INJECTION THERAPY FOR PRIFORMIS SYNDROME

What is Priformis Syndrome?

Piriformis syndrome is a well-known ailment that is frequently misdiagnosed and difficult to identify because imaging tests are frequently normal. Only once all other causes of buttock discomfort have been ruled out could piriformis syndrome be diagnosed. Most “piriformis syndromes” are associated to the lower back, such as a disc injury producing compression of the sciatic nerve (‘sciatica’), sacroiliac dysfunction, or a hip injury such as femoral acetabular impingement (FAI) or osteoarthritis, according to our experience. Piriformis syndrome can be confused with proximal hamstring (also known as high hamstring) tendinopathy.

Pain in the buttocks and posterior thigh/leg, as well as pins and needles into the foot, are all common symptoms of piriformis syndrome. The piriformis muscle irritates or compresses the sciatic nerve, causing these symptoms. The piriformis muscle is a tiny hip muscle that connects the femur (thigh bone) to the sacral (bone in your lower back).

The size of the piriformis muscle, as well as the size and closeness of the nerve, can be visualised using an MRI scan and diagnostic ultrasonography. Piriformis syndrome, on the other hand, is frequently a diagnosis of exclusion.

Physiotherapy is used to restore normal movement of the lower back and hip, as well as to improve the flexibility of the piriformis muscle and other hip muscles like the gluteal muscle and the deep lateral rotator muscle group. A physiotherapy programme should include exercises to strengthen the hip and lower back, as well as postural awareness and activity changes.

An ultrasound guided steroid injection can be a helpful treatment for piriformis syndrome if you are still experiencing discomfort or if rehabilitation aggravates your symptoms.

.What are the symptoms of Priformis Syndrome?

  • Pain in the buttocks and the back of the thigh
  • Sitting, walking, and stair climbing cause pain.
  • Numbness and pins and needles in the leg and foot
    If this sounds like your issue, keep reading…

Other disorders that can be mistaken for Piriformis Syndrome include:

  • Iliopsoas Tendinopathy/Bursitis
  • Trochanteric Bursitis
  • Osteoarthritis of the hip
  • Proximal hamstring tendinopathy
  • FAI (Femoro acetabular impingement)
  • Sacrolitis
  • Discogenic low back pain 

Priformis Syndrome vs Sarcolitis

Both piriformis syndrome and sacroiliac joint discomfort can have comparable pain patterns, and the two disorders can coexist. Prolonged sitting, continued walking, and stair climbing aggravate them both. Sacroiliitis, on the other hand, is frequently associated with more morning discomfort, stiffness, and nocturnal pain than piriformis syndrome. Piriformis syndrome causes leg discomfort (due to sciatic nerve stimulation), whereas sacroiliitis causes less leg pain because there is no nerve compression.

Anatomy and Muscle components of Hip

The articulation of the huge ball-shaped head of the femur (long bone of the thigh) and the cup-shaped socket of the pelvis forms the hip joint (called the acetabulum).

The sciatic Nerve and the Priformis Muscle Anatomy:
The anterior surface of the S2–S4 sacral (lower vertebra), the capsule of the sacroiliac joint (joint between the sacrum and the pelvis), and the crest of the hip all contribute to the pyramidal shape of the piriformis muscle. It subsequently connects to the femur’s greater trochanter (Khan & Nelson, 2018).

The deep gluteal muscles are all involved in hip external rotation. They are only visible in cadaveric specimens if the gluteus maximus has been peeled away, as they are hidden dorsally by this muscle. Piriformis is the deep gluteal group’s most superior muscle.

The piriformis muscle’s primary function is abduction and external rotation of the femur, so it can help you bring your leg out to the side and turn it out. Because the sciatic nerve travels underneath the piriformis muscle and subsequently separates to innervate the lower limb, the piriformis can be a substantial source of discomfort and also particularly sensitive.

What is Priformis Syndrome?

Piriformis syndrome is characterised by hip and buttock discomfort and is caused by a peripheral neuritis (nerve inflammation) of the sciatic nerve produced by an abnormal state of the piriformis muscle. Piriformis syndrome is a type of’sciatica’ that is caused by the piriformis muscle compressing the sciatic nerve (Probst et al, 2019).

Differences in the anatomical structure of the sciatic nerve were considered to play a role in piriformis pain, however a large recent retrospective investigation found no link between sciatic nerve variations and piriformis syndrome (Bartret et al, 2018).

In the clinical setting, the illness is frequently misdiagnosed and over-diagnosed. Intervertebral disc issues, lumbar radiculopathy, sacral dysfunctions, sacroiliitis, sciatic problems, piriformistrochanteric bursitis, and proximal hamstring pain are all probable causes of piriformis syndrome (Boyajian-O’Neill et al, 2008).

According to Boyajian-O’Neill et al. (2008), at least 6% of individuals diagnosed with low back pain actually have piriformis syndrome; however, the percentage can range from 5-36 percent depending on the diagnostic criteria.

How do you know if you have Priformis Syndrome?

Among the signs and symptoms are:

  • Sitting causes discomfort.
  • Single leg motions cause pain in the sacrum, gluteal area, and thigh.
  • Pain when rising from a seated or crouching position
  • Sacrum pain on the contralateral (opposite) side
  • Low back discomfort with numbness in the foot

The most common symptoms, according to an updated systematic review (Hopayian & Daniellyan, 2017), were buttock pain, pain aggravated by sitting, external tenderness near the greater sciatic notch, pain on any movement that increased piriformis muscle tension, and a limitation of lifting the leg up in a straight line on the same side.

How do we diagnose Priformis syndrome?

Delays in recognising piriformis syndrome can result in sciatic nerve pathology, chronic dysfunction, and compensatory alterations that cause pain, paraesthesia, hyperesthesia, and muscular weakness. Physiotherapists must be able to recognise symptoms and signs that are specific to piriformis syndrome in order to provide timely therapy.

Clinical Examination

A clinical examination is done to provide information to the physiotherapist about the variables that have contributed to the onset of your symptoms. It’s utilised to come up with a hypothesis for why you’re in pain and to come up with a therapy plan to address these concerns.

To further comprehend your circumstances, a clinical interview is conducted. Questions will be asked about how and why your pain began, what aggravates and relieves your symptoms, and how long you’ve been in pain. A complete medical history will be collected, including medication history if applicable.

After that, a physical examination is performed, which includes lumbar and hip joint range of motion testing, strength and flexibility of the surrounding muscles, and palpation (feeling) of various lumbar spine and hip structures. Squatting, single leg balancing, gait analysis and running analysis (if you’re a runner) are among the functional tests performed, as are provocation tests for discomfort originating from the sacroilliac joint. In addition, unique neurodynamic tests of the lower limb will be performed, as well as a comprehensive neurological screen of the lower limb (reflexes, dermatomes and myotomes).

This procedure gives you a lot of information about what’s causing your problems and can lead to a piriformis syndrome diagnosis. Specialist imaging is frequently required to thoroughly confirm the diagnosis and rule out alternative causes of disease when symptoms are chronic or the diagnosis is still unclear.

Diagnosis

X-ray

An X-ray isn’t used to diagnose piriformis syndrome, but it can help rule out other causes of pain that could be mistaken for it. X-rays are widely used to evaluate the hip and lumbar spine’s bone and joint structure. An X-ray is a useful tool for determining the shape of the bones in the hip joint, as well as any structural changes, serious disease, joint space quality, and the existence of fractures, including stress reactions.
Magentic Resonance Imaging:

Both bone and soft tissue diseases can be accurately assessed with MRI imaging. The size of the piriformis, the size and fluctuation of the sciatic nerve (Bartret et al, 2018), and any inflammation can all be accurately demonstrated and measured using MRI imaging. An MRI is a procedure that entails you laying immobile in a huge cylinder for 30 minutes to an hour. An MRI creates a detailed 3D representation of your hip architecture by taking a sequence of images of your hip. It’s worth noting that MRI doesn’t always accurately diagnose piriformis syndrome.

Ultrasound imaging for diagnostic purposes 

Ultrasound Imaging for diagnostic purposes

Diagnostic ultrasound imaging can show inflammation and swelling associated with piriformis syndrome as well as the outer edge of the hip joint. It also has the added benefit of allowing you to visualise your hip while moving, which is useful for gauging pain during particular exercises.

Diagnostic musculoskeletal ultrasound imaging is a good imaging tool for detecting soft tissue hip pathologies and quantifying the size and thickness of structures such as the piriformis muscle and the sciatic nerve (Cheatham et al., 2016). The use of ultrasound to diagnose piriformis syndrome appears to be a viable method (Zhang et al, 2019).

Joint injections offers a staff of clinicians who are both physiotherapists and musculoskeletal sonographers with extensive experience. Your clinician will utilise both clinical examination and diagnostic imaging to assist evaluate the source of your hip discomfort during your evaluation.

How do we treat Priformis syndrome?

Physiotherapy usually works wonders for piriformis syndrome.

  • A tailored, progressive rehabilitation programme for the gluteal region and supporting tissues that includes mobility and strengthening exercises.
  • Advice on how to modify your activities to reduce the likelihood of aggravating your symptoms.
  • Assessment and adjustment of functional motions and sporting activities are examples of movement re-education.
  • Soft tissue release techniques can also help to relieve discomfort and improve hip flexibility.
  • To desensitise the area, acupuncture and dry needling procedures might be used.

    Here are a few pointers you might want to try:
  • Avoid positions that are irritating. Sitting for lengthy periods of time and crossing your legs are known to irritate the piriformis region by loading and compressing the sciatic nerve. Try to sit evenly and, if possible, stand for long periods of time while working.
  • Try to figure out what functional movements or workouts trigger a symptom flare-up. If you can, modify these or stop for a while, and then visit your physiotherapist or personal trainer for alternatives.
  • Stretch your gluteal muscles, piriformis, calf muscles, and hamstrings gently.
  • Pilates-style workouts can help strengthen your gluteal region while also engaging your core and postural muscles.
  • An ultrasound-guided injection may be helpful for you if physiotherapy has been ineffective in lowering pain and symptoms and the diagnosis has been confirmed on imaging.

Patients who respond exceptionally effectively to corticosteroid injections typically report pain that:

  • It keeps you up at night and interferes with your ability to sleep, reducing your capacity to fulfil daily duties such as work and leisure activities.
  • has an impact on your ability to participate in physiotherapy rehab

 Corticosteroid Injection guided by Ultrasound

Ultrasound-guided corticosteroid injection is an excellent evidence-based therapy option for piriformis syndrome discomfort that has been widely documented in literature and trials (Misirlioglu et al, 2015: Smith et al, 2006). According to Jeong et al. (2015), 65 percent of patients saw considerable improvement after receiving an ultrasound-guided injection.

A needle is precisely inserted into the piriformis during an ultrasound-guided injection. A modest amount of corticosteroid (a powerful anti-inflammatory drug often used in musculoskeletal injection therapy) is mixed with a short-acting local anaesthetic. An ultrasound-guided injection should offer significant pain relief for 6–8 weeks and pain reduction for at least 12 months (Masala et al, 2011), after which physiotherapy intervention should prevent recurrence (Masala et al, 2011).

As a stand-alone treatment, injection therapy should be avoided. An ultrasound-guided injection gives you a pain-free ‘window of opportunity,’ allowing you to effectively repair your problem. To get the best results, Joint Injections recommend starting physiotherapy two weeks after the injection.

Our clinicians are all fully qualified Extended Scope Physiotherapists (ESP), musculoskeletal sonographers, and independent prescribers at Joint Injections. For all ultrasound-guided injections, we may give same-day service

Joint Injection’s experts are dual-trained, highly specialised physiotherapists and musculoskeletal sonographers with extensive experience diagnosing all Hip and pelvis disorders. We provide a ‘one-stop’ clinic, which means you’ll get an examination, a diagnostic ultrasound, and, if necessary, an ultrasound-guided injection.