What is the treatment for piriformis disease?

Treatment of Piriformis Syndrome

Start with supervised physical therapy focusing on active exercise programs, specifically piriformis stretching and sciatic nerve mobilization, as this is the first-line treatment recommended by major rheumatology societies. 1

First-Line Conservative Management

Physical therapy should emphasize active interventions over passive modalities:

• Supervised exercise programs are conditionally recommended as superior to passive treatments like massage, ultrasound, or heat therapy 1
• Home exercise programs should include specific piriformis stretches (both hip flexion over 90 degrees and under 90 degrees) and sciatic nerve mobilization techniques 1, 2
• Nerve gliding techniques produce less strain than tensioning techniques and should be preferred 2
• Stretching may be augmented with ultrasound or Fluori-Methane spray application before stretching 3

Address underlying biomechanical factors concurrently:

• Correct leg length discrepancies, weak hip abductors, and associated myofascial involvement 3
• Activity modification and correction of positioning that aggravates symptoms (prolonged hip flexion, adduction, internal rotation) 3

NSAIDs may be used for symptomatic pain relief following principles for other musculoskeletal conditions 1

Second-Line Interventional Treatment

If symptoms persist after at least 3 months of conservative therapy, proceed to local injections:

• Glucocorticoid injections into the piriformis muscle are conditionally recommended for persistent pain 1
• Up to three steroid injection trials should be attempted before considering surgery 3
• Botulinum toxin type A injections have Category A2 evidence showing effectiveness for 8-12 weeks 1
• Image-guided injections (ultrasound or other modalities) are recommended to ensure accurate placement 1, 4

Adjunctive Electrical Modalities

TENS and peripheral nerve stimulation can be incorporated:

• Transcutaneous electrical nerve stimulation (TENS) as part of multimodal pain management 1
• Subcutaneous peripheral nerve stimulation for persistent pain not responding to other therapies 1

Surgical Intervention

Surgery should be considered only after failure of at least 3 months of appropriate conservative treatment:

• Piriformis muscle resection with or without sciatic nerve neurolysis achieved satisfactory results in 83% of surgical candidates 5
• Surgical candidates typically had intractable sciatica despite comprehensive conservative management for 4-72 months 5
• Buttock pain improves more than sciatica with conservative treatments, which may guide surgical decision-making 5
• Piriformis tenotomy and sciatic nerve decompression are the primary surgical options 4

Important Clinical Caveats

Avoid high-velocity spinal manipulation in patients with spinal fusion or advanced spinal osteoporosis 1

The diagnosis remains primarily clinical as no investigations have proved definitive, and electrodiagnostic studies are mainly useful to exclude other causes 3, 6

Buttock pain typically responds better to treatment than sciatic symptoms, which should inform patient expectations and treatment planning 5