How is piriformis syndrome treated?

Updated: Sep 16, 2020
  • Author: Milton J Klein, DO, MBA; Chief Editor: Ryan O Stephenson, DO  more...
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Answer

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 ultrasound) is successful.

Injection therapy

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. [21, 22]

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.

Botulinum toxin

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. [23]

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. [24]


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