Active Piriformis Test | Piriformis Syndrome | Deep Gluteal Syndrome of the Hip

Deep gluteal syndrome, abbreviated as DGS is defined as pain in the buttock area caused by a non-discogenic entrapment of the sciatic nerve in the subgluteal space.

The structures that can be involved in sciatic nerve entrapment are not only the piriformis but also fibrous bands containing blood vessels, gluteal muscles, hamstring muscles, the gemelli-obturator internus complex, vascular abnormalities and space-occupying lesions. For this reason, the term “deep gluteal syndrome” instead of “pirformis syndrome” is now preferred.

Commonly reported symptoms include hip or buttock pain and tenderness in the gluteal and retro-trochanteric region. The pain is often described to be sciatica-like, often unilateral and exacerbated with rotation of the hip in flexion and knee extension. Other symptoms include intolerance of sitting for more than 20 to 30 minutes, limping, disturbed or loss of sensation in the affected extremity and pain at night getting better during the day.

According to a study done by Martin et al. (2013), the active piriformis test had a sensitivity of 78% and a specificity of 80% in the diagnosis of endoscopically confirmed sciatic nerve entrapment. This is the only study evaluating this test yet, which is why we give this test a moderate clinical value to in- and exclude the condition in practice.

Before you conduct the test, make sure you have examined and excluded more prevalent pathologies in the lumbar spine and SI joint that could explain the patient’s symptoms.
To perform the test, have the patient in side-lying position on the unaffected side. The patient flexes the knee of the affected side and places his foot on the examination table. The examiner palpates for the piriformis muscles running from S2 to S4 to the greater trochanter. While the examiner gives resistance at the flexed knee with his other hand, the patient is asked to drive their heel into the examination table, initiating active hip abduction and external rotation.

The test is positive if the patient’s familiar complaints of gluteal pain and/or paraesthesia radiating into the posterior aspect of the lower extremity are reproduced.

Other common tests to assess for deep gluteal syndrome are:

• Freiberg Sign
• FAIR Test
• Seated Piriformis Stretch Test
• Heel Contralateral Knee (HCLK) Maneuver 
• Piriformis Test
• Beatty Maneuver
• Pace Maneuver

21 OF THE MOST USEFUL ORTHOPAEDIC TESTS IN CLINICAL PRACTICE

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Martin, H. D., Kivlan, B. R., Palmer, I. J., & Martin, R. L. (2014). Diagnostic accuracy of clinical tests for sciatic nerve entrapment in the gluteal region. Knee Surgery, Sports Traumatology, Arthroscopy, 22(4), 882-888.