What is the recommended management for a patient with piriformis syndrome?

Management of Piriformis Syndrome

First-Line Treatment: Physical Therapy and Exercise

Physical therapy with supervised exercise programs should be initiated as the primary treatment for piriformis syndrome, focusing on active interventions rather than passive modalities. 1

• Active physical therapy interventions (supervised exercise) are strongly preferred over passive interventions such as massage, ultrasound, or heat therapy 1
• Manual physical therapy techniques should target trigger point resolution, muscle lengthening of the piriformis, and release of fascial restrictions 2, 3
• A home exercise program is essential after initial instruction, specifically including piriformis stretches and sciatic nerve mobilization techniques 1
• Stretching should be prolonged and may be augmented with ultrasound or topical cooling sprays before stretching 4
• Physical therapy aims to break the cycle of pain and muscle spasm while addressing underlying biomechanical factors 4

Key clinical findings to confirm diagnosis before treatment:

• Buttock tenderness extending from sacrum to greater trochanter 4
• Piriformis tenderness on rectal or pelvic examination 4
• Pain aggravated by prolonged sitting and hip flexion, adduction, and internal rotation (FADIR test) 5, 4
• Tenderness in the sciatic notch 5

Pharmacological Management

NSAIDs should be used for symptomatic pain relief as part of the initial conservative management approach 1

• Topical agents including lidocaine patches and diclofenac patches provide localized pain relief without systemic side effects 2, 3
• Muscle relaxants may be considered for documented muscle spasm 2
• Tricyclic antidepressants or SNRIs can be used for persistent pain, particularly when sleep disturbance or central sensitization is present 2, 3

Critical caveat: Strong opioids should not be used for myofascial pain management 3

Second-Line Treatment: Injections

Local glucocorticoid injections are conditionally recommended for persistent piriformis-related pain that doesn't respond to at least 3 months of conservative treatment. 1, 6

• Image-guided injections are recommended to ensure accurate placement 1
• A trial of up to three steroid injections should be attempted before considering more invasive options 4
• Botulinum toxin type A injections have Category A2 evidence showing effectiveness for piriformis pain lasting 8-12 weeks 1, 7
• Trigger point injections should be considered as part of a comprehensive multimodal program, not standalone therapy, and limited to 4 sets maximum to assess therapeutic response 2

Important distinction: Corticosteroids have no role in isolated myofascial pain syndrome unless concomitant joint pathology exists 3

Adjunctive Therapies

• Transcutaneous electrical nerve stimulation (TENS) can be used as part of a multimodal approach 1
• Cognitive behavioral therapy and relaxation techniques may benefit some patients 3
• Avoid high-velocity spinal manipulation in patients with spinal fusion or advanced spinal osteoporosis 1

Surgical Management

Surgical intervention should be reserved as a last resort only after failure of all conservative modalities for at least 3 months, when symptoms significantly affect daily living activities. 7, 6

• Endoscopic decompression of the sciatic nerve with or without piriformis muscle release is the preferred surgical approach over open release due to higher success rates and lower complication rates 7
• Surgery involves resection of the piriformis muscle with or without neurolysis of the sciatic nerve 6
• Satisfactory results are obtained in approximately 83% of surgical patients with refractory sciatica 6
• Buttock pain typically improves more than sciatica with conservative treatments, which should guide surgical decision-making 6

Common pitfall: Piriformis syndrome comprises 0.3%-6% of all low back pain cases and is frequently underdiagnosed because it's often seen as a diagnosis of exclusion 7, 5. The diagnosis is primarily clinical, as no investigations have proved definitive 4. Electrodiagnostic studies should be used to exclude other causes but may not confirm piriformis syndrome initially 5.