
series by Barton in 1991 showed that piriformis symptoms can be aggravated by prolonged flexion, adduction, and
internal rotation (FAIR) of the hip in the absence of low back or hip findings.15
Fishman et al. demonstrated objective electromyog- raphy (EMG) findings in patients with piriformis syndrome.
A delay in H reflex on EMG in the FAIR position in patients with piriformis syndrome was discovered by them, as

to compare with asymptomatic controls. Thus, a delay in H reflex at 3 standard deviaTable3. Recognized Various Spine Pathologies and Associated with Secondary Piriformis Syndrome
Spine Diseases/Medical Disorders
Subset Sample
Patient Population
with PS* N = 93 (%)
n = 16 (%) P
Lumbar facet joint syndrome 28 (30.1) 6 (17.6) 0.932 Spinal stenosis 24 (25.8) 6 (20.0) 0.622 Sacroiliac joint disorder
15 (16.1) 6 (28.6) 0.117 Prolapsed intervertebral disc 16 (17.2) 5 (23.8) 0.362 Failed back surgery syndrome 15
(16.1) 1 (6.3) 0.202
PS, Piriformis syndrome. *The total number of subset patient with piriformis syndrome was more than 16 as some
patients presented with more than one spine pathology.

tions, FAIR test had sensitivity and specificity of 0.881 and 0.832, respectively.13
In this study, we evaluated the prevalence of pirifor- mis syndrome via a combination of the two most reli- able
clinical diagnoses of piriformis syndrome: Lase`gue sign and FAIR test (modified FAIR test). Clinical tests for
piriformis syndrome are aimed at assessing the ten- sion of the sciatic nerve and the irritability of the pirifor- mis
muscle. The rationale of combining both tests was that an inflamed and irritable piriformis muscle would be more
sensitive to external pressure in stretched condi- tion. Thus, the combination of both tests was expected to increase
the efficacy of diagnosis of piriformis syn- drome. Patients who were diagnosed to have piriformis syndrome with
modified FAIR test was subjected to piri- formis muscle injection. All 16 patients had > 50% pain relief, and the
sciatica experienced was disappeared after the piriformis muscle injection (11 patients had com- plete pain relief and
the remaining 5 patients had > 50% reduction in VAS). When these patients were re- examined with modified FAIR
test, all of them did not experience similar pain intensity as prior to injection (modified FAIR test was found to be
negative in 10 patients while 6 others claimed that tenderness was still present but VAS was 50% lower compare to
that prior to injection). All 16 patients with piriformis syndrome had a mean follow-up of 13 months, range from 9
to 17 months. Two patients required only single piriformis injection (during diagnostic block) for pain relief lasting
for twelve months. Ten patients required 2 injections while the remaining 4 required 3 injections. All the subsequent piriformis injections were done under fluoro- scopic guidance. The duration of pain relief after piriformis
muscle injection varied among patients, depending on the primary pathology and the chronicity of pain. There was
no complication related to piriformis injection noted in the course of this study.
With the advancement of technology, contemporary electro-diagnostic, and imaging techniques has been introDiagnosis of Piriformis Syndrome with Modified FAIR 5
Table 4. The Various Diagnostic Techniques in Clinical Diagnosis of Piriformis Syndrome
Diagnostic Test/Sign Description
Pace sign Pain and weakness are experienced on resisted abduction and external rotation of the thigh.8 Flexion
Adduction
Internal Rotation test
Pain is felt when the hip is flexed to an angle of 60 and the knee is flexed to an angle of 60 to 90, at the same
time the hip is adducted and internally rotated.
15
Beatty test Pain and recreation of sciatic symptoms when the patient lies on the unaffected side, lifting and holding
the
superior knee approximately 4 inches off the examination table.23 Solheims sign Pain with adduction of the flexed
thigh, which stretches the piriformis muscle against the sciatic nerve.
2
4 Freiberg sign Pain is experienced during passive internal rotation of the hip.25 Lase`gue sign Localized pain when
pressure is applied over the piriformis muscle and its tendon, especially when the hip is
flexed at an angle of 90 and the knee is extended.26

duced into clinical practice and has shown to increase the efficacy in diagnosing piriformis syndrome.1316 However, the selection criteria in these studies and the validity of these techniques have been vigorously disputed.17,18
In this study, the authors used piriformis muscle injection to confirm the diagnosis of piriformis syndrome as this
tech- nique served both diagnostic and therapeutic purposes, and it is also widely accepted.19,20
The prevalence of piriformis syndrome among chronic low back pain patients was 17.2% in this study using
modified FAIR test. This figure was consistent with previous prevalence rates for piriformis syndrome. Comparing
with the study with sample population of similar characteristics, the prevalence in this study was higher than those in
a study by Cummings in 1991. In Cummings series of 123 patients who visited his clinic for lumbo-gluteal pain

with or without radicular pain, 12 patients (10%) were diagnosed to have piri- formis syndrome. However, the
author did not specify which diagnostic test was used to make the diagnosis of piriformis syndrome. Dry needling
technique or acupuncture was used to confirm the diagnosis, while piriformis muscle injection with local anesthetic
was used in this study.1 The higher prevalence of piriformis syndrome from this study indirectly implies that piriformis syndrome has been under-diagnosed, and this delay in diagnosis and treatment for chronic back pain patients
have led to unnecessary suffering.9
Although piriformis syndrome may only involves piriformis muscle itself, this entity frequently occurs as part of
a cluster of soft tissue injuries, for example, facet joint, sacroiliac joint, or intervertebral disc, as a result of rotation
or flexion of the torso and hip.2 In our pain unit, facet joint pain was diagnosed by medial branch of dorsal rami
block; sacroiliac joint pain was diagnosed by diagnostic sacroiliac joint injection; spinal stenosis and prolapsed
intervertebral disc are diagnosed by magnetic resonance imaging; failed back surgery syndrome was diagnosed
clinically by history and phys-

ical examination. This study failed to demonstrate any significant associations between the clinical diagnosis of
piriformis syndrome and spine pathology. Previously, sacroiliac joint disorder has been considered a common
component of piriformis syndrome.21 However, there is still controversy whether a relationship between pirifor- mis
and sacroiliac disorder exists.22
As this was a non-controlled study, sensitivity and specificity of modified FAIR test in diagnosis of pirifor- mis
syndrome are unable to be determined in this study. The findings of this study merit further investi- gation on the
sensitivity and specificity of modified FAIR test. There were several limitations related to the study design. First, the
confirmation of piriformis syn- drome by piriformis injection may not be conclusive as there is some degree of pain
relief when injecting local anesthetic into a tender area of muscle. We did not perform rectal or vaginal
examinations, which may provide important information in making the diagno- sis. The small sample size in this
study could also be a limiting factor, as a bigger sample population may have shown significant association between
piriformis syndrome and spine pathology.
Piriformis syndrome should always be included in the differential diagnosis of chronic buttock or low back pain
as it is not an uncommon disorder. Modified FAIR test together with piriformis muscle injection can be a reliable
technique for clinical diagnosis of pirifor- mis syndrome.
ACKNOWLEDGEMENTS The authors thank Dr. Esther Lim Hui Cheng for her helpful comments
on the manuscript.
REFERENCES
1. Cummings TM. Piriformis syndrome. Acupunct Med. 2000;18:108121.
2. Durrani Z, Winnie AP. Piriformis muscle syndrome: an underdiagnosed cause of sciatica. J Pain Symptom Man- age.
1991;6:374379.
3. Windisch G, Braune M, Anderhuber F. Piriformis muscle: clinical anatomy and consideration of the piriformis syndrome.
Surg Radiolc Anat. 2007;29:3745.
4. Hallin RP. Sciatic pain and piriformis muscle syn- drome. Postgrad Med. 1983;74:6972.
5. Byrd JWT. Piriformis syndrome. Oper Tech Sports Med. 2005;13:7179.
6. Travell JG, Simons DG. Myofascial Pain & Dysfunction. The Trigger Point Manual. Volume 2. The Lower
Extremities. Baltimore: Williams & Wilkins; 1992.

6
CHEN AND NIZAR
7. Foster MR. Piriformis syndrome. Orthopedics. 2002;25:821825.
8. Pace JB, Nagle D. Piriform syndrome. West J Med. 1976;124:435439.
9. Benson ER, Schutzer SF. Posttraumatic piriformis syndrome: diagnosis and results of operative treatment. J Bone Joint
Surg Am. 1999;81:941949.
10. Fishman LM, Schaefer MP. The piriformis syndrome is underdiagnosed. Muscle Nerve. 2003;28:646649.
11. Rodrigue T, Hardy RW. Diagnosis and treatment of piriformis syndrome. Neurosurg Clin N Am. 2001;12:311 319.
12. Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344:363370.
13. Fishman LM, Dombi GW, Michaelsen C, Ringel S, Rozbruch J, Rosner B. Piriformis syndrome: diagnosis, treat- ment, and
outcomea 10-year study. Arch Phys Med Reha- bil. 2002;83:295301.
14. Filler AG, Haynes J, Jordan SE, et al. Sciatica of non- disc origin and piriformis syndrome: diagnosis by magnetic
resonance neurography and interventional magnetic reso- nance imaging with outcome study of resulting treatment. J Neurosurg
Spine. 2005;2:99115.
15. Barton PM. Piriformis syndrome: a rational approach to management. Pain. 1991;47:345352.
16. Lewis AM, Layzer R, Engstrom JW, Barbaro NM, Chin CT. Magnetic resonance neurography in extraspinal sciatica. Arch

Neurol. 2006;63:14691472.
17. Hopayian K, Song F, Riera R, Sambandan S. The clinical features of the piriformis syndrome: a systematic review. Eur
Spine J. 2010;19:20952109.
18. Tiel RL, Kline DG. Piriformis syndrome. J Neurosurg Spine. 2006;5:102104.
19. Benzon HT, Katz JA, Benzon HA, Iqbal MS. Pirifor- mis syndrome: anatomic considerations, a new injection tech- nique
and a review of the literature. Anesthesiology. 2003; 98:14421448.
20. Dalmau-Carola J. Myofascial pain syndrome affecting the piriformis and the obturator internus muscle. Pain Pract.
2005;5:362363.
21. Bernard TN, Kirkaldy-Willis WH. Recognizing spe- cific characteristics of nonspecific low back pain. Clin Orthop.
1987;217:266280.
22. Papadopoulos EC, Khan SN. Piriformis syndrome and low back pain: a new classification and review of the lit- erature.
Orthop Clin North Am. 2004;35:6571.
23. Beatty RA. The piriformis muscle syndrome: a simple diagnostic manaeuver. Neurosury. 1994;34:512514.
24. Solheim LF, Siewers P, Paus B. The piriformis muscle syndrome: sciatic nerve entrapment treated with section of the
piriformis muscle. Acta Orthop Scand. 1981; 52:7375.
25. Freiberg AH, Vinke TH. Sciatica and the sacro-iliac joint. J Bone Joint Surg Am. 1934;16:126136.
26. Freiberg AH. Sciatic pain and its relief by operations on the muscle and fascia. Arch Surg. 1937;34:337350.