How is pain managed in acute piriformis syndrome?

Updated: Dec 21, 2018
  • Author: Shishir Shah, DO; Chief Editor: Sherwin SW Ho, MD  more...
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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. [2]

  • 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. [6, 7, 8]  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. [9]

  • 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). [5] 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. [10]

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