Piriformis Syndrome Treatment

Treatment for piriformis syndrome focuses on reducing buttock and leg pain, stabilizing the hip and thigh, and improving mobility in the hip. Nonsurgical treatments are typically tried first, including rest, physical therapy, and medication. Injection treatments may be recommended when adequate pain relief is not obtained with oral medication. Rarely, surgery for piriformis syndrome may be warranted when the underlying cause is severe and/or progressive neurological deficits, such as leg weakness occur.

Nonsurgical treatments for piriformis syndrome typically include some combination of activity modifications (such as avoiding prolonged sitting), posture training, and physical therapy.¹Hicks BL, Lam JC, Varacallo M. Piriformis Syndrome. [Updated 2022 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448172/ In mild cases, resting for 1-2 days may help relieve the symptoms.¹Hicks BL, Lam JC, Varacallo M. Piriformis Syndrome. [Updated 2022 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448172/

Medications for Piriformis Syndrome Pain

Both prescription and over-the-counter (OTC) medications may help relieve piriformis syndrome pain. A few examples of medications used to treat piriformis syndrome pain include²Boyajian-O’Neill LA, McClain RL, Coleman MK, Thomas PP. Diagnosis and management of piriformis syndrome: an osteopathic approach. J Am Osteopath Assoc. 2008.108(11):657-664. http://doi.org/10.7556/jaoa.2008.108.11.657^,3Vij, N. Kiernan H, Bisht R, et al. Surgical and Non-surgical Treatment Options for Piriformis Syndrome: A Literature Review. Anesth Pain Med. 2021.11(1):e112825. http://doi.org/10.5812/aapm.112825:

• Analgesics, such as acetaminophen, help relieve pain by blocking pain signals to the brain. These medications can be bought over the counter and do not require a doctor’s prescription.
• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, aspirin, and naproxen, reduce inflammation and decrease pain. NSAIDs are available as OTC medications and through a prescription if a higher dosage is indicated. It is important to note that some NSAIDs may not be suitable for all patients due to the potential risk of gastric irritation and cardiac problems. To avoid these risks, consulting a physician before taking these medications is advisable.
• Anticonvulsant medications, such as gabapentin and pregabalin, help by calming the nerves and reducing the burning, stabbing, or shooting pain often caused by nerve pain. Anticonvulsant medications require a prescription.
• Opioid analgesics, such as codeine, hydrocodone, and oxycodone, change the brain's perception of pain and help with severe pain. Opioid analgesics require a prescription and should only be used for short periods and gradually tapered to prevent addiction or withdrawal symptoms.

Pain-relieving medication can help obtain immediate pain relief and allow the patient to participate in more active treatment plans like piriformis muscle stretching and physical therapy. Medications such as opioid analgesics are generally only prescribed for short-term durations when there is a severe traumatic injury to the piriformis muscle.²Boyajian-O’Neill LA, McClain RL, Coleman MK, Thomas PP. Diagnosis and management of piriformis syndrome: an osteopathic approach. J Am Osteopath Assoc. 2008.108(11):657-664. http://doi.org/10.7556/jaoa.2008.108.11.657 The use of pain-relieving medications must be discussed with a physician to avoid interactions with other current medications or potential side effects that patients may not be aware of.

Injection Treatments for Piriformis Syndrome

An injection may be recommended for severe sciatica-like pain caused by piriformis syndrome that does not respond to oral pain medication. Injections may help provide enough pain relief to allow the patient to participate in a physical therapy program. Common types of injections for piriformis syndrome are described below.

Steroid injections for piriformis syndrome

A local anesthetic and corticosteroid may be injected directly into the piriformis muscle to reduce inflammation and swelling in the muscle. These tissue changes help alleviate pain and improve mobility. The injection may be administered at a doctor's office or an outpatient surgery center.⁴Patel VB, Wasserman R, Imani F. Interventional Therapies for Chronic Low Back Pain: A Focused Review (Efficacy and Outcomes). Anesth Pain Med. 2015.5(4). http://doi.org/10.5812/aapm.29716^,5Vij N, Traube B, Bisht R, Singleton I, Cornett EM, Kay AD, et al. An Update on Treatment Modalities for Ulnar Nerve Entrapment: A literature Review. Anesth Pain Med. 2020.10(6).e112070 http://doi.org/10.5812/aapm.112070

A small-group study evaluating 49 patients with piriformis syndrome who were given steroid injections to reduce acute pain found that:

• Around 73% of patients reported moderate to a high levels of pain relief⁶Rosales J, Garcia N, Rafols C, Perez M, Verdugo MA. Perisciatic Ultrasound-Guided Infiltration for Treatment of Deep Gluteal Syndrome: Description of Technique and Preliminary Results. J Ultrasound Med. 2015.34911)2093-7. http://doi.org/10.7863/utra.14.12030
• Around 50% of patients reported a recurrence of pain after 5 weeks, suggesting that steroid injections may eventually wear off⁶Rosales J, Garcia N, Rafols C, Perez M, Verdugo MA. Perisciatic Ultrasound-Guided Infiltration for Treatment of Deep Gluteal Syndrome: Description of Technique and Preliminary Results. J Ultrasound Med. 2015.34911)2093-7. http://doi.org/10.7863/utra.14.12030

As with all injection treatments, in rare cases, steroid injections may cause side effects and adverse events, including but not limited to pain at the injection site, infection, bleeding, or bruising at the injection site.

See Epidural Steroid Injections: Risks and Side Effects

Botox injections for piriformis syndrome

For persistent piriformis spasms, an injection of Botox (botulinum toxin), a muscle-weakening agent, may be helpful. Botox acts as a neurotoxin and temporarily paralyzes the muscle. The goal of a Botox injection is to help the piriformis muscle relax and help reduce pressure on the sciatic nerve.⁷Fishman LM, Wilkins An, Rosner B. Electrophysiologically identified piriformis syndrome is successfully treated with incobotuliunum toxin a and physical therapy. Muscle Nerve. 2017.56(2):258-63. http://doi.org/10.1002/mus.25504

Botox injections may help provide immediate pain relief by reducing the frequency of muscle spasms and tension in the piriformis muscles. The effects of a single injection may last for several months and can help the patient participate in physical therapy treatments.⁸Santamato A, Micello MF, Valeno G, Beatrice R, et al. Ultrasound-Guided Injection of Botulinum Toxin Type A for Piriformis Muscle Syndrome: A Case Report and Review of Literature. Toxins. 2015.7(8):3045-3056. http://doi.org/10.3390/toxins7083045

Rarely, adverse events may occur following Botox injections, including injection site pain, flu-like symptoms, stiff neck, and severe buttock pain.⁹Al-Al-Shaikh M, Michel F, Parratte B, Kastler B, Vidal C, Aubry S. An MRI evaluation of changes in piriformis muscle morphology induced by botulinum toxin injections in the treatment of piriformis syndrome. Diagn Interv Imaging. 2015.96(1):37-43. http://doi.org/10.1016/j.diii.2014.02.015

Prolotherapy injections for piriformis syndrome

Prolotherapy is a type of regenerative treatment that involves injecting a medicated solution near ligaments and joint spaces around the muscle, with the goal of inducing tissue regeneration, promoting healing, and reducing pain.¹⁰Yelland MJ, Mar C, Pirozzo S, Schoene ML, Vercoe P. Prolotherapy injections for chronic low-back pain [review]. Cochrane Database Syst Rev. 2004.29(19):2126-33. http://doi.org/10.1097/01.brs.0000141188.83178.b3^,11Bae G, Kim S, Lee S, Lee WY, Lim Y. Prolotherapy for the patients with chronic musculoskeletal pain: systematic review and meta-analysis. Anesth Pain Med. 2021.16(1):81-95. https://pubmed.ncbi.nlm.nih.gov/33348947/

There is limited research on the effectiveness of prolotherapy.¹⁰Yelland MJ, Mar C, Pirozzo S, Schoene ML, Vercoe P. Prolotherapy injections for chronic low-back pain [review]. Cochrane Database Syst Rev. 2004.29(19):2126-33. http://doi.org/10.1097/01.brs.0000141188.83178.b3 A physician experienced in performing prolotherapy can help determine whether the treatment may be effective based on the underlying cause and duration of piriformis syndrome.

Platelet-rich plasma (PRP) injections for piriformis syndrome

PRP injections contain a concentration of platelets and growth factors taken from the patient's blood and then injected into the piriformis muscle. The goal of PRP is to stimulate the body's healing process and promote tissue repair.¹²Ozturk GT, Erden E, Erden E, Ulasli AM. Effects of ultrasound-guided platelet rich plasma injection in patients with piriformis syndrome. J Back Musculoskelet Rehabil. 2022.5(3):633-639. http://doi.org/10.3233/BMR-210032

The potential drawbacks of PRP injections are that there is limited research on the effectiveness of this therapy, as well as a small risk of infection at the injection site.¹²Ozturk GT, Erden E, Erden E, Ulasli AM. Effects of ultrasound-guided platelet rich plasma injection in patients with piriformis syndrome. J Back Musculoskelet Rehabil. 2022.5(3):633-639. http://doi.org/10.3233/BMR-210032

Modalities Effective for Piriformis Syndrome

Electrotherapy uses electrical stimulation to help manage pain, improve muscle function, and promote healing in painful muscles and connective tissue. Several types of electrotherapy may be used to treat the symptoms of piriformis syndrome, including transcutaneous electrical nerve stimulation (TENS) or interferential current stimulator (IFC).¹³Awan WA, Babur MN, Ali S, Janjua U. The effectiveness of Electrotherapy with Manual Therapy in the Treatment of Piriformis Syndrome. International Journal of Rehabilitation Sciences. 2012.1(1):16-19.

Transcutaneous electrical nerve stimulations (TENS) for piriformis syndrome

TENS is a form of electrotherapy that uses low-voltage electrical current to stimulate the nerve fibers and reduce pain by releasing endorphins. A TENS unit contains electrodes on small, sticky pads, which are attached by wires to a battery-operated device. The device is portable and can be used by patients at their homes.

The efficacy of TENS therapy varies for each patient, and some individuals have reported little to no reduction in their symptoms.¹⁴Visconti MJ, Haidari W, Feldman SR. Transcutaneous electrical nerve stimulation (TENS): a review of applications in dermatology. Journal of Dermatological Treatment. 2020.31(8):846-849. https://doi.org/10.1080/09546634.2019.1657227

Light amplification by stimulated emission of radiation (laser) therapy for piriformis syndrome

Laser therapy is a treatment rendered by a healthcare provider (HCP) that uses focused light to promote tissue healing by reducing pain and inflammation. Laser therapy can penetrate deep into the tissue to stimulate cellular repair and may be directed at the piriformis muscle to treat piriformis syndrome symptoms.¹⁵Ojha S, Jailiya C. To find the Efficacy of Therapeutic Laser for Piriformis Syndrome. J Mahatma Gandhi Univ Med Sci Tech. 2017.2(1):14-17. http://doi.org/10.5005/jp-journals-10057-0024

The efficacy of laser therapy varies for each patient; some individuals have reported a reduction in pain and an increased range of motion in the lower back and hip.¹⁵Ojha S, Jailiya C. To find the Efficacy of Therapeutic Laser for Piriformis Syndrome. J Mahatma Gandhi Univ Med Sci Tech. 2017.2(1):14-17. http://doi.org/10.5005/jp-journals-10057-0024 A series of 6-12 treatments over 2-6 weeks is commonly recommended.¹⁶Cotler HB, Chow RT, Hamblin MR, Carroll J. The Use of Low Level Laser Therapy (LLLT) for Musculoskeletal Pain. MOJ Orthop Rheumatol. 2015.2(5).00068. http://doi.org/10.15406/mojor.2015.02.00068

See Cold Laser Therapy Advantages and Disadvantages

Ultrasound-guided dry needling for piriformis syndrome

Ultrasound-guided dry needling is a minimally invasive procedure that involves inserting thin needles into muscles, tendons, or other soft tissues to alleviate pain and function. Ultrasound imaging is used to guide the placement of the needles to target the piriformis muscle. By inserting the needles into trigger points of the piriformis muscle, the muscle fibers can be stimulated to relax, which can help to relieve pain and improve mobility.¹⁷Bagcier F, Tufanoglu FH. A new treatment modality in piriformis syndrome: Ultrasound guided dry needling treatment. Agri. 2020.32(3):175-176. http://doi.org/10.14744/agri.2019.92170

Ultrasound-guided dry needling is considered safe when performed by a licensed HCP, but its effectiveness for piriformis syndrome may vary for some individuals.¹⁷Bagcier F, Tufanoglu FH. A new treatment modality in piriformis syndrome: Ultrasound guided dry needling treatment. Agri. 2020.32(3):175-176. http://doi.org/10.14744/agri.2019.92170

Acupuncture for piriformis syndrome

Acupuncture is a minimally invasive procedure rooted in traditional Chinese medicine that involves inserting thin needles into specific points on the body to promote healing and relieve pain. The mechanism for acupuncture is not fully understood but studies have suggested that the treatment could promote nerve regeneration and reduce inflammatory factors.¹⁸Wang H, Cui J, Zhao S, et al. Progress on the Experimental Research of Sciatic Nerve Injury with Acupuncture. Evid Based Complement Alternat Med. 2021.2021.1401756. http://doi.org/10.1155/2021/1401756

Acupuncture treatment for the piriformis muscle has limited studies but is considered a safe alternative when performed by a trained practitioner. The effectiveness of acupuncture may vary for each individual and often requires multiple treatments before there are noticeable improvements.¹⁹Cox J, Varatharajan S, Cote P. Effectiveness of Acupuncture Therapies to Manage Musculoskeletal Disorders of the Extremities: A Systematic Review. J. Orthop. Sports Phys. Ther. 2016.46(6):409-429. http://doi.org/10.2519/jospt.2016.6270

Surgery for Piriformis Syndrome

Surgery for piriformis syndrome is rare and is only recommended for severe cases that have not responded to nonsurgical treatments for several months and progressed over time. Surgery may be considered if an individual is experiencing significant pain and function impairment that significantly impacts their quality of life.²⁰Han SK, Kim YS, Kim TH, Kang SH. Surgical Treatment of Piriformis Syndrome. Clin Orthop Surg. 2017.9(2):136-144. http://doi.org/10.4055/cios.2017.9.2.136

A surgeon who specializes in musculoskeletal conditions can advise if surgery is an option for piriformis syndrome pain and the potential benefits and risks that may be associated with the procedure.

Surgical treatments for piriformis syndrome include:

• Piriformis muscle release. This surgery aims to relieve compression on the sciatic nerve by cutting the tendon that attaches the piriformis muscle to the top of the thighbone (femur).³Vij, N. Kiernan H, Bisht R, et al. Surgical and Non-surgical Treatment Options for Piriformis Syndrome: A Literature Review. Anesth Pain Med. 2021.11(1):e112825. http://doi.org/10.5812/aapm.112825
• Sciatic nerve decompression. This surgery aims to relieve compression on the sciatic nerve and reduce pain caused by the inflamed piriformis muscle by removing a small portion of the muscle that compresses the nerve to alleviate the pressure on it.²Boyajian-O’Neill LA, McClain RL, Coleman MK, Thomas PP. Diagnosis and management of piriformis syndrome: an osteopathic approach. J Am Osteopath Assoc. 2008.108(11):657-664. http://doi.org/10.7556/jaoa.2008.108.11.657

Endoscopy is a minimally invasive surgical method that may be considered for patients with piriformis syndrome as it may provide better outcomes and fewer complications compared to open surgical approaches.⁵Vij N, Traube B, Bisht R, Singleton I, Cornett EM, Kay AD, et al. An Update on Treatment Modalities for Ulnar Nerve Entrapment: A literature Review. Anesth Pain Med. 2020.10(6).e112070 http://doi.org/10.5812/aapm.112070^,21Hernando MF, Cerezal L, Perez-Carro L, Abascal F, Canga A. Deep gluteal syndrome: anatomy, imaging, and management of sciatic nerve entrapments in the subgluteal space. Skeletal Radiol. 2015.44(7):919-934. http://doi.org/10.1007/s00256-015-2124-6

As with most surgeries, a potential risk of bleeding, nerve damage, and infection may be present in piriformis surgeries.

A piriformis muscle endoscopic surgery is considered minimally invasive and elective, meaning it is a surgery that can be planned in advance and scheduled with the surgeon rather than performed urgently/emergently.

It is important to note that surgery is not a guarantee for a complete resolution of symptoms, and patients are advised to discuss the potential benefits, risks, and surgical alternatives with the surgeon before deciding on surgery.

Read more about Piriformis Syndrome Surgery