Treatment of Piriformis Syndrome

Piriformis Syndrome is caused by spasms or tightening of the piriformis muscle which irritates the sciatic nerve causing sciatic type pain. A differential diagnosis must be made to determine the cause of the disorder. A bulging or herniated lumbar disc protruding causes pressure on the sciatic nerve resulting in pain, numbness and tingling in the affected extremity, called sciatica. Treatment for a lumbar disc problem and sciatica is quite different from that needed to clear up the pain associated with Piriformis Syndrome. Anatomy of the Piriformis Muscle The piriformis muscle is connected to the sacrum, the triangular shaped bone at the base of the spine, and to the greater trochanter, the bump of bone at the top of the hip bone (femur). It is one of the muscles that is an external rotator of the hip, meaning it helps turn the leg and foot outward. The sciatic nerve runs under and sometimes through the piriformis muscle on its way out of the pelvis. The muscle can squeeze and irritate the nerve, leading to the symptoms of sciatica.

Treatment of Piriformis Syndrome

• The RICER regimen should be implemented for at least the first 48 to 72 hours after injury.
  
  
  
  • This consists of Rest, Ice, Compression, Elevation, Referral for medical evaluation.
  
  
  • This regimen may not be implemented soon enough as symptoms don't always appear for a day or two.
  
  
• After diagnosis, treatment will be started and an ice pack or ice massage may help reduce inflammation.
• Rest is usually recommended and, at least, a two or three week break from all sports or activities that cause pain.
• Anti-inflammatory medications like ibuprophen and naproxen are helpful in treating the pain and inflammation caused by the nerve irritation.
• Corticosteroid injections with an anesthetic medication may be injected into the piriformis muscle.
• Oral cortisone may also be prescribed to reduce the sciatic nerve inflammation.
• Heat Packs ease muscle spasms and reduce the inflammation.
• TENS is helpful and, sometimes, a low voltage current to the area is combined with a cold application.
• Ultra-sound Treatments provide deep heating and are ideal preparation for deep massage.
• Deep massage and specialized soft tissue mobilization may be useful.
• Custom foot orthotics can help with both treatment and prevention. Gait correction can reduce the use of the piriformis muscle, allowing the muscle to relax and begin to heal.
• A Botox injection may be used which actually paralyzes the piriformis muscle, causing it to relax, taking pressure off the sciatic nerve. Both types A and B botulinum toxin have been used. The injection is done using either Ultra-sound or a CAT 9 (computerized axial tomography) for guidance. Both toxins are effective and pain relief usually lasts for more than 3 months.
• During this time, a stretching program may be started which may correct the problem.

Exercise and Stretching Once the pain has been decreased, the next treatment phase will begin. The goal is to regain the strength, power, endurance and flexibility of the muscles and tendons that were injured. Physical therapy will involve:

• Stretching of the gluteal and piriformis muscles


• Stretching exercises will target the piriformis muscle but may also focus on the hamstrings and hip muscles to reduce pain and increase range of motion.


• Strengthening the core muscles of the back and abdomen will help reduce strain on the piriformis.

Surgery Surgery is a last resort and there are 2 methods of relieving the spasms in the muscle:

• The piriformis muscle is cut where it attaches to the greater trochanter (the boney bump on the top of the leg bone at the hip).


• The other method is to cut through the piriformis muscle itself to relieve pressure on the sciatic nerve.

After surgery, physical therapy may be prescribed for 4 to 6 weeks. Ultra-sound, massage, and electrical stimulation will help the healing process, which takes up to 3 months.

Prevention of Piriformis Syndrome
The more you can do to prevent this syndrome, the better off you will be. The most important things to remember are:

• A thorough and correct warm-up to prepare the muscles and tendons for activity. Without a warm-up, muscles are stiff and there is reduced blood flow to the hip area, making it more injury-prone.


• Let muscles rest and recover after any strenuous activity.


• Strengthening and conditioning the muscles of the hips, buttocks, lower back will help prevent this disorder.


• Keep muscles and tendons supple and flexible through a structured stretching routine.