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1. Acute Phase
Rehabilitation Program
Physical Therapy
After a diagnosis of piriformis syndrome has been made, the patient should be instructed to rest from offending
activities and initiate physical therapy treatment. Physical therapy modalities are often beneficial forms of
treatment when used in conjunction with stretching and manual therapy.
The use of moist heat and/or ultrasound is often recommended before stretching of the piriformis muscle. The
piriformis muscle is stretched with flexion, adduction, and internal rotation of the hip adductors and the knee
while the patient lies supine. This stretching is performed by bringing the foot of the affected side across and
over the knee of the other leg. To enhance the stretch of the piriformis muscle, the physical therapist may
perform a muscle-energy technique. This is completed by having the patient abduct the limb against light
resistance provided by the therapist for 5-7 seconds, and then it is repeated 5-7 times.
Soft-tissue massage to the gluteal and lumbosacral regions may help to decrease tightness of the affected
musculature and reduce irritation of the sciatic nerve. Some physical therapists may be trained in performing
myofascial release techniques for the piriformis muscle as well. In addition to stretching the piriformis, the
patient should also be instructed to stretch the iliopsoas, tensor fascia latae, hamstrings, and gluteal muscles.
In addition to the specific stretching exercises, the patient can perform the following at home: (1) Before arising
from bed, roll side to side and flex and extend the knees while lying on each side. This exercise can be
repeated for a total of 5 minutes. (2) Rotate side to side while standing with the arms relaxed for 1 minute every
few hours. (3) Take a warm bath with the full body (to the shoulders) immersed; the buoyancy effect is effective.
(4) Lie flat on the back and pedal the legs as if riding a bicycle by raising the hips with the hands. (5) Perform
knee bends, with as many as 6 repetitions every few hours. A countertop can be used for hand support.
Cold packs and, occasionally, electrical stimulation are applied after exercise or manual therapy. Cold
modalities help to decrease pain and inflammation that may have been further triggered by stretching or
massage. Remember to stress to patients the importance of light and gradual stretching techniques for the
piriformis muscle to avoid overstretching and possible further irritation to the sciatic nerve.
Occupational Therapy
Professions that involve prolonged sitting can worsen symptoms of piriformis syndrome, and patients should
avoid sitting for long periods. Patients should be instructed to stand and walk every 20 minutes. Patients should
make frequent stops when driving to stand and stretch.

Surgical Intervention
Release of the piriformis tendon and sciatic neurolysis can lead to promising results. Benson and Schutzer
performed such a procedure in 14 patients (15 cases) with an average symptom duration of 38 months
(minimum, 2 y) ( Benson, 1999). All patients had piriformis syndrome secondary to trauma. Benson and
Schutzer reported that 11 patients had excellent outcomes, and 4 had good results( Benson, 1999).Similarly,
Frieberg reported favorable results in 10 of 12 patients in whom conservative treatment failed.
Most intraoperative findings include adhesions around the piriformis muscle and anatomic variations of the
divisions of the sciatic nerve above, below, and through the belly of the piriformis muscle.

See the list below:

Physical therapists are helpful in instructing the patient about the various maneuvers for stretching and
pain relief.
Referral to an orthopedic surgeon is indicated when the diagnosis is not clear or when conservative
therapy fails and a surgical evaluation is needed.
Referral to a neurologist and/or neurosurgeon is indicated for EMG studies and for an evaluation of
associated disc herniation and spinal stenosis.
An osteopathic physician can perform manipulation techniques, along with primary conservative
medical intervention. (Boyajian, 2008)
A gynecologist can also assist in differentiating causes of dyspareunia and pelvic pain in women with
suspected piriformis syndrome. A gynecologist can assist in identifying trigger points for local injections in
female patients via the vaginal route.

Other Treatment
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.( Benson, 1999)

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. (Fowler, 2014)
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
patients 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 patients 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
authors 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.

2. Recovery Phase
Rehabilitation Program
Physical Therapy
In the recovery phase, the patient may begin gradual strengthening activities for the piriformis and gluteal
muscles. Therapeutic modalities may be continued through this phase to enhance the benefits of rehabilitation.
As the patient becomes asymptomatic, he or she may initiate light sport-specific activities and functional
training. Addressing posture and faulty pelvic mechanics is important when resuming activity. Some athletes
may need to change their footwear or undergo an orthotic consultation to correct their pelvic alignment and
avoid further stress on the piriformis muscle.

Other Treatment (Injection, manipulation, etc.)

See Other Treatment for the acute phase.

3. Maintenance Phase
Rehabilitation Program
Physical Therapy
During the maintenance phase of rehabilitation, the patient should continue performing a home exercise
program for increasing flexibility and strength. Athletes may gradually increase their training volume as
tolerated. Runners should be cautious when resuming speed training and hill running, doing so in a gradual
fashion with proper warm-up and cool-down periods. Compliance to a daily stretching program is crucial to
avoid recurrence of this syndrome. Return to play is dependent on many factors (eg, severity of condition, how
soon treatment was initiated, level of patient compliance to program).

Surgical Intervention
See Surgical Intervention for the acute phase.

See Consultations for the acute phase.

Other Treatment
See Other Treatment for the acute phase.

Recurrence of pain in the piriformis muscle can be prevented by continuing the stretching exercises and by
avoiding risk factors.

Most patients with piriformis syndrome progress well after a local trigger-point injection. Recurrences are
uncommon after 6 weeks of therapy. After surgery, patients treated with piriformis release return to their
activities in an average of 2-3 months.

Patients with piriformis syndrome should modify their activity habits. For example, patients are recommended
to adhere to the following: avoid prolonged sitting, perform the suggested stretching exercises 2 or 3 times a
day and before participating in a sports activity, and avoid direct trauma to the gluteal region.
Patient education should be an ongoing process throughout the course of rehabilitation. Physical therapists and
occupational therapists are valuable members of the team for teaching the patient strategies used to recover

from this syndrome and also to prevent recurrences. Patients should be informed of the importance of their
routine compliance with an individualized home exercise program.

NSAIDs are mentioned not in this section because of the lack of any documented or studied effectiveness in
piriformis syndrome. However, physicians may use any number of these agents, on the basis of their
experience in managing LBP or neuropathies.
Naja et al investigated whether clonidine-bupivacaine nerve-stimulator guided injections are effective in
achieving long-lasting pain relief in piriformis syndrome compared with bupivacaine guided injection( Naja,
2009).Significantly lower pain scores and analgesic consumption were observed with bupivacaine-clonidine
compared with bupivacaine-saline. Additionally, pain at 6 months was significantly greater in the bupivacainesaline group (78%) compared with the bupivacaine-clonidine group (8%) ( Naja, 2009).

Class Summary
The drugs of choice for local injection in painful piriformis syndrome include the anesthetic agents lidocaine
and/or bupivacaine. Both are in the family of amide anesthetics. Use is based on the desired duration of action.
Doses, as described below, are intramuscularly (IM) administered by identifying the trigger point. Be sure to
aspirate first to avoid injecting the medication into a blood vessel.