Piriformis Syndrome, Deep Gluteal Pain & The Confused Modern Medicine: Which Treatment Is The Best?

Deep gluteal syndrome (DGS), once enclusively called piriformis syndrome (PS), is a pain conditIon that is located at posterior hip. Several musculoskeletal disorders can compress the sciatic nerve as it passes through the deep gluteal space. Collectively, they are known as the deep gluteal syndrome (DGS) (Hopayian et al, 2019).

The term piriformis syndrome (PS) was used because the piriformis was the first muscle to be implicated. To date, reports including the term “deep gluteal syndrome” (DGS) in orthopedic and radiologic journals have been limited, however, many articles discuss or focus on piriformis syndrome (Carro LP et al, 2016).

Currently, there are many known causes of sciatic nerve entrapment that have nothing to do with piriformis syndrome, which is actually a subtype of Deep Gluteal Pain (DGS) (Carro LP et al, 2016).

Symptoms of DGS

The most common symptoms of DGS include hip or buttock pain and tenderness in the gluteal and retro-trochanteric region and sciatica-like pain, often unilateral but sometimes bilateral, exacerbated with rotation of the hip in flexion and knee extension. Intolerance of sitting more than 20 to 30 min, limping, disturbed or loss of sensation in the affected extremity (Carro LP et al, 2016).

Pain of DGS is often exacerbated by activity associated with hip flexion, including walking, sitting, reclining, lifting, or even standing. Deep gluteal pain may be intermittent and paroxysmal or persistent and unrelenting. The degree of pain associated with DGS can limit activities and result in sleep deprivation (Black SB, 2018).

Diagnosis: Uncertainty

The diagnosis of piriformis syndrome as a cause of gluteal pain and potentially sciatic nerve involvement had been controversial (Black SB, 2018).

Clinical assessment of patients with DGS is difficult since the symptoms are imprecise and may be confused with other lumbar and intra - or extraarticular hip diseases (Carro LP et al, 2016).

Although there are clinical signs to help differentiate DGS from other conditions like lumbar spine disease, there is no one specific physical finding or anatomic abnormality that definitively diagnoses DGS (Black SB, 2018).

Treatment: Nothing Impressively Works

The terminology and clinical description of piriformis syndrome (PS) was established in as early as in 1940s (Black SB, 2018). In the last 80 years, many conservative and surgical treatments have been recommended for PS or DGS treatment. However, evidence supporting superiority of one treatment over another is lacking (Hopayian K et al, 2023).

The recommended treatments include physical therapy, lifestyle modification, NSAIDS and muscle relaxants, and the avoidance of recognized contributory activities.

In 2023, researchers from Cypus and Iran (Hopayian K et al, 2023) published their systematic review on the effectiveness of treatments. Thirteen studies with 508 patients were included, eight RCTs with 336 patients and 5 case series with 172 patients.

The treatments used in those RCTs included:

• Physiotherapy, intramuscular infiltration, and surgery.
• The physiotherapy modalities included tissue mobilisation and selective strengthening of specific muscle groups.

The review found that overall quality of evidence was low. The authors concluded (Hopayian K et al, 2023): Given the low quality of evidence, no single conservative treatment can be recommended over another.

That is, if we ask "which treatment is the best?" The answer is: None.

In medicine, when you have a lot of "solutions" but no single one is superior to another, that means you have no confidence at all in the efficacy but “a scattergun shot then pray”.

Conjectures, Myths & Fallacies

While we have no confidence at all, we do have invented many conjectures, myths or fallacies about PS and/or DGS.

The variability in sciatic nerve position as it transverses the piriformis has been considered as a risk factor, but to date, no concrete evidence has documented that variances play a role in sciatic nerve entrapment (Black SB, 2018).

Although it has been postulated that individuals who run, bicycle, or do similar activities are more susceptible especially if they do not routinely stretch and strengthen laterally before exercise, the evidence for this is insufficient and unsubstantiated (Black SB, 2018).

A Miserable Failure of Modern Medicine

DGS is a disorder falling into musculoskeletal category. For musculoskeletal conditions in general, modern medicine provides no solutions which are more effective and less harmful than placebo or no treatments.

That is why, in 2018, the British Journal of Sports Medicine published an editorial titled: "Is it time to reframe how we care for people with non-traumatic musculoskeletal pain?" The editorial loudly voiced:

• “Current Approach to Musculoskeletal Pain Is Failing ...
• “We contend this requires those of us working in the musculoskeletal field?to acknowledge the limitations of current surgical and non-surgical interventions for persistent and disabling non-traumatic presentations ...”

The leading author of the editorial is Professor Jeremy Lewis, who is also a consultant physiotherapist working in the UK-NHS, with over 20 years of experience of musculoskeletal pain management.

Questions Modern Medicine Has No Answers

Dr Sturt B. Black, MD, Chief of Neurology at Baylor University Medical Center at Dallas, TX, talked about the confusions surrounding PS and DGS (Black SB 2018). He wrote on practicalneurology.com: “In clinical practice, DGS remains an underdiagnosed condition. Symptoms are easily attributed to lumbosacral spine disease and sometimes hip pathology.”

Dr Black raised a few questions. These questions, in my view, serve as a very insightful summary of the confusing issue over PS & DGS:

Question 1: Is it possible that some patients with chronic low back pain, radicular pain, gluteal pain, or failed spinal surgery actually have symptoms related to DGS with discomfort secondary to an entrapment neuropathy in the pelvis?

Question 2: Because pain from degenerative lumbar spine disease may overlap with the pain of DGS, can patients, or even experienced physicians, clinically distinguish between them?

Question 3: Since both degenerative lumbar spine disease and DGS may occur simultaneously with similar risk factors (eg, athletics, trauma, prolonged sitting, or aging), what are the patient's distinguishing factors that differentiate the etiology of severe low back pain and radicular or gluteal pain on a clinical basis?”

Dr Black raised these deep-thinking questions, but the modern medicine is not able to give any answers, at least for now.

The Answers Lie in An Ancient Healing Art

While a simple pain in the hip defeated the entire modern medicine world, few healthcare practitioners today are aware that there was a healing art 2000 years ago in China which could instantly knock out or greatly relieve any pain or abnormal sensation on the body including hip pain. More importantly, the palpation techniques used in Neijing acupuncture could provide extremely simple and clear answers to all the questions Dr Black raised.

The magic intervention ancient Chinese doctors used to treat diseases was needle therapy (not the acupuncture or the dry needling used today). I call it Neijing acupuncture.

Even a distorted small portion of this healing art has already changed many conventional health practitioners' professional perspectives forever (Read this )! And it even helped in saving a 130 years old non-conventional medical profession which would have otherwise been history (Read this )!

Unfortunately, Neijing acupuncture, the most brilliant jewels of wisdom that ever existed in the history of medicine, all of a sudden became a “forgotten item” at a turning point in history.

The purpose of my Newsletter – Truth of acupuncture science, is to dig out the jewels from the dust, particularly to clarify their value which is beyond our imagination, and why they ended up being ignored, forgotten and discarded.

PS & DGS Pain Relief: Just A Breeze

With Neijing Acupuncture, PS & DGS pain relief and permanent cure is just a breeze: Upon a needle insertion far away from the hip, the pain at hip will subside or disappear in 3 seconds.

“The wind blows away the cloud”, says Huandi Neijing in Linshu 1.

Keep reading my Newsletter – The Truth of Acupuncture Science, a Science has been deeply buried in the dust of 2000 years. Knowing this truth will help all healthcare professionals worldwide work together to have the sicken modern medicine cured, and more importantly, help human beings ourselves to escape from the agony.

References

Carro LP et al. Deep gluteal space problems: piriformis syndrome, ischiofemoral impingement and sciatic nerve release. Muscles Ligaments Tendons J. 2016 Dec 21;6(3):384-396.

Black SB, From Piriformis Syndrome to Deep Gluteal Syndrome. Spotlight Topic: Pain | September 2018, practicalneurology.com

Hopayian K et al, A systematic review of conservative and surgical treatments for deep gluteal syndrome. J Bodyw Mov Ther. 2023 Oct;36:244-250.

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