Sciatica is pain that radiates along the path of the sciatic nerve, extending from the lower back through the hip and down the leg, usually affecting only one side. This nerve pain is typically caused by nerve root compression from a spinal issue, such as a herniated disc or spinal stenosis. Piriformis syndrome is a neuromuscular disorder where the piriformis muscle, located deep in the buttock, spasms or tightens and irritates the underlying sciatic nerve. This causes pain that mimics true sciatica. Finding the right medical professional is necessary for an accurate diagnosis and effective treatment plan.
The Initial Consultation: Primary Care and Referral
The first medical professional most people consult is a general practitioner, family doctor, or internist, who acts as the entry point into the healthcare system. The primary care provider (PCP) rules out serious conditions that might be causing the leg pain, such as infection or tumors, which are often referred to as “red flags.” The PCP takes a comprehensive medical history and performs a basic physical and neurological examination, looking for signs like weakness, altered reflexes, and nerve tension.
Differentiation between spinal-related sciatica and piriformis syndrome begins here, although piriformis syndrome is often a diagnosis of exclusion. The provider may use specific physical maneuvers, such as the FAIR (Flexion, Adduction, and Internal Rotation) test, to assess if the piriformis muscle is involved.
If symptoms are mild or acute, the PCP typically prescribes a conservative, short-term treatment plan. This plan involves rest, over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs), and possibly muscle relaxants. If the condition does not improve after several weeks of conservative management, or if symptoms are severe, the PCP facilitates a referral to specialists equipped to manage musculoskeletal and nerve-related disorders.
Specialists Focused on Non-Surgical Treatment
For the majority of patients, treatment focuses on non-surgical methods, led by specialists in physical medicine and rehabilitation, known as physiatrists. Physiatrists are medical doctors who specialize in restoring function and managing conditions affecting the nerves, muscles, and bones without performing surgery. They often coordinate the conservative care team, designing a comprehensive plan that includes medication management, physical therapy, and interventional procedures.
The physiatrist works closely with physical therapists (PTs), who are central to non-surgical recovery for both sciatica and piriformis syndrome. PTs employ therapeutic exercises, strengthening routines, and stretching techniques to improve flexibility and core stability. For piriformis syndrome specifically, they focus on stretching the tight piriformis muscle and strengthening the surrounding gluteal muscles to relieve sciatic nerve compression.
Another specialist often involved is a chiropractor, whose expertise lies in spinal manipulation and adjustments to improve movement and reduce nerve irritation originating from the spine. They also perform soft tissue manipulation, which can help alleviate muscular tension associated with piriformis syndrome. When oral medications and physical therapy alone are not enough, pain management specialists may provide interventional procedures. These specialists are trained to administer targeted injections, such as epidural steroid injections for spinal-related sciatica or local anesthetic and corticosteroid injections directly into the piriformis muscle to reduce localized inflammation and spasm.
Advanced Diagnostics and Surgical Intervention
When conservative treatments fail to provide lasting relief, or the diagnosis remains unclear, the next step involves advanced diagnostic testing and potentially surgical consultation. Neurologists are medical doctors specializing in the nervous system, and they play a necessary role in confirming the precise location and extent of nerve damage. They frequently perform electrodiagnostic studies, such as Electromyography (EMG) and Nerve Conduction Studies (NCS).
These tests measure the electrical activity of muscles and the speed of nerve signals, helping to distinguish between nerve root compression in the spine and nerve compression peripheral to the spine, such as in piriformis syndrome. Neurologists may also manage medications that specifically target nerve pain, such as gabapentin or pregabalin. If diagnostic testing confirms structural compression that requires mechanical correction, a patient may be referred to a spine surgeon.
The surgical team typically consists of orthopedic surgeons with a focus on the spine or neurosurgeons. Surgery is reserved as a last resort for severe cases where conservative care has failed, or if the patient experiences progressive neurological deficits like foot drop or bowel dysfunction. Procedures for sciatica caused by disc herniation include a microdiscectomy, which removes the portion of the disc pressing on the nerve. For piriformis syndrome, a specialized surgeon may perform a piriformis tendon release or sciatic nerve decompression to physically free the nerve from the tight muscle.