From the Research
Management of piriformis syndrome should start with conservative measures, including physical therapy, NSAIDs, and muscle relaxants, with surgical release considered only in severe cases unresponsive to conservative management, as supported by the most recent and highest quality study 1. The initial treatment approach for piriformis syndrome typically involves a multimodal strategy focusing on conservative measures. This includes:
- Rest from aggravating activities
- Physical therapy that focuses on piriformis stretching and strengthening exercises
- Application of heat or ice to reduce muscle spasm and inflammation
- Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 1-2 weeks to help reduce pain and inflammation
- Muscle relaxants like cyclobenzaprine (5-10mg three times daily) may be prescribed for short-term use (1-2 weeks) to alleviate muscle spasm
For persistent cases, the following options can be considered:
- Trigger point injections with local anesthetics (such as 5-10mL of 0.5% bupivacaine) with or without corticosteroids (40mg methylprednisolone) can provide relief
- Botulinum toxin injections (50-100 units) into the piriformis muscle may be beneficial for refractory cases by reducing muscle hypertonicity
- Physical therapy modalities including ultrasound, electrical stimulation, and manual therapy techniques can complement stretching exercises
In severe cases unresponsive to conservative management, surgical release of the piriformis muscle may be considered, with endoscopic release being preferred over open release due to its higher success rate and lower complication rate, as indicated by 1. The effectiveness of these interventions stems from addressing the underlying pathophysiology: reducing inflammation, decreasing muscle spasm, improving flexibility, and decompressing the sciatic nerve that may be entrapped by the piriformis muscle.
Key considerations in the management of piriformis syndrome include:
- A comprehensive evaluation to design a treatment plan specific to the involved structures and the functional needs of the individual
- Treatment protocols that stress exercises promoting strength, flexibility, and functional activities to restore the ability to return to pain-free activity
- The use of minimally invasive methods such as steroid injections, botulinum toxin injections, and dry needling for cases not responding to initial conservative treatments, as supported by 1 and 2.