Sciatica or Something That Mimics It? Piriformis Syndrome vs. Disc Herniation vs. Hip Rotator Weakness

If you have radiating pain from the low back or buttock into the leg—especially below the knee—you are likely calling it sciatica. That single word hides multiple possible causes. The most common is a lumbar disc herniation irritating a nerve root. But persistent “sciatica” can also come from piriformis syndrome (or other deep gluteal space entrapments that pinch the sciatic nerve outside the spine) or from hip rotator weakness that overloads tissues and keeps nerves irritable. Untangling which one you have changes everything—from how long you wait before getting imaging to which exercises and procedures actually help.^[1]

Below you will find a practical, evidence-based roadmap: how each condition feels, what to try at home, the clinical tests with the strongest backing, when to consider imaging, and which treatments have the best odds of relief.

Seek urgent care now if you notice new or progressive leg weakness, foot drop, loss of bowel or bladder control, numbness in the saddle region, high fever with severe back pain, or profound, rapidly worsening pain after significant trauma. These can signal cauda equina syndrome, severe nerve root compromise, infection, or other emergencies that require prompt specialist care.^[1]

Clinicians use “sciatica” as a patient-friendly term for pain down the leg from lumbosacral nerve root pathology (radicular pain). Current guidelines emphasize that you should not rush to imaging in the absence of red flags; most people improve with time and appropriate conservative care, and scans are reserved for situations where the result will change management.^[1]

A disc herniation can compress or inflame a nerve root (often L5 or S1), causing sharp, shooting pain down the leg, numbness or tingling in a dermatomal pattern, and sometimes weakness or reflex changes. The pain often worsens with coughing, sneezing, or bearing down, and may ease a little when you lie down with knees bent. Most symptomatic disc herniations improve over six to eight weeks without surgery; both conservative and surgical pathways lead to similar outcomes by the medium to long term, although surgery can relieve severe symptoms faster when it is truly indicated.^[1]

Piriformis syndrome is a form of deep gluteal syndrome: the sciatic nerve is irritated in the buttock (outside the spine), often near or under the piriformis muscle. People describe buttock pain with sitting, tenderness deep behind the hip, and radiation down the leg that mimics sciatica. You might feel better when you stand or walk, worse when you sit on a firm chair or in a car for long stretches. Reviews remind us that piriformis syndrome is real but frequently over-diagnosed; careful evaluation is essential because other muscles or fibrous bands in the deep gluteal space can entrap the nerve as well.^[4]

Sometimes your “sciatica” does not come from a single compressed nerve at all. Weakness of the hip abductors and external rotators (especially the gluteus medius and deep rotator group) can alter pelvic control and stride, overloading tissues around the greater trochanter and the deep gluteal space, and keeping neural tissues irritable. Research shows people with low back pain often have weaker hip abductors and extensors than pain-free peers, and targeted strengthening can reduce pain and disability—especially when combined with core control. While this is not the same as a single entrapment point, it can be the background issue that makes your sciatica “hard to fix” until the hip is addressed.^[6]

Reality check: these patterns can overlap. Some people have a true disc herniation and hip weakness at the same time, or a deep gluteal entrapment that developed after months of protective gait. When the story is mixed, testing and a short trial of targeted care help to identify the dominant driver.^[4]

Guidelines advise not to order imaging early for most people with low back pain or sciatica in non-specialist settings. Imaging is considered when the result is expected to change management (for example, if surgery or an epidural injection is being weighed) or when red flags are present. The NICE guideline spells this out clearly and also notes that epidural injections of local anesthetic and corticosteroid can be considered for acute, severe sciatica. The American College of Radiology likewise recommends reserving imaging for red flags or persistent, severe radicular symptoms that do not respond to initial care.^[1]

• Time and reassurance. Many improve over six to eight weeks; pain often fades as the disc loses some volume and inflammation quiets down.^[1]
• Graded activity and physical therapy. Focus on symptom-modulated exercise, hip hinge patterns, and neural mobility as tolerated—aiming for calm strength, not provocation.
• Medication. Short courses of nonsteroidal anti-inflammatory drugs, if safe for you, can reduce pain. Avoid long-term opioids for chronic low back pain; guideline-based prescribing favors the lowest effective dose for the shortest time.^[1]
• Epidural injection. For acute, severe sciatica, an epidural injection can provide temporary relief to help rehabilitation; discuss risks and benefits.^[1]
• Surgery. Considered for progressive neurologic deficit or disabling pain that matches imaging and does not improve with good conservative care. Surgery often relieves leg pain faster; medium- to long-term outcomes converge with non-surgical care for many patients.^[8]

• Movement retraining and strength. A skilled therapist will restore hip rotation control, reduce compressive positions on the sciatic nerve, and build strength in the external rotators and abductors.
• Injections for refractory pain. Small randomized and controlled studies report benefit from botulinum toxin injections to the piriformis combined with physical therapy, though high-quality evidence remains limited. Consider this only after a careful diagnostic process.^[5]
• Surgical decompression. Reserved for rare cases with clear, persistent entrapment that fails targeted non-operative care.^[4]

• Targeted strengthening. Build gluteus medius and deep rotator capacity (side-lying abduction progressions, standing lateral steps, single-leg hinges, controlled external-rotation work). Trials and systematic reviews suggest that adding hip-focused strengthening to standard programs reduces pain and disability in low back pain populations.^[6]
• Gait and load management. Shorten stride a touch, avoid excessive cross-over, and gradually reintroduce hills and speed. A few weeks of consistent work often changes symptoms meaningfully.
• Do not forget the spine. Even when the hip is primary, a short block of lumbar-pelvic control and neural mobility can help settle stubborn irritability.

1. Does coughing or sneezing send a bolt down the leg, and does straight-leg raise reproduce the same line of pain?
   That pattern points to spinal nerve root irritation from a disc herniation. Try graded activity, short-term pain control, and appropriate physical therapy; seek care sooner if neurologic changes appear.^[2]
2. Is the worst pain in the deep buttock, worse with sitting and better when standing or walking, and is the back itself relatively quiet?
   That leans toward deep gluteal entrapment (often labeled piriformis syndrome). Ask for a hip-focused assessment; consider diagnostic injection only if conservative care and a solid exam point in the same direction.^[4]
3. Do you notice pelvic drop or fatigue at the outer hip, and does strengthening the hip abductors and rotators steadily reduce symptoms?
   Then hip rotator weakness is likely a key piece. Keep going—people often feel better within weeks when the program is well-dosed.^[6]

If any red flags show up at any time—new weakness, foot drop, bowel or bladder changes—seek urgent care.^[2]

Yes. Some patients have a disc herniation that irritated the nerve initially and later develop deep gluteal sensitivity from altered gait and guarding, or vice versa. Clinicians treat the dominant driver first, then reassess.^[4]

If there are no red flags and you can gradually function better week over week, most guidelines say you can delay imaging and focus on active care. Consider magnetic resonance imaging if disabling symptoms persist despite appropriate management or if a procedure or surgery is being considered.^[1]

They can reduce pain enough to let you move and work the plan, but they are best viewed as an adjunct to rehabilitation—especially for acute, severe radicular pain. For deep gluteal entrapment, a precisely placed botulinum toxin injection plus therapy has supporting evidence, but it is not first-line.^[1]

Surgery often provides faster relief of leg pain when the disc herniation clearly matches your symptoms and conservative care has failed, but long-term outcomes often resemble those with structured non-operative care. The decision depends on your function, goals, neurologic status, and imaging.^[8]

• Weeks 1–2: Calm the nerve, keep moving. Short, frequent walks; supported hip hinges; gentle nerve-gliding within comfort; brief periods of side-lying with a pillow between knees. Use nonsteroidal anti-inflammatory drugs if appropriate for you and only as directed.^[1]
• Weeks 2–4: Rebuild the hip. Add gluteus medius and external rotator work (side-lying abduction progressions, banded lateral steps, single-leg sit-to-stands), plus trunk endurance in tolerable ranges.^[4]
• Weeks 4–8: Return to form. Extend walking times, reintroduce stairs and gentle hills, refine hinge mechanics, and gradually test running or sport-specific drills if that is your goal. If pain remains high or function is stuck, discuss imaging or targeted injection with your clinician.^[1]

• Disc herniation is the top cause of true sciatica; most cases improve in six to eight weeks with thoughtful, active care, and imaging is not routine early on. Consider surgery only for clear neurologic emergencies or disabling pain that fails good conservative treatment and matches imaging.^[1]
• Piriformis syndrome and deep gluteal entrapment imitate sciatica but live outside the spine. The story leans on buttock pain with sitting, FAIR-provoked symptoms, and tenderness deep in the gluteal region. Start with rebuilding hip mechanics; consider botulinum toxin only in select, persistent cases.^[5]
• Hip rotator weakness can keep nerves irritated and prolong pain. Strengthening gluteus medius and the external rotators alongside smart spinal rehab reduces symptoms for many people.^[6]

With a clear map of your pain pattern and a plan that fits it, “sciatica that will not quit” often becomes sciatica that finally does.

References:

Educational information only; not a substitute for personal medical care.