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Piriformis Syndrome: Treatment & Medication
Updated: Apr 28, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
Occupational Therapy
Professions that involve prolonged sitting can worsen symptoms of piriformis syndrome, and patients should avoid sitting for long periods. Patients should be instructed to stand and walk every 20 minutes. Patients should make frequent stops when driving to stand and stretch.
Surgical Intervention
Release of the piriformis tendon and sciatic neurolysis can lead to promising results. Benson and Schutzer performed such a procedure in 14 patients (15 cases) with an average symptom duration of 38 months (minimum, 2 y).1 All patients had piriformis syndrome secondary to trauma. Benson and Schutzer reported that 11 patients had excellent outcomes, and 4 had good results.1 Similarly, Frieberg reported favorable results in 10 of 12 patients in whom conservative treatment failed.Most intraoperative findings include adhesions around the piriformis muscle and anatomic variations of the divisions of the sciatic nerve above, below, and through the belly of the piriformis muscle.
Consultations
- Physical therapists are helpful in instructing the patient about the various maneuvers for stretching and pain relief.
- Referral to an orthopedic surgeon is indicated when the diagnosis is not clear or when conservative therapy fails and a surgical evaluation is needed.
- Referral to a neurologist and/or neurosurgeon is indicated for EMG studies and for an evaluation of associated disc herniation and spinal stenosis.
- An osteopathic physician can perform manipulation techniques, along with primary conservative medical intervention.3
- A gynecologist can also assist in differentiating causes of dyspareunia and pelvic pain in women with suspected piriformis syndrome. A gynecologist can assist in identifying trigger points for local injections in female patients via the vaginal route.
Other Treatment
Treatment options to alleviate the pain in the region of the piriformis include the use of local anesthetics, nonsteroidal anti-inflammatory medications (NSAIDs), transrectal massage, ultrasound treatment (~2 W/cm2 for 5-10 min), and manual manipulation. Benson and Schutzer noted a success rate of approximately 85% after conservative treatment with manual therapy and local injections.1- The most widely recognized treatment is local injection. Local anesthetics (eg, lidocaine, bupivacaine) can be injected in trigger points. The painful piriformis muscle can be identified by palpating the buttocks or by palpating transrectally in males and transvaginally in females. A spinal needle or 25-gauge, 1.5-inch needle is directly aimed at the examining finger. The location is usually through the sciatic notch and inferior to the bony margin; the most common trigger point is 1 inch lateral and caudal to the midpoint of the lateral border of the sacrum. An intramuscular (IM) dose of 50-100 mg can be injected.
- Manual manipulation can also be applied (see Physical Therapy above). A common method, mobilization of the spine, is often used by osteopathic physicians (those with a DO degree).3 The patient is placed in a lateral recumbent position on the unaffected side. The physician faces the patient and rotates the patient’s upper body away by laterally pulling on the lower arm. Then the physician places his or her cephalad hand most superiorly on the paravertebral muscles.The patient’s top leg is brought over the edge of the table. The physician places her caudal hand over the patient's hip in the line of the lowered leg. Force is applied in the direction of the lowered leg but perpendicular to the muscle fibers. When tension is reduced, a thrust (high-velocity low-amplitude [HVLA]) technique can be applied.
- NSAIDs and opiates can also be administered to patients with piriformis syndrome. However, to the author’s knowledge, no study has been performed to assess the treatment of piriformis pain with intravenous (IV) or oral medications. Physician discretion is recommended in using medications such as those used to treat LBP.
Recovery Phase
Rehabilitation Program
Physical Therapy
In the recovery phase, the patient may begin gradual strengthening activities for the piriformis and gluteal muscles. Therapeutic modalities may be continued through this phase to enhance the benefits of rehabilitation. As the patient becomes asymptomatic, he or she may initiate light sport-specific activities and functional training. Addressing posture and faulty pelvic mechanics is important when resuming activity. Some athletes may need to change their footwear or undergo an orthotic consultation to correct their pelvic alignment and avoid further stress on the piriformis muscle.
Other Treatment (Injection, manipulation, etc.)
See Other Treatment for the acute phase.
Maintenance Phase
Rehabilitation Program
Physical Therapy
During the maintenance phase of rehabilitation, the patient should continue performing a home exercise program for increasing flexibility and strength. Athletes may gradually increase their training volume as tolerated. Runners should be cautious when resuming speed training and hill running, doing so in a gradual fashion with proper warm-up and cool-down periods. Compliance to a daily stretching program is crucial to avoid recurrence of this syndrome. Return to play is dependent on many factors (eg, severity of condition, how soon treatment was initiated, level of patient compliance to program).
Surgical Intervention
See Surgical Intervention for the acute phase.
Consultations
See Consultations for the acute phase.
Other Treatment
See Other Treatment for the acute phase.
Medication
NSAIDs are mentioned not in this section because of the lack of any documented or studied effectiveness in piriformis syndrome. However, physicians may use any number of these agents, on the basis of their experience in managing LBP or neuropathies.
Naja et al investigated whether clonidine-bupivacaine nerve-stimulator guided injections are effective in achieving long-lasting pain relief in piriformis syndrome compared with bupivacaine guided injection.4 Significantly lower pain scores and analgesic consumption were observed with bupivacaine-clonidine compared with bupivacaine-saline. Additionally, pain at 6 months was significantly greater in the bupivacaine-saline group (78%) compared with the bupivacaine-clonidine group (8%).4
Anesthetics
The drugs of choice for local injection in painful piriformis syndrome include the anesthetic agents lidocaine and/or bupivacaine. Both are in the family of amide anesthetics. Use is based on the desired duration of action. Doses, as described below, are intramuscularly (IM) administered by identifying the trigger point. Be sure to aspirate first to avoid injecting the medication into a blood vessel.
Lidocaine HCL (Xylocaine, Dilocaine, Anestacon)
Amide anesthetic that stabilizes neuronal membrane by inhibiting ionic fluxes. Absorbed completely with parenteral administration. Metabolized by the liver. Unchanged metabolites are excreted by the kidneys. Half-life is typically 1.5-2 h. Lidocaine crosses blood-brain and placental barriers by passive diffusion. Indicated for regional and local anesthesia.
Adult
<7 mg/kg IM; should not exceed 4.5 mg/kg when used with epinephrine
Regional anesthesia: typically <100 mg IM
Pediatric
<3 years: Not established
>3 years: <3 mg/kg IM; typically, <50 mg IM
Coadministration with cimetidine or beta-blockers increases toxicity; coadministration with procainamide and tocainide may result in additive cardiodepressant action; may increase the effects of succinylcholine
Documented hypersensitivity to amide-type local anesthetics; avoid in Adams-Stokes and Wolf-Parkinson-White syndromes; avoid in severe sinoatrial, AV, or intraventricular block if artificial pacemaker not in place
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Oxygen and resuscitative equipment should be available for immediate use; carefully administer solutions containing epinephrine in areas of end arteries (eg, digits, genitalia, nose); perform cardiovascular and respiratory monitoring; caution in patients with liver disease and impaired cardiovascular function; can trigger familial malignant hyperthermia; IM use may increase in creatinine phosphokinase levels (CPK) (can compromise use of CPK as sole marker for myocardial infarction)
Bupivacaine Hydrochloride (Sensorcaine, Marcaine)
Amide anesthetic that blocks conduction of nerve impulses by inhibiting ionic fluxes. Absorbed completely with parenteral administration and metabolized by the liver. Unchanged metabolites are excreted by the kidneys. Half-life is typically 3-4 h and peak levels are achieved in 30-40 min. Bupivacaine crosses blood-brain and placental barriers by passive diffusion. Indicated for regional and local anesthesia.
Adult
<400 mg IM
Regional anesthesia: <100 mg IM
Pediatric
<12 years: Not established
>12 years: <50 mg IM
Bupivacaine solutions containing epinephrine may interact with MAOIs or tricyclic antidepressants and cause severe, prolonged hypertension; phenothiazines and butyrophenones may reduce the effect of epinephrine solutions; vasopressor drugs and ergot oxytocic drugs may cause persistent hypertension or cerebral vascular accidents when used with lidocaine.
Documented hypersensitivity; septicemia; spinal deformities; severe hypertension; existing neurologic disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Oxygen and resuscitative equipment should be available for immediate use; in solutions containing epinephrine, carefully administer in areas of end arteries (eg, digits, genitalia, nose); perform cardiovascular and respiratory monitoring; caution in patients with liver disease and impaired cardiovascular function; can trigger familial malignant hyperthermia; IM use may increase CPK levels (can compromise use of CPK as sole marker for myocardial infarction)
More on Piriformis Syndrome |
| Overview: Piriformis Syndrome |
| Differential Diagnoses & Workup: Piriformis Syndrome |
 Treatment & Medication: Piriformis Syndrome |
| Follow-up: Piriformis Syndrome |
| References |
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References
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[Best Evidence] Naja Z, Al-Tannir M, El-Rajab M, et al. The effectiveness of clonidine-bupivacaine repeated nerve stimulator-guided injection in piriformis syndrome. Clin J Pain. Mar-Apr 2009;25(3):199-205. [Medline].
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Naja Z, Al-Tannir M, El-Rajab M, et al. The effectiveness of clonidine-bupivacaine repeated nerve stimulator-guided injection in piriformis syndrome. Clin J Pain. Mar-Apr 2009;25(3):199-205. [Medline].
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Further Reading
Keywords
piriformis syndrome, hip pocket neuropathy, sciatic neuritis, wallet neuritis, lower back pain, low back pain, LBP, periarthritis of the anterior sacroiliac joint, piriformis muscle, piriformis hypertrophy, sciatic nerve entrapment, herniated nucleus pulposus, muscle spasm due to chronic or overuse injury, sciatica, Morton foot, spinal stenosis, nerve entrapment syndromes
