eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions

Piriformis Syndrome: Treatment & Medication

Author: Milton J Klein, DO, MBA, Consulting Physiatrist, Heritage Valley Health System-Sewickley Hospital, Allegheny General Hospital, and Ohio Valley General Hospital.
Contributor Information and Disclosures

Updated: Sep 14, 2009

Treatment

Rehabilitation Program

Physical Therapy

Because there is no definitive method to accurately diagnose piriformis syndrome, treatment regimens are controversial and have not been subjected to randomized, blind clinical trials. Despite this fact, numerous treatment strategies exist for patients with this condition.

Functional biomechanical deficits associated with piriformis syndrome may include the following:

  • Tight piriformis muscle
  • Tight hip external rotators and adductors
  • Hip abductor weakness
  • Lower lumbar spine dysfunction
  • Sacroiliac joint hypomobility

Functional adaptations to these deficits include the following:

  • Ambulation with the thigh in external rotation
  • Functional limb length shortening
  • Shortened stride length

Once the diagnosis has been made, these underlying, perpetuating biomechanical factors must be corrected.

Consider the use of ultrasonography and other heat modalities prior to physical therapy sessions. Before piriformis stretches are performed, the hip joint capsule should be mobilized anteriorly and posteriorly to allow for more effective stretching. Soft-tissue therapies for the piriformis muscle can be helpful, including longitudinal gliding with passive internal hip rotation, as well as transverse gliding and sustained longitudinal release with the patient lying on his/her side. Addressing sacroiliac joint and low back dysfunction also is important.

A home stretching program should be provided to the patient. These stretches are an essential component of the treatment program. During the acute phase of treatment, stretching every 2-3 hours (while awake) is a key to the success of nonoperative treatment. Prolonged stretching of the piriformis muscle is accomplished in either a supine or an orthostatic position with the involved hip flexed and passively adducted/internally rotated.

Medical Issues/Complications

Due to lack of objective clinical trials, no consensus exists on the overall treatment of piriformis syndrome. In most cases, conservative treatment (eg, stretching, manual techniques, injections, activity modifications, natural healing, modalities such as heat and ultrasonography) is successful.

Injection therapy can be incorporated if the situation is refractory to the aforementioned treatment program. For effective injection, the piriformis muscle must be localized manually by digital rectal examination. The piriformis muscle is then injected using a 3.5-inch (8.9-cm) spinal needle. Care must be taken to avoid direct injection of the sciatic nerve. Fluoroscopic or ultrasonographic imaging guidance can significantly enhance the effectiveness of the piriformis muscle injection, because this deep muscle cannot otherwise be directly visualized.12,13

Failure or partial failure of piriformis syndrome treatment may be secondary to an underlying obturator internus muscle injury, since this problem can be obscured by piriformis syndrome. The obturator internus muscle is inferior to the piriformis muscle and is also an external hip rotator. It originates at the medial surface of the pubis and passes through the lesser sciatic notch to insert on the greater trochanter. Physical examination demonstrates a trigger point that is more caudal than that in piriformis syndrome. Injection therapy would require direct visualization by fluoroscopy, due to the small size and location of this muscle.

Surgical Intervention

Surgical management is the treatment of last resort for piriformis syndrome. Surgery for this condition involves resection of the muscle itself or of the muscle tendon near its insertion at the superior aspect of the greater trochanter of the femur (as described by Mizuguchi).14 These surgical procedures are described as effective, and they do not cause any associated superimposed postoperative disability.

Consultations

  • Because of the enigmatic nature of piriformis syndrome, the initial consultation obtained from an orthopedic surgeon or a similar specialist usually is nonspecific. This disorder is considered to be a soft-tissue problem that presents as low back or buttock pain with sciatica.
  • After all of the differential diagnoses have been excluded, consider piriformis syndrome. Due to the traumatic etiology of most cases, piriformis syndrome usually is associated with other, more proximal causes of low back pain, sciatica, and buttock pain (thereby further clouding the diagnosis).

Other Treatment

  • Prior to physical therapy sessions, the use of ultrasonography and the spray-'n-stretch myofascial treatment is helpful.
  • Manual muscle medicine, including facilitated positional release, may be helpful.
  • Injections with steroids, local anesthetics, and botulinum toxin type B (12,500 U) have been reported in the literature for the management of piriformis syndrome.15,16,17,18,19 No single technique is universally accepted. Localization techniques include manual localization of the muscle or localization with fluoroscopic, ultrasonographic, and electromyographic guidance. The piriformis muscle, after localization with a digital rectal examination, can be injected with a 3.5-inch (8.9-cm) spinal needle. Care should be taken to avoid direct injection of the sciatic nerve.
  • Medical acupuncture, including vigorous, direct needling of the piriformis muscle performed in conjunction with the use of traditional meridian acupuncture, can be employed to remove the blockage of so-called “chi.”20

Medication

No specific medication management of piriformis syndrome is indicated. The use of muscle relaxant medication can be beneficial, but this remains a nonspecific treatment.

More on Piriformis Syndrome

Overview: Piriformis Syndrome
Differential Diagnoses & Workup: Piriformis Syndrome
Treatment & Medication: Piriformis Syndrome
Follow-up: Piriformis Syndrome
Multimedia: Piriformis Syndrome
References
Further Reading
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References

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Further Reading

Related eMedicine topics:
 Botulinum Toxin in Pain Management
Chronic Pain Syndrome
Chronic Pelvic Pain
Injection, Piriformis
Nerve Entrapment Syndromes
Nerve Entrapment Syndromes of the Lower Extremity
Piriformis Syndrome [Sports Medicine]

Clinical guidelines:
Pain (chronic). Work Loss Data Institute - Public For Profit Organization. 2003 (revised 2008 May 19). 475 pages. NGC:006564

The initial management of chronic pelvic pain. Royal College of Obstetricians and Gynaecologists - Medical Specialty Society. 2005 Apr. 12 pages. NGC:004471

Clinical trials:
Effectiveness of Oral Prednisone in Improving Physical Functioning and Decreasing Pain in People With Sciatica

Ultrasound Description of the Sciatic Nerve

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Keywords

piriformis syndrome, sciatica, sciatic nerve, piriformis, sciatic, sciatic nerve pain, piriformis muscle, sciatic pain, sciatica treatment, sciatica exercises, nerve compression, sciatic nerve treatment, piriformis sciatica, pyriformis, pyriformis syndrome, hip socket neuropathy, pseudosciatica, wallet sciatica, deep gluteal syndrome

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Contributor Information and Disclosures

Author

Milton J Klein, DO, MBA, Consulting Physiatrist, Heritage Valley Health System-Sewickley Hospital, Allegheny General Hospital, and Ohio Valley General Hospital.
Milton J Klein, DO, MBA is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Medical Acupuncture, American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, American Pain Society, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Rajesh R Yadav, MD, Assistant Professor, Section of Physical Medicine and Rehabilitation, MD Anderson Cancer Center, University of Texas at Houston
Rajesh R Yadav, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael T Andary, MD, MS, Residency Program Director, Professor, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine
Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists
Disclosure: allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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