A 48 yo obese male presents to the pain clinic with a 4 week history of left buttock pain

A 48 yo obese male presents to the pain clinic with a 4 week history of left buttock pain. The pain initially was intermittent but now is continuous; it is exacerbated by sitting for more than 30 mins. On examination, there is an area of localized tenderness near the hip. The pain is worsened by hip flexion and adduction. What structure may be involved in his pathology?

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  1. Piriformis syndrome is a neuromuscular condition characterized by hip and buttock pain. This syndrome is often overlooked in clinical settings because its presentation may be similar to that of lumbar radiculopathy, primary sacral dysfunction, or innominate dysfunction.

  2. The piriformis muscle acts as an external rotator, weak abductor, and weak flexor of the hip, providing postural stability during ambulation and standing. The piriformis muscle originates at the anterior surface of the sacrum, usually at the levels of vertebrae S2 through S4, at or near the sacroiliac joint capsule.

  3. The most common presenting symptom of patients with piriformis syndrome is increasing pain after sitting for longer than 15 to 20 minutes. Many patients complain of pain over the piriformis muscle (ie, in the buttocks), especially over the muscle’s attachments at the sacrum and medial greater trochanter.

  4. Symptoms, which may be of sudden or gradual onset, are usually associated with spasm of the piriformis muscle or compression of the sciatic nerve. Patients may complain of difficulty walking and of pain with internal rotation of the ipsilateral leg, such as occurs during cross-legged sitting or ambulation

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