When we have a patient with the piriformis syndrome, we have to find out whether the piriformis is:

• Congested (bad blood supply).
• Shortened (spasm).
• Overstretched.

In the case of congestion, we will have the following signs:

• The complaint is a less sharp pain then in overstretched or spasm.
• The complaint is constantly there and improves when walking (circulation improves).
• The whole area of foramen infrapiriformis is sore on palpation, also in the regions of foramen suprapiriforme, IS-joint, sacrospinous and sacrotuberous ligaments.
• Visceral palpation deep in the iliac fossa on the ipsilateral side gives a mostly burning pain.
• In some cases there are pelvic visceral complaints.
• Congestion can also be caused by an anterior rotation lesion of the ilium because this type of lesion closes the foramen infrapiriforme.
 
In the case of a shortened (spasm) piriformis:
• The observation of the patient standing gives an external rotation of the leg (hip) and a sacrum posterior position. This combination (origin and attachment closer to each other) gives a shortened muscle.
• Sharp, pain localized on the muscle itself.
• Somatic dysfunction of L5 and the sacrum (segment of the piriformis muscle is L5, S1-2).

In the case of an overstretched piriformis:
• The observation of the patient standing gives an external rotation of the leg (hip) and a sacrum anterior position. This combination (origin and attachment further away from each other) gives an overstretched muscle.
• Sharp, pain localized on the muscle itself.

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