Piriformis Syndrome Treatment & Management

Rehabilitation Program

Physical Therapy

After a diagnosis of piriformis syndrome has been made, the patient should be instructed to rest from offending activities and initiate physical therapy treatment. Physical therapy modalities are often beneficial forms of treatment when used in conjunction with stretching and manual therapy.

The use of moist heat and/or ultrasound is often recommended before stretching of the piriformis muscle. The piriformis muscle is stretched with flexion, adduction, and internal rotation of the hip adductors and the knee while the patient lies supine. This stretching is performed by bringing the foot of the affected side across and over the knee of the other leg. To enhance the stretch of the piriformis muscle, the physical therapist may perform a muscle-energy technique. This is completed by having the patient abduct the limb against light resistance provided by the therapist for 5-7 seconds, and then it is repeated 5-7 times.

Soft-tissue massage to the gluteal and lumbosacral regions may help to decrease tightness of the affected musculature and reduce irritation of the sciatic nerve. Some physical therapists may be trained in performing myofascial release techniques for the piriformis muscle as well. In addition to stretching the piriformis, the patient should also be instructed to stretch the iliopsoas, tensor fascia latae, hamstrings, and gluteal muscles.

In addition to the specific stretching exercises, the patient can perform the following at home: (1) Before arising from bed, roll side to side and flex and extend the knees while lying on each side. This exercise can be repeated for a total of 5 minutes. (2) Rotate side to side while standing with the arms relaxed for 1 minute every few hours. (3) Take a warm bath with the full body (to the shoulders) immersed; the buoyancy effect is effective. (4) Lie flat on the back and pedal the legs as if riding a bicycle by raising the hips with the hands. (5) Perform knee bends, with as many as 6 repetitions every few hours. A countertop can be used for hand support.

Cold packs and, occasionally, electrical stimulation are applied after exercise or manual therapy. Cold modalities help to decrease pain and inflammation that may have been further triggered by stretching or massage. Remember to stress to patients the importance of light and gradual stretching techniques for the piriformis muscle to avoid overstretching and possible further irritation to the sciatic nerve.

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). ^[3] All patients had piriformis syndrome secondary to trauma. Benson and Schutzer reported that 11 patients had excellent outcomes, and 4 had good results. ^[3] 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. ^[8]

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. ^[3]

• 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. Studies have established that ultrasound, MRI, and CT-guided piriformis injections can confirm the correct placement of the local anesthetic within the muscle. ^{[9, 10, 11]}  A double-blind, randomized study that considered the clinical efficacy of local piriformis muscle injections found that local anesthetic (LA) injections were clinically effective. The authors also reported that the addition of corticosteroid (CS) to LA did not give an additional benefit. ^[12]

• 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). ^[8] 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.

• A study by Fishman et al found that incobotulinum toxin A chemodenervation may be useful for treating piriformis syndrome. ^[13]

• Botulinum toxin has been used to help alleviate the symptoms of piriformis syndrome. However, because the duration of pain relief may be short-lived, repeated injections are often necessary. ^[1] A meta-analysis that compared botulinum toxin injection with local anesthetic plus corticosteroid, local anesthetic, and corticosteroid injection therapy showed that injection of local anesthetics plus a corticosteroid provided the most effective pain relief. ^[14] The results of a systematic review suggested that botulinum toxin is a safe option for pain reduction in patients with piriformis syndrome; however, insufficient data exist to quantify pain relief, and the optimal dose of botulinum toxin is unclear. ^[15]

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.

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.

Return to play

Athletes with piriformis syndrome may return to play when they demonstrate full pain-free range of motion and strength of the affected side and can perform their sport-specific activities without discomfort. Patients must adhere to the aforementioned stretching exercises and perform a liberal warm-up before the activity. The duration for return to play varies with each individual and the type of treatment rendered. The longer an athlete ignores the problem before seeking treatment, the longer his or her rehabilitation will take.

Prevention

Recurrence of pain in the piriformis muscle can be prevented by continuing the stretching exercises and by avoiding risk factors.