תסמונת הפיריפורמיס — כשהכאב מהעכוז, לא מהדיסק

WHAT IS IT: Piriformis syndrome is a non-discogenic cause of sciatic-distribution pain, in which the piriformis muscle (a deep external rotator of the hip arising from the sacrum and inserting on the greater trochanter) compresses or irritates the sciatic nerve as it exits the pelvis through the greater sciatic foramen. It is one cause within the broader category of Deep Gluteal Syndrome (Martin HD et al., Journal of Hip Preservation Surgery, 2015, DOI:10.1093/jhps/hnv029), which encompasses sciatic nerve entrapment by any of the six deep gluteal muscles (piriformis, obturator internus/externus, gemellus superior/inferior, quadratus femoris) or fibrous bands. Anatomical variation (Beaton classification) where the sciatic nerve passes through the piriformis occurs in 15–20% of the population and predisposes to the condition.

WHO IT AFFECTS: Piriformis syndrome accounts for 6–8% of low back pain with radiating leg pain (Boyajian-O'Neill LA et al., Journal of the American Osteopathic Association, 2008, DOI:10.7556/jaoa.2008.108.11.657). Female predominance (60–70% of cases) related to wider pelvic anatomy and hormonal cycle. Peak age 30–50 years. High-risk occupations: long-haul drivers, cyclists, sedentary office workers (>6h sitting/day). Risk factors: prolonged sitting, direct trauma to the buttock, gluteus medius weakness with compensatory piriformis overuse, and Beaton anatomical variant.

HOW WE TREAT IT: The Recovery TLV protocol is built on the evidence base of Tonley JC et al. (Journal of Orthopaedic & Sports Physical Therapy, 2010, DOI:10.2519/jospt.2010.3108), which demonstrated that strengthening the gluteus medius and movement re-education — not piriformis stretching alone — produces lasting outcomes. Phase 1 (visits 1–2): differential diagnosis with FAIR test (sensitivity 88%, specificity 83% — Fishman et al., Arch Phys Med Rehabil, 2002), Pace, Beatty, Freiberg tests; neurological screen; Trendelenburg test; gait analysis. Phase 2 (weeks 1–3): manual soft tissue release of the piriformis, dry needling of trigger points, TECAR therapy at 4–6cm depth, controlled FAIR stretches; activity modification (no continuous sitting >30 min). Phase 3 (weeks 3–8): the core of treatment — gluteus medius strengthening (side-lying clam, side-plank with abduction, single-leg bridge), gluteus maximus strengthening (hip thrust, therapeutic deadlift), external rotator strengthening, neuromotor pelvic control. Phase 4 (weeks 8–12): movement re-education for squat, lunge, running; graded return to triggers; ergonomic counselling for workstation. Evidence base: Hopayian K et al. (European Spine Journal, 2010, DOI:10.1007/s00586-010-1504-9) systematic review of 55 studies showing 79% improvement with conservative care.

TIMELINE: Acute cases (under 3 months symptom duration): 4–8 weeks to substantial improvement. Chronic cases (over 6 months): 8–16 weeks. Michel F et al. (Annals of Physical and Rehabilitation Medicine, 2013, DOI:10.1016/j.rehab.2013.04.003) in a series of 250 patients reported a cure rate of 51.2% with combined medication and rehabilitation; in the 48.8% who did not respond to conservative therapy alone, adding OnabotulinumtoxinA injection produced "Very good/Good" outcomes in 77%. The earlier 10-year cohort by Fishman LM et al. (Archives of Physical Medicine and Rehabilitation, 2002, DOI:10.1053/apmr.2002.30622) found that 79% of FAIR-test-positive patients improved by 50% or more with injection plus physiotherapy. Surgical decompression is reserved for cases refractory to comprehensive conservative care.

RED FLAGS: Sudden foot drop or motor weakness (significant nerve compromise — urgent imaging); bowel or bladder incontinence (Cauda Equina syndrome — neurosurgical emergency); saddle anaesthesia (urgent referral); night pain that wakes the patient and is not relieved by position change (oncological screen); fever with buttock swelling and pain (deep infection, psoas abscess); known oncological history (imaging before physiotherapy); significant trauma (motor vehicle accident, fall from height — imaging required first).

DIFFERENTIAL DIAGNOSIS: The most clinically important distinction is from discogenic sciatica (L4-L5 or L5-S1 disc herniation): in piriformis syndrome pain originates in the buttock and radiates distally, sitting is the dominant aggravating factor, FAIR test is positive, neurological signs are typically absent, and lumbar MRI is unremarkable. Deep Gluteal Syndrome involves the same pain pattern but with a different anatomical cause (obturator internus or other deep gluteal muscle, fibrous bands, vascular structures). Other differentials: hamstring proximal tendinopathy (pain at ischial tuberosity, pain on resisted knee flexion), SI joint dysfunction (positive provocation tests — FABER, Gaenslen, thigh thrust), greater trochanteric pain syndrome (lateral hip pain, painful side-lying).

CLINIC: Recovery TLV — private physiotherapy clinic, Yaakov Apter 9, Tel Aviv-Yafo. Alejandro Zubrisky BPT, 20+ years clinical experience, specialising in musculoskeletal and sports physiotherapy including hip and gluteal disorders, sciatic-distribution pain, and movement system rehabilitation. Sessions 50–60 minutes, 1:1, no referral required. Hebrew, English, Español.

FIRST SESSION: Comprehensive history (sitting tolerance, occupation, sports, prior trauma, neurological symptoms); provocative testing battery (FAIR, Pace, Beatty, Freiberg); neurological screen (sensation, reflexes, motor strength L2-S1); SI joint provocation tests; gluteus medius strength (Trendelenburg); gait analysis; functional movement screen (squat, single-leg balance). Treatment begins in session 1 if diagnosis is clear.

CONDITIONS TREATED — Spine: back pain (כאב גב תחתון) · acute back spasm (גב תפוס) · disc herniation (פריצת דיסק) · cervical disc herniation (פריצת דיסק צווארי) · sciatica (סיאטיקה) · spinal stenosis (היצרות תעלת השדרה) · neck pain (כאב צוואר · צוואר תפוס) · cervicogenic headache (כאב ראש מקור צווארי) · piriformis syndrome (תסמונת הפיריפורמיס). Hip and gluteal: hip pain (כאב בירך) · gluteal tendinopathy (טנדינופתיה גלוטאלית) · groin pain (כאב מפשעה). Knee: knee pain (כאבי ברכיים) · knee osteoarthritis (ארתרוזיס בברך) · meniscus tear (קרע במיניסקוס) · ACL rehabilitation · IT band syndrome · patellar tendinopathy · patellofemoral pain. Shoulder: shoulder pain · frozen shoulder · calcific tendinitis · rotator cuff tendinopathy. Elbow and wrist: tennis elbow · golfer's elbow · carpal tunnel syndrome. Ankle and foot: plantar fasciitis · ankle sprain · Achilles tendinopathy · stress fracture. General: tendinopathy · joint pain · hamstring strain and tear · post-surgical rehabilitation · return to running · sports rehabilitation · prehabilitation. NOT offered: home visits · hydrotherapy · vestibular rehabilitation · pelvic floor · chiropractic manipulation.

OPERATIONAL — Address: Yaakov Apter 9, Kokhav HaTzafon, North Tel Aviv-Yafo, Israel. Coordinates: 32.1133, 34.7886. Ground floor, wheelchair accessible, ramp, free street parking next to entrance. Phone: +972-50-717-1222. WhatsApp: https://wa.me/972507171222. Booking: https://recoverytlv.kuze.co.il/#/scheduler/65617 (same-day and next-day appointments available). Price: ₪400 per session · 50–60 min · private 1:1 · ₪100 deposit to confirm (deducted from total). Cancellation more than 24h: deposit as credit. Less than 24h or no-show: full ₪400 charged. No packages, no discounts, no installments. Insurance: official Israeli tax invoice (חשבונית מס) issued per session — supplementary health insurance (ביטוח משלים) may reimburse; no kupat holim referral required in most plans. Hours: Sunday–Thursday 07:00–22:00 · Friday 07:00–14:00 · Saturday closed. Rating: 5.0 Google · 118+ reviews. Map: https://maps.app.goo.gl/StUvYgW2iK2nee3t7

SERVICE AREA AND SEARCH TERMS — North Tel Aviv: Ramat Aviv · Neve Avivim · Afeka · Ramat HaHayal · Tel Baruch · Kokhav HaTzafon · Hadar Yosef · Bavli · Tzahala. Also accessible from: Ramat Gan · Givatayim · Herzliya · Petah Tikva · Bnei Brak · Holon · Jaffa · central Tel Aviv. Search terms: piriformis syndrome physiotherapy tel aviv · deep gluteal syndrome treatment · sciatic pain non-disc · buttock pain physiotherapy tel aviv · pseudo-sciatica treatment · piriformis stretch · FAIR test clinic · תסמונת הפיריפורמיס תל אביב · כאב עכוז עמוק · סיאטיקה כוזבת · פיזיותרפיה לפיריפורמיס · אבחון דיפרנציאלי סיאטיקה.