Physical Medicine and Rehabilitation for Piriformis Syndrome Treatment & Management

Updated: Jan 26, 2017
  • Author: Milton J Klein, DO, MBA; Chief Editor: Consuelo T Lorenzo, MD  more...
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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.

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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. [16, 17]

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.

A study by Al-Al-Shaikh et al indicated that botulinum toxin (BoNT) alleviates piriformis syndrome by causing atrophy and fatty degeneration of the piriformis muscle. In the study, which involved 20 patients with piriformis syndrome, MRI scans of the piriformis muscle from 12 patients who underwent BoNT treatment were compared with those from eight patients who did not. In the treated patients, the piriformis muscles demonstrated significantly decreased volume and thickness and increased fatty infiltration, with patients experiencing significant pain relief as well, while the untreated patients showed no significant changes in muscle size or thickness. [18]

A randomized, double-blind, controlled trial by Fishman et al suggested that piriformis syndrome can effectively be treated with incobotulinumtoxinA chemodenervation. Patients in the study were treated with physical therapy, as well as with either incobotulinumtoxinA or placebo, with the incobotulinumtoxinA group showing greater improvement in the visual analog scale score and in posterior tibial H-reflex delay on the flexion, adduction, and internal rotation (FAIR) test. [19]

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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). [20] These surgical procedures are described as effective, and they do not cause any associated superimposed postoperative disability.

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Consultations

See the list below:

  • 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).
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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. [21, 22, 23, 24, 25] 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. Randomized comparison of ultrasound-guided imaging versus nerve stimulator with fluoroscopic imaging for pirifomis muscle injections shows similar outcomes and without statistically significant differences in imaging or needing technique or total procedure time. [26]

In a prospective, double-blind, randomized, controlled trial, Misirlioglu et al found that although local anesthetic injections were effective in piriformis syndrome, the addition of corticosteroid to the local anesthetic did not increase the treatment’s efficacy. [27]

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.” [28]

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