This article is divided into several pages for easier reading:
- Part 01: Introduction and Defining the Terms.
- Part 02: What is Piriformis Syndrome?
- Part 03: Anatomy of the Gluteal Region.
- Part 04: What can cause Piriformis Syndrome?
- Part 05: Who can be Affected by Piriformis Syndrome?
- Part 06: Prevalence and Risk Factors.
- Part 07: What are the Symptoms?
- Part 08: How is Piriformis Syndrome Diagnosed?
- Part 09: Differential Diagnosis for Piriformis Syndrome.
- Part 10: Treatment.
- Part 11: What is the Prognosis or Outlook?
- Part 12: References and Bibliography.
The current chronological treatment plan for piriformis syndrome is based on:
- Conservative Management:
- Rest: Dependant on identifying a cause, a short break from exercise/sports can be helpful. For active individuals, a relative rest, meaning less intense/fewer miles, can also be helpful.
- Osteopathic manipulative treatment.
- Physical Therapy: Rest and home and/or physiotherapist-led stretching/mobility exercises, as well as activity modification.
- Anti-inflammatory Medications: Introducing analgesia (non-opioids and weak opioids).
- Muscle Relaxants: Usually combined with the above.
- Correction of biomechanical abnormalities.
- Interventional Management:
- Intramuscular injections in the affected piriformis muscle with or without image-guided techniques (e.g. commuted tomography (CT), magnetic resonance imaging (MRI), ultrasound (US), fluoroscopy, electrical stimulators, and electromyography (EMG)).
- Extracorporeal shock wave therapy (for at least three months); and
- Surgery is discussed in a few treatment-resistant cases.
Figure 1 provides an outline of this treatment.
Figure 1: Algorithm for the Diagnosis and Treatment of Piriformis Syndrome (Han et al., 2017).
The factors or positions that increase or decrease pain can dictate the diagnostic approach. For example (Blankenbaker, 2013; Martin et al., 2015):
- A sitting pain is usually associated with sciatic entrapment beneath the piriformis muscle.
- A walking pain lateral to the ischium is associated with ischiofemoral impingement, in which the lesser trochanter rubs the lateral border of the ischium.
10.1 Pain Management
“Regardless of the muscle length, most people can achieve short-term relief of their symptoms if they sit with their legs crossed at the ankles. In this position, tension is taken off the piriformis muscle that would otherwise create irritation/compression on the sciatic nerve. If you sit all day, this can be a great first step to dealing with this injury.” (Horschig, 2017).
10.2 Osteopathic Manipulative Treatment
The goals of osteopathic manipulative treatment (OMT) for patients who have piriformis syndrome are to restore normal range of motion and decrease pain.
These goals can be achieved by decreasing piriformis spasm and there are a number of OMT techniques includeing:
- Indirect OMT techniques have been used to treat patients with piriformis syndrome. The two indirect OMT techniques most commonly reported for the management of piriformis syndrome are (Grant, 1987; DiGiovanna et al., 2005):
- Counter-strain; and
- Facilitated positional release.
- Direct OMT techniques can be performed using either active or passive methods. The direct OMT techniques that are the most useful in treating patients with piriformis syndrome include (DiGiovanna, 2005):
- Muscle energy;
- Still; and
- High velocity/low amplitude.
Both techniques involve the principle of removing as much tension from the piriformis muscle as possible.
10.3 Stretches for Piriformis Syndrome
A number of stretching exercises for the piriformis, hamstrings and hip extensors can aid decreasing the painful symptoms along the sciatic nerve and facilitate a return to a normal range of motion (ROM) for the patient.
The stretches decrease compression of the sciatic nerve through relaxation of piriformis muscle by increasing the resting length.
- Piriformis Stretches: There are a number of ways to stretch the piriformis muscle, with two simple methods including:
- Lie on the back with both feet flat on the floor and both knees bent. Pull the right knee up to the chest, grasp the knee with the left hand and pull it towards the left shoulder and hold the stretch. Repeat for each side.
- A seated variation of the above which can be used generally and for post-operative rehabilitation. In seated position, the patient crosses the leg that will be stretched with the foot positioned next to the knee. The stretching is performed with the patient bringing the knee towards to the contralateral shoulder. The duration and quantity of stretch is determined according with the advance of the healing process.
- Lie on the back with both feet flat on the floor and both knees bent. Rest the ankle of the right leg over the knee of the left leg. Pull the left thigh toward the chest and hold the stretch. Repeat for each side.
- Each piriformis stretch should be held for five (5) seconds to start, and gradually increased to hold for thirty (30) seconds, and repeated three (3) times each day.
- Hamstring Stretches: Stretching the hamstrings (the large muscle along the back of each thigh) is important to alleviate any type of sciatic pain. There are a number of ways to stretch the hamstrings:
- Place two chairs facing each other. Sit on one chair and place the heel of one leg on the other chair. Lean forward, bending at the hips until a gentle stretch along the back of the thigh is felt, and hold the stretch.
- Lie on the back with both legs straight. Pull one leg up and straighten by holding on to a towel that is wrapped behind the foot until a mild stretch along the back of the thigh is felt.
- Again, try to work up to holding each stretch for thirty (30) seconds and repeat three (3) times each day.
Stretches lasting 20-30 seconds for a total of 7-14 stretches over 5 minutes can increase the length of the piriformis muscle by 30-40% (Gulledge et al., 2014).
“Placing the hip joints in 115° of hip flexion, 40° of external rotation and 25° of adduction or 120° of hip flexion, 50° of external rotation and 30° of adduction increased PiM elongation by 30–40% compared to conventional stretches (15.1 and 15.3% increases in PiM muscle length, respectively).” (Gulledge et al., 2014, p.218).
According to Horschig (2017) the piriformis muscle should only be stretched if you have a short piriformis muscle because “If you try to stretch a muscle that is already lengthened, it will only contribute to the injury and make things worse!”
Horschig (2017) suggests the following stretch for those with a short piriformis muscle:
- Start by lying on your back with your knees bent. Cross the ankle of your affected leg over your opposite thigh. From this position, grab your pain free thigh and pull it towards your chest until a stretch is felt deep in your hip. Can also be performed seated.
Horshig’s article has a number of exercises that can be useful for those with a short piriformis muscle, read it here.
In addition to basic stretching, a comprehensive physical therapy and exercise programme can be developed for each patient’s individual situation.
In addition to stretching and physical therapy, most treatment approaches for piriformis syndrome will include additional therapies, discussed in the following sections.
In their research, Michel and colleagues (2013) noted that combined medication and rehabilitation treatments had a cure rate of 51.2% (121/250), with 48.8% not responding to treatment receiving Botulinum toxin injections (Section 10.8).
- Range of motion (ROM) exercises by a physical therapist or other qualified specialist can develop a customised programme of stretching and range of motion (ROM) exercises to help stretch the muscle and decrease spasm.
- Deep massage (manual release) by a physical therapist or other qualified specialist is thought to enhance healing by increasing blood flow to the area and decreasing muscle spasm.
10.5 Thermal Therapy
Thermal therapy can take one of two forms:
- Ice Packs and Ice Massage:
- At the onset of pain, lie in a comfortable position on the stomach and place an ice pack on the painful area for approximately 20 minutes.
- Repeat as needed every 2 to 4 hours.
- It may be more helpful to combine a gentle massage with the ice.
- Lie on the stomach and have someone gently massage the painful area with a large ice cube.
- If ice is applied directly to the skin (instead of a cold pack), limit it to 8 to 10 minutes to avoid an ice burn.
- If specific activities are usually followed by increased pain, it may be a good idea to apply ice immediately following the activity.
- Heat Therapy:
- Some people find it helpful to alternate cold with heat.
- If using a heating pad, lie on the stomach and place the heating pad on the painful area for up to 20 minutes.
- Be sure to avoid falling asleep on a heating pad, as this may lead to skin burns.
10.6 Kinesio Taping
In a study by Hasemirad and colleagues (2016) involving 51 patients (33 intervention and 18 controls), the intervention group received kinesio taping with unloading techniques, with the tape kept in place for three weeks.
Although the results demonstrated improvements in pain and hip internal rotation immediately after tape application and at a 72 hour follow up, the researchers did not conduct a three week follow up. This was a major limitation of the research. Why ask participants to keep the tape on for three weeks and then conduct no three week follow up? It is difficult to know if the tape had any effect after the 72 hour follow up.
Since most episodes of pain include some degree of inflammation, non-steroidal anti-inflammatory medications (NSAIDs), such as ibuprofen or naproxen, may help decrease inflammation in the affected area.
For severe sciatica pain from piriformis syndrome, an injection may form part of the treatment.
- Piriformis Injection:
- Usually offered as part of multi-modal therapy.
- A local anaesthetic and/or corticosteroid may be injected directly into the piriformis muscle to help decrease the spasm and pain.
- The purpose of an injection is usually to decrease acute pain to enable progress in physical therapy.
- The muscle can be targeted by a landmark-based technique, with or without the assistance of electrophysiological stimulation or image-guided techniques.
- The response to injections can be immediate but may be of short duration.
- Botulinum Toxin (BT) Injection:
- For persistent piriformis spasm that is resistant to treatment with anaesthetic/corticosteroid injections, an injection of Botulinum Toxin (BT, e.g. Botox®), a muscle weakening agent, may be useful.
- The goal of the injection is to help the muscle relax and help reduce pressure on the sciatic nerve.
- Research suggests that “BT leads to atrophy and fatty degeneration of the piriformis muscle that can be quantified by MRI and these factors explain why BT injections are effective in the treatment of PS [piriformis].” (Al-Al-Shaikh et al., 2015, p.38).
- At least one commentator suggests that BT injection “produces more scar tissue around the sciatic nerve.” (Martin et al., 2015, p.102). Scar tissue is a potential cause of pain recurrence.
The goal with both injections is to help the patient progress with stretching and physical therapy, so that when the effect of the injection is over the muscle will be remain stretched and relaxed.
The application of electrical stimulation to the buttock with a transcutaneous electrical nerve stimulation (TENS) unit or interferential current stimulator (IFC) can help to block pain and reduce muscle spasm related to piriformis syndrome.
10.10 Extracorporeal Shock Wave Therapy
Extracorporeal shock wave therapy for at least 3 months (Han et al., 2017).
“Since the introduction of Botulinum toxin therapy, however, surgical interventions have rarely been necessary in patients with PS [piriformis syndrome].” (Jankovic, Peng & Zundert, 2013, p.1009).
Surgical intervention (either open or endoscopic) should be considered only when non-surgical treatment has failed and the symptoms are becoming intractable and disabling, as the results can often be disappointing (Jankovic, Peng & Zundert, 2013) or good (Martin et al. 2015).
There is a lack of literature on surgical treatment for piriformis syndrome for both the general population and professional athletes in particular (Jankovic, Peng & Zundert, 2013; Zeren et al., 2015).
Endoscopy allows for a complete extra-pelvic sciatic nerve visualisation and safe nerve decompression in the deep gluteal space.
In persistent cases, the piriformis muscle can be cut to relieve symptoms, but this is rarely performed.
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