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Piriformis Injection

  • Author: Mary Louise Caire, MD; Chief Editor: Erik D Schraga, MD  more...
 
Updated: May 16, 2016
 

Background

Piriformis syndrome is a common cause of buttock and posterior leg pain. Pain in these areas can begin spontaneously or after an injury. The symptoms are commonly seen in patients with other inflammatory conditions and in patients who sit for most of their work day.

The pain usually begins when the piriformis muscle becomes taut, tender, and contracted. This process causes a deep aching sensation in the midgluteal region that is sometimes associated with pain radiating down the posterior leg or up to the lower back. The tight piriformis may cause a nerve and vessel entrapment syndrome as a consequence of its close proximity to the sciatic nerve and surrounding vessels.

Piriformis syndrome may constitute as many as 6-8% of low back pain conditions associated with sciatica.[1] Some patients experience symptoms in all five toes (multiple dermatomes) rather than in either lateral toes (S1 radiculopathy) or medial toes (L5 radiculopathy), as is generally the case in patients with herniated lumbar discs. The straight-leg raise (SLR) test is generally negative. Pain in the gluteal area is the predominant symptom. Numbness or weakness is rare.[2]

Piriformis syndrome is frequently a diagnosis of exclusion. Before the diagnosis is made, other causes of gluteal, hip, and leg pain must be ruled out (see Periprocedural Care). Michel et al created a 12-point clinical scoring system for standardization of the diagnosis and development of a treatment plan for piriformis syndrome.[3]

Many forms of therapy, medication, and injections have been used effectively to alleviate the pain associated with piriformis syndrome. This topic describes the most commonly piriform injection techniques (see Technique).[4]

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Indications and Contraindications

Patients who do not improve with a conservative regimen of piriformis stretching, physical therapy, and administration of nonsteroidal anti-inflammatory drugs (NSAIDs) or other analgesics are candidates for piriformis injection.[5]

Contraindications for piriformis injection include the following:

  • Local infection
  • Bleeding disorders
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Technical Considerations

Anatomic considerations

The piriformis exits the pelvis through the greater sciatic foramen and inserts on the greater trochanter of the femur. The obturator internus exits the pelvis by passing through the lesser sciatic foramen; it also inserts on the greater trochanter of the femur. Both muscles assist in the external rotation and abduction of the thigh.[6]

The primary symptom of piriformis syndrome is buttock pain, with or without posterior thigh pain, that is aggravated by sitting or activity. Associated low back pain is common and can be a result of piriformis pain, but it can also suggest the involvement of other structures, such as facet joints or iliopsoas muscles. In an isolated piriformis syndrome, the major findings include buttock tenderness from the sacrum to the greater trochanter and reproduction of buttock pain on prolonged hip flexion, adduction, and internal rotation.[7]

Pain is often referred down the posterior portion of the leg, following the distribution of the tibial and peroneal branches of the sciatic nerve. These branches become inflamed as they pass over, under, or through the tight piriformis. Pain is thought to be caused by myotendinous breakdown of the piriformis, as well as by focal demyelination of the affected branches of the sciatic nerve.

The piriformis is usually tight and contracted, with focal trigger-point tenderness on palpation. Piriformis syndrome is frequently associated with sacroiliac dysfunction and leg length discrepancies.

Best practices

To decrease bruising and hematoma formation, the patient should be asked to stop taking NSAIDs (eg, ibuprofen and naproxen) 5 days before the procedure, if possible. This is helpful but not required.

For the best long-term relief, piriformis injection should be followed by a month of physical therapy (see Piriformis Syndrome).

Complication prevention

Sciatic injury can be largely avoided by advancing the needle slowly and asking the patient to report any tingling, numbness, electrical sensations, or pain down the back of the leg. At the first signs of discomfort, the needle should be pulled back and then redirected laterally. Injecting in the outer third of the muscle also lowers the chance of sciatic nerve injury.

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Contributor Information and Disclosures
Author

Mary Louise Caire, MD Consulting Staff, Department of Physical Medicine and Rehabilitation, Wise Regional Medical Center

Mary Louise Caire, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Texas Medical Association, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Robert David Menzies, MD Faculty, Sports Medicine and Pain Management Fellowship, JPS Hospital; Assistant Professor, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School

Robert David Menzies, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Patrick T Prevo, MD Fellow in Sports Medicine, John Peter Smith Health Network

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Acknowledgements

Laurie Scudder, DNP, NP Nurse Planner, Medscape; Clinical Assistant Professor, School of Nursing, George Washington University, Washington, DC

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
  1. Hallin RP. Sciatic pain and the piriformis muscle. Postgrad Med. 1983 Aug. 74(2):69-72. [Medline].

  2. Filler AG, Haynes J, Jordan SE, et al. Sciatica of nondisc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment. J Neurosurg Spine. 2005 Feb. 2(2):99-115. [Medline].

  3. Michel F, Decavel P, Toussirot E, Tatu L, Aleton E, Monnier G, et al. Piriformis muscle syndrome: Diagnostic criteria and treatment of a monocentric series of 250 patients. Ann Phys Rehabil Med. 2013 Apr 25. [Medline].

  4. Miller TA, White KP, Ross DC. The diagnosis and management of Piriformis Syndrome: myths and facts. Can J Neurol Sci. 2012 Sep. 39(5):577-83. [Medline].

  5. Papadopoulos EC, Khan SN. Piriformis syndrome and low back pain: a new classification and review of the literature. Orthop Clin North Am. 2004 Jan. 35(1):65-71. [Medline].

  6. Moore KL, Agur, AMR. Lower Limb. Patricia Coryell. Essential Clinical Anatomy. First. Baltimore, Maryland: Lippincott Williams & Wilkins; 1995. 239-247/6.

  7. Barton PM. Piriformis syndrome: a rational approach to management. Pain. 1991 Dec. 47(3):345-52. [Medline].

  8. Huerto AP, Yeo SN, Ho KY. Piriformis muscle injection using ultrasonography and motor stimulation--report of a technique. Pain Physician. 2007 Sep. 10(5):687-90. [Medline].

  9. Naja Z, Al-Tannir M, El-Rajab M, Ziade F, Daher Y, Khatib H, et al. The effectiveness of clonidine-bupivacaine repeated nerve stimulator-guided injection in piriformis syndrome. Clin J Pain. 2009 Mar-Apr. 25(3):199-205. [Medline].

  10. Raj PP. Piriformis muscle injection. Lampert R, ed. Radiographic Imaging for Regional Anesthesia and Pain Management. Philadelphia: Elsevier; 2003. 250-3.

  11. Blunk JA, Nowotny M, Scharf J, Benrath J. MRI Verification of Ultrasound-Guided Infiltrations of Local Anesthetics into the Piriformis Muscle. Pain Med. 2013 Jun 11. [Medline].

  12. Phan DC, Gleason BC, Fan X, Chan OT, Himmelfarb E, Bannykh SI. Injection site pseudosarcoma in piriformis syndrome. Histopathology. 2011 Aug. 59(2):327-32. [Medline].

 
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Testing for piriformis pain. Involved hip is flexed, passively adducted, and internally rotated with patient standing.
Testing for piriformis pain. Involved hip is flexed, passively adducted, and internally rotated with patient reclining.
Testing for piriformis pain. Involved hip is flexed, passively adducted, and internally rotated with patient reclining.
Freiberg test. Forceful internal rotation of thigh on affected side elicits pain.
Beatty maneuver. Patient lies on uninvolved side and abducts involved thigh upward, which elicits pain.
Fluoroscopy-guided piriformis injection. Anteroposterior fluoroscopic image of piriformis after contrast administration.
Ultrasound-guided piriformis injection. Greater trochanter and lateral border of sacrum are identified. Ultrasound probe is directed parallel to piriformis. Needle is inserted in lateral third of piriformis.
Ultrasonogram identifies sciatic nerve, gluteus, and piriformis.
Fluoroscopy-guided piriformis injection. Greater trochanter and lateral border of sacrum are identified fluoroscopically and used as markers for needle insertion.
 
 
 
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