Movement Health · Sciatica & Hip Function

Pain in your glute or shooting down your leg? Most people — and many clinicians — jump straight to “disc problem.” That’s sometimes right. But one of the most underdiagnosed causes of sciatic pain has nothing to do with your spine. It starts in your glutes.

The assumption everyone makes about sciatica

When leg pain follows the path of the sciatic nerve — through the glute, down the back of the thigh, sometimes into the calf or foot — the word “sciatica” is almost immediately paired with “disc.” And a herniated disc pressing on a spinal nerve root is a real and common cause.

But it’s not the only one.

The sciatic nerve doesn’t just pass through your lower back. It travels the entire length of your leg — and along the way, it runs directly through a region called the deep gluteal space, where it’s in close contact with several muscles, most notably the piriformis. When those muscles become tight, overloaded, or irritated, they can compress the nerve just as effectively as a disc can.

The condition has two names you’ll see in the literature: piriformis syndrome (when the piriformis is the primary culprit) and the broader term deep gluteal syndrome (when other structures in the region are involved). Both are consistently underdiagnosed — in part because standard lumbar MRI doesn’t image the deep gluteal space at all.

What is piriformis syndrome?

Piriformis syndrome is a condition where the piriformis muscle — a deep hip external rotator that sits beneath the gluteus maximus — compresses or irritates the sciatic nerve as the nerve passes through the deep gluteal space.

The anatomy is the key. In over 80% of people, the sciatic nerve runs directly beneath the piriformis as both exit through the greater sciatic foramen. When the piriformis is in spasm, hypertrophied, or chronically overloaded, it squeezes the nerve — producing exactly the burning, aching, shooting pain that people (and scans) routinely attribute to the spine.

Piriformis syndrome was first described in 1928, but the incompletely understood mechanism and lack of clear diagnostic criteria kept it controversial for decades. More recently, advances in MRI imaging and endoscopic surgery have confirmed it as a distinct, treatable condition — and surgical release of contracted piriformis muscles has successfully resolved symptoms in patients where previous lumbar surgery had failed.

Research Note

A 2019 review in the British Journal of Sports Medicine identified deep gluteal syndrome as significantly underdiagnosed and confirmed the sciatic nerve can be entrapped by multiple structures in the deep gluteal space — not just the piriformis. The authors found that standard investigations for sciatica (lumbar MRI) do not visualise this region at all. [PMC, 2019]

What actually causes piriformis syndrome — the glute connection

Here’s the part most articles miss: piriformis syndrome rarely starts with the piriformis.

It starts upstream — with the gluteal muscles that are supposed to stabilise the hip in the first place.

Three muscles matter here:

Gluteus Maximus Primary hip extensor. The largest muscle in the body — and one of the most commonly inhibited, especially in people who sit for long periods.

Gluteus Medius Pelvic stabiliser during single-leg stance. Controls hip drop and frontal-plane movement. Frequently underactive in runners and desk workers alike.

Piriformis Deep external hip rotator. Not designed for sustained hip stabilisation — but forced into that role when the glutes go quiet.

When glute max and glute med are underactive, the hip loses its primary stabilisers. The body doesn’t tolerate instability — it recruits whatever is available. The piriformis, along with other deep hip rotators, compensates. Over time:

The piriformis overworks. It gets tight. It can hypertrophy. And as it does, it puts pressure on the sciatic nerve that runs directly beneath it — producing pain that feels exactly like spinal sciatica.

This is why people with piriformis syndrome so often end up with normal lumbar MRIs. Their spine is fine. The problem was never there.

For runners: why this pattern is so common

Running is a predominantly sagittal-plane activity. You train forward propulsion. You almost never train lateral hip stability. Over months and years, gluteus medius — the primary pelvic stabiliser during single-leg stance — becomes progressively underactive.

Every stride is a single-leg loading event. Without adequate glute med function, the pelvis drops on the swing side, the femur rotates inward, and the deep hip rotators — including the piriformis — absorb forces they aren’t built for.

A 2016 systematic review with meta-analysis confirmed significantly reduced gluteus medius activity duration in injured runners compared to healthy controls — suggesting glute med dysfunction is a contributing factor to injury, not just a consequence of it. [PubMed, 2016]

Piriformis syndrome vs spinal sciatica: how to tell them apart

Clinically, the two conditions can overlap significantly. But several patterns point in one direction:

Suggests piriformis / muscular cause

• Pain worsens with prolonged sitting (especially on hard surfaces)
• Deep buttock tenderness near the greater sciatic notch
• Pain with hip internal rotation and flexion
• No significant neurological deficits (weakness, reflex changes)
• Normal lumbar MRI
• Negative or late-positive straight leg raise
• Relief with movement and walking

Suggests spinal / disc cause

• Clear onset with lifting, bending, or disc event
• Significant neurological signs (foot drop, reflex loss)
• Positive straight leg raise at lower angles (<60°)
• MRI confirms nerve root compression at matching level
• Constant pain unrelated to position
• Bladder or bowel changes (seek urgent review)

Important

Many people have both spinal and muscular contributions simultaneously. Treating one while ignoring the other is a common reason pain persists. A thorough clinical assessment is essential to identify all contributing factors and guide management appropriately.

How to fix piriformis syndrome: exercises, rehab, and sports acupuncture

If the root cause is a piriformis that is overworking because the glutes are underperforming, the fix is not aggressive piriformis stretching. Stretching an already-overloaded muscle without fixing why it’s overloaded is short-term symptom management at best.

The priority sequence for muscular sciatica:

1. Restore gluteus medius and gluteus maximus activation. Targeted isolation exercises — side-lying hip abduction, glute bridges, clamshells — re-establish the neuromuscular connection before load is added.
2. Reduce piriformis overload. Once the glutes activate appropriately, the piriformis no longer needs to compensate. Tightness typically reduces without the piriformis itself being the primary focus of treatment.
3. Progress to functional single-leg loading. Hip hinge patterns, lateral band walks, and step-up progressions build the capacity to sustain movement without compensation returning.
4. Address training patterns (especially for runners). Integrate lateral-plane training, controlled hip drop work, and progressive loading to prevent the pattern from re-establishing itself over the following months.

Clinical Note

Restoring glute activation is a critical early intervention — not a standalone cure for all sciatic presentations. Exercise selection and progression should be guided by a qualified physiotherapist following individual clinical assessment. If you have significant or worsening neurological symptoms (weakness, bladder changes, constant severe pain), seek assessment promptly.

How sports acupuncture treats piriformis syndrome

One of the most effective — and underutilised — tools for piriformis syndrome is sports acupuncture, specifically motor point acupuncture. Unlike general acupuncture, motor point acupuncture is guided entirely by anatomy and neuromuscular function. It targets the neuromuscular junction — the precise point where the motor nerve enters a muscle — to directly influence how that muscle fires.

For piriformis syndrome, a skilled sports acupuncturist works on two fronts simultaneously: reactivating the inhibited glutes that started the problem, and releasing the overloaded piriformis that is compressing the sciatic nerve.

Motor point: Gluteus Maximus Needling the glute max motor point elicits a local twitch response that resets the neuromuscular junction — restoring inhibited activation in a muscle that may have been underperforming for months or years.

Motor point: Gluteus Medius Glute med motor point needling re-establishes lateral hip stability. For runners especially, restoring glute med firing capacity reduces the compensatory load on the piriformis on every single stride.

Direct release: Piriformis Precise needling of the piriformis muscle — guided by anatomical landmarks — produces a local twitch response that releases chronic tension, reduces hypertrophy-related nerve compression, and restores normal muscle length.

This approach is particularly powerful because it addresses both sides of the equation at once: activating what’s switched off (glutes) and releasing what’s overloaded (piriformis). Exercise alone can be slow to change deeply inhibited muscles — motor point acupuncture can accelerate the neuromuscular reset, making subsequent rehabilitation exercises significantly more effective.

What is motor point acupuncture?

Motor point acupuncture involves placing an acupuncture needle directly into the motor point of a muscle — the neuromuscular junction where the motor nerve enters the muscle belly. This triggers a local twitch response: an involuntary contraction of the muscle fibres that resets the muscle’s resting state. The result is either activation of an inhibited, underactive muscle, or release of a shortened, overactive one — depending on the clinical presentation and technique used.

In the context of piriformis syndrome, motor point acupuncture to glute max and glute med re-establishes the neuromuscular drive that the muscles have lost, while direct piriformis needling releases the chronic tightness that has built up from months of compensatory overwork.

Sports acupuncturists who specialise in motor point techniques integrate this approach with functional movement assessment and rehabilitation — making it a clinical tool rather than a standalone treatment. To find a qualified sports acupuncturist trained in motor point techniques, visit sportsacupuncturist.com.

Frequently asked questions

Can sciatica be caused by muscles instead of a disc?

Yes. Muscles in the deep gluteal space — particularly the piriformis — can compress the sciatic nerve and produce pain that feels identical to spinal sciatica. This is called piriformis syndrome or deep gluteal syndrome. It is significantly underdiagnosed because standard lumbar MRI does not image the deep gluteal space.

What is piriformis syndrome and what causes it?

Piriformis syndrome is a condition where the piriformis muscle compresses the sciatic nerve in the deep gluteal space, causing buttock pain and leg pain that mimics spinal sciatica. It is most commonly caused by the piriformis overworking as a hip stabiliser when the primary gluteal muscles (gluteus maximus and gluteus medius) are underactive. Prolonged sitting, trauma, and repetitive activity without lateral training are also contributing factors.

How do I know if my sciatica is piriformis syndrome or a disc?

Piriformis syndrome typically causes pain that worsens with sitting, deep buttock tenderness, and pain with hip internal rotation. A normal lumbar MRI with persistent sciatic symptoms is a strong indicator. Spinal disc sciatica more commonly involves neurological signs (weakness, reflex changes), a positive straight leg raise, and matching nerve root compression on MRI. Both can coexist, so a clinical assessment is needed to differentiate.

Why do runners get piriformis syndrome?

Running is a sagittal-plane activity that does not train lateral hip stability. Over time, gluteus medius — the primary pelvic stabiliser during single-leg loading — becomes underactive. Without adequate glute med function, the piriformis overworks on every stride to compensate for lost hip stability. This cumulative overload leads to tightness, irritation, and eventual compression of the sciatic nerve.

What exercises fix piriformis syndrome?

The most effective approach addresses the underlying cause — gluteal underactivation. Exercises include side-lying hip abduction, glute bridges, clamshells, standing hip abduction with a band, and single-leg progressions such as single-leg deadlifts and lateral band walks. Simply stretching the piriformis without restoring glute function provides temporary relief at best. Exercise should be guided by a physiotherapist.

Can you have both piriformis syndrome and a herniated disc?

Yes — this is more common than widely appreciated. Having spinal pathology does not rule out a muscular contribution, and vice versa. When both are present and only one is treated, pain often persists. A thorough assessment is needed to identify and address all sources.

How long does piriformis syndrome take to heal?

With appropriate rehabilitation targeting gluteal activation and hip stability, significant improvement is typically seen within 4–8 weeks. Chronic or severe cases, or those involving structural changes to the piriformis, may take longer. Outcomes are generally good with conservative treatment. Surgery is rarely needed but has shown success in cases where conservative management has failed.

Can sports acupuncture help piriformis syndrome?

Yes. Sports acupuncture — particularly motor point acupuncture — is an effective approach for piriformis syndrome. A sports acupuncturist needles the motor points of gluteus maximus and gluteus medius to restore neuromuscular activation in inhibited muscles, while also needling the piriformis directly to release tension and reduce compression on the sciatic nerve. This two-pronged approach addresses both the cause (glute underactivation) and the symptom (piriformis overload) simultaneously. Find a qualified sports acupuncturist at sportsacupuncturist.com.

What is motor point acupuncture and how does it work?

Motor point acupuncture involves needling the neuromuscular junction — the point where the motor nerve enters the muscle — to reset the muscle’s resting length and restore normal firing patterns. A local twitch response is elicited, which resets the muscle. In sports acupuncture, this technique is used both to activate inhibited muscles (such as underactive glute max and glute med) and to release overactive, shortened muscles (such as a tight piriformis). It is guided by anatomy and neuromuscular function rather than traditional meridian theory.

What does a sports acupuncturist do differently for piriformis syndrome?

A sports acupuncturist uses motor point needling to directly address the neuromuscular dysfunction driving piriformis syndrome. They assess the activation status of gluteus maximus and gluteus medius, needle their motor points to restore inhibited firing, then release the overloaded piriformis with direct needling. This integrated approach treats underactive glutes and overactive piriformis together, working alongside rehabilitation exercises for faster and more durable recovery. To find a sports acupuncturist trained in motor point techniques, visit sportsacupuncturist.com.

References

1. Hopayian K, et al. Deep gluteal syndrome: an overlooked cause of sciatica. British Journal of Sports Medicine, 2019. PMC6774708
2. Semciw AI, et al. Running related gluteus medius function in health and injury: A systematic review with meta-analysis. Journal of Electromyography and Kinesiology, 2016. PubMed 27367574
3. Martin HD, et al. From Piriformis Syndrome to Deep Gluteal Syndrome. Practical Neurology, 2021. Practical Neurology
4. Konstantinou K & Dunn KM. Piriformis Syndrome. StatPearls, NCBI Bookshelf. NBK448172
5. Smoll NR. Variations of the piriformis and sciatic nerve. Clinical Anatomy, 2010. PMC5193530
6. Semciw AI, et al. Gluteal muscle activity during running in asymptomatic people. Journal of Electromyography and Kinesiology, 2020. PubMed 32563058
7. Sports Acupuncturist. Motor Point Acupuncture for Musculoskeletal Conditions. sportsacupuncturist.com

Medical disclaimer: This article is for educational purposes only and does not constitute medical advice, diagnosis, or treatment. If you are experiencing persistent pain, neurological symptoms, or have concerns about your condition, please consult a qualified healthcare professional for individual assessment. Do not delay seeking professional advice based on information in this article.