Piriformis Syndrome and Sciatica Pain

Ross A. Hauser, MD; Danielle R. Steilen-Matias, MMS, PA-C

We see many patients who are not really sure what is wrong with them, or, they are diagnosed with a problem that they do not really understand. Such is the case with Piriformis syndrome. For some, since lower back pain is a problem, a trip to the chiropractor was made. It is here that some of these patients were first made aware that Piriformis syndrome may be a problem for them.

In the chiropractor’s office, the patient may have been given an explanation that their problem is not one of a bulging or herniated disc pressing on a sciatic nerve, but it is the piriformis muscle that has entrapped the sciatic nerve and causing “herniated disc like symptoms.”

In this article, I will cover various treatments and difficulties in diagnosing Piriformis syndrome.

Article summary

Part 1: Piriformis syndrome diagnosis. When you have numerous tests, no one knows what to make of them

  • Piriformis muscle syndrome is rarely a problem in isolation.
  • My piriformis syndrome: It started like this.
  • Understanding piriformis syndrome, is it really a syndrome? What is this diagnosis? How can we treat this?
  • Piriformis syndrome centers on the piriformis muscle as it rubs on the sciatic nerve causing irritation.
  • “Piriformis muscle pathology can cause sciatica as this has been clearly demonstrated.” Not all sciatica-like manifestations are of lumbar spine origin.
  • Piriformis syndrome centers on the piriformis muscle as it rubs on the sciatic nerve causing irritation.
  • Idiotypic pelvic pain, pelvic visceral pain, pudendal neuralgia, and pelvic organ dysfunction.
  • “Piriformis muscle pathology can cause sciatica as this has been clearly demonstrated.” Not all sciatica-like manifestations are of lumbar spine origin.
  • What is causing Piriformis syndrome-related problems?
  • What are the cluneal nerves? Are they the cause of your Piriformis syndrome?

Part 2: Treatments for Piriformis Syndrome

  • Making sense of why treatment focused only on the Piriformis muscle is not helping you.
  • Corticosteroid injections for piriformis syndrome.
  • Shockwave therapy and corticosteroid injection.
  • Botulinum toxin injection can help. How much help? Not sure.
  • Dry Needling
  • Hydro-dissection for Piriformis syndrome.
  • For many of you reading this article, you have found that these treatments were not effective and you are facing the surgical recommendation, the “last resort.”
  • Osteopathic manipulative treatment
  • The problem of finding any comfortable sleep position with Piriformis syndrome
  • Surgery: endoscopic piriformis release with a sciatic nerve neurolysis
  • What is causing Piriformis syndrome-related problems?
  • The patient is a long-distance runner, who developed sacroiliac joint pain, iliotibial band problems, piriformis syndrome, patella femoral syndrome, and pain all along her entire right side.
  • Prolotherapy injections for Piriformis syndrome.
  • Platelet Rich Plasma Injections for Piriformis Syndrome.

Part 1: Piriformis syndrome diagnosis. When you have numerous tests, no one knows what to make of them

Piriformis muscle syndrome is rarely a problem in isolation

When a patient comes in with a diagnosis of Piriformis muscle syndrome, we may also find that the patient may also suffer from signs and symptoms related to trochanteric bursitis  (please see our article Greater trochanteric pain syndrome – It is not sports-related bursitis?) and weakness in the iliotibial band. (Please see our accompanying article Iliotibial band friction syndrome Knee pain in Runners.) These problems can also cause “sciatica.”

When examining the patient with Piriformis muscle syndrome, we may also find weakness in the sacroiliac joint, hip joint, sacrotuberous and sacrospinous ligaments, trochanteric bursa, and iliotibial band/tensor fascia lata.

The difficulty in getting to this point of diagnosis is demonstrated by the stories people tell of their medical histories. One such story goes like this:

“I am 32 years old and for 16 years I have suffered from pain in my buttocks that shoots down my leg when I bend forward or walk. The pain has been excruciating and gradually led to weakness in my leg. At first, I thought that it was sciatica. I have done therapy, exercise, stretches, etc., but only gotten mild relief. Some days the pain is so excruciating that I can barely walk. Because of this pain, I have gotten injuries to both knees as a result of joint instability when I play soccer. I would like to get relief for my leg. Just to be able to run on the soccer field without wobbling. Run for a mile without dragging one leg and limping in pain. I just recently learned about piriformis syndrome and nerve entrapment.”

For others, confusing diagnoses lead them to a lot of research and self-diagnosis. These are people who became frustrated with their lack of progress. You can read it in their emails that go something like this:

Numerous tests, no one knows what to make of them.

I have had an MRI, and I have had a nerve conduction study. I had an EMG that suggested a sciatica problem with radiculopathy. I don’t think it is sciatica because I am not responding to all the medications I am getting for my “back pain.” Now my doctor is talking to me about epidural steroid injections but I am also showing tendinopathy on some of my scans. My physical therapist is talking to me about the possibility of greater trochanteric pain syndrome or hip bursitis. MAYBE it is Piriformis syndrome.

I think I have piriformis syndrome

Having been given this explanation, the patient then seeks out a treatment plan. Hopefully, they will find the one that works for them.

I told my doctor I think I have piriformis syndrome. Maybe it is wishful thinking but a recommendation for sciatica surgery is not the route I want to go right now.  But my doctor is telling me my nerve test showed lumbar radiculopathy pinpointed to the L5/S1, but I believe it is piriformis, as another scan showed tendinitis and another doctor recommended I look into this being a problem of deep gluteal syndrome or piriformis syndrome.

Piriformis syndrome: It started like this

A typical Piriformis syndrome diagnosed patient we see is someone who exercises or works out a lot, or, competes in demanding levels of sports. For this person, their problems start sometimes suddenly as:

  • severe lower back pain,
  • pain in the hamstrings,
  • “tight thighs” or “tight glutes” or “weak glutes,”
  • significant or burning buttock pain
  • and sciatica-like symptoms of burning, numbing pain radiating down one or both legs and even a sense of “numb toes.”

Many of these patients/ athletes will tell us that they did try to work their way through these problems. They continued to run, swim, and cycle and managed the pain these activities were causing with anti-inflammatories, ice, massage, and stretching. A foam roller is always in their sports kit.

Unfortunately, these treatments, as they found, would sometimes make their problems worse. In fact, some people had to eliminate all stretching exercises as they had become injury-causing.

Understanding piriformis syndrome, is it really a syndrome? What is this diagnosis? How can we treat this?

The difficulty in understanding Piriformis syndrome, making the correct diagnosis, and getting the right treatment is highlighted in a February 2021 paper in the journal Anesthesiology and Pain Medicine. (1) The study authors described the problem in this way:

“Piriformis syndrome is an important differential diagnosis in the workup of lower back pain and should not be ruled out with proper examination and testing. Clinicians should consider medical management and conservative management in the initial treatment plan for piriformis syndrome. There are many options within the conservative management and the literature shows much promise regarding these. Physical therapy, steroid injections, botulinum toxin injections, and dry needling are all potentially effective therapies with few adverse effects.”

The point to highlight here is that doctors should not rule out piriformis syndrome until it is examined.

Piriformis syndrome centers on the piriformis muscle as it rubs on the sciatic nerve causing irritation.

  • In Piriformis syndrome, like the sciatica symptoms we mentioned above, the pain can often travel down the back of the thigh and/or into the low back. Some patients will report spasms in addition to muscle pain in addition to tingling, and numbness in the butt, leg, and thighs.

Many times a patient will come in with an MRI that may show sciatic nerve and piriformis muscle abnormalities. However, because of the difficulty in making a piriformis syndrome diagnosis via MRI, the primary diagnosis is usually made following a physical examination.

Doctors describe the challenge of a correct diagnosis: For the patient, a second opinion should be considered to diagnose or not diagnose Piriformis syndrome

Doctors writing in the European Journal of Orthopaedic Surgery & Traumatology (2) gave an updated assessment of the challenges of diagnosing piriformis syndrome as the true cause of a patient’s radiating pain.

They write that piriformis syndrome can be defined by a quartet of symptoms and signs. The most common symptoms reported were:

  • buttock pain,
  • pain aggravated on sitting,
  • external tenderness near the greater sciatic notch and
  • pain on any maneuver that increases piriformis muscle tension

They also warn that doctors should be aware that the simple straight leg raising test may not be adequate and more testing would need to be done to determine if Piriformis syndrome is the pain culprit or contributor to the patient’s pain.

They also agree that piriformis muscle pathology can cause sciatica as this has been clearly demonstrated.

A March 2023 study in the journal Hip & Pelvis (3) found that in a review of the published literature “piriformis syndrome is over-diagnosed.” The study issued these observations of other problems thought to be Piriformis Syndrome.

Alternate Diagnosis of Non-Discogenic Sciatica (Potentially Mimicking Piriformis Syndrome)

  • Deep gluteal syndrome
  • Hamstring syndrome
  • Sciatic notch syndrome. (Sciatic nerve entrapment caused by any structure in the posterior pelvis.)
  • Wallet neuritis (Compression of the ipsilateral sciatic nerve from the patient’s wallet in the back pocket.)
  • Alternate nerves are involved. (Buttock pain can also represent the entrapment of gluteal nerves and hamstring pain can represent the entrapment of the posterior cutaneous nerve of the thigh.)

Idiotypic pelvic pain, pelvic visceral pain, pudendal neuralgia, and pelvic organ dysfunction

An October 2022 study in the journal Surgical and Radiologic Anatomy (4) suggests the piriformis muscle may be impacting more than the sciatic nerve.

The authors write: “The piriformis muscle may compress additional nerve structures (beyond the sciatic nerve) in other regions and cause idiotypic pelvic pain, pelvic visceral pain, pudendal neuralgia, and pelvic organ dysfunction. There is still a lack of detailed description of the muscle origin, topography, and possible relationships with the anterior branches of the sacral spinal nerves and with the sacral plexus. In this study, the researchers found: “(the piriformis muscle) may result in the compression of the anterior branches of the sacral spinal nerves when crossing the muscle (causing pain in groin and buttocks).

“Piriformis muscle pathology can cause sciatica as this has been clearly demonstrated.” Not all sciatica-like manifestations are of lumbar spine origin.

A study from October 2020 (5) gives a more detailed list of sciatic mimics.

“Not all sciatica-like manifestations are of lumbar spine origin. Some of them are caused at points along the extra-spinal course of the sciatic nerve, making diagnosis difficult for the treating physician and delaying adequate treatment.

While evaluating a patient with sciatica, straightforward diagnostic conclusions are impossible without first excluding sciatica mimics.

Examples of benign extra-spinal sciatica are piriformis syndrome, walletosis (or Wallet Neuritis or Wallet Sciatica so called because men with fat wallets would put them in their back pockets and as they sat on them the wallet would cause compression in the lower buttocks and lower hip), quadratus lumborum myofascial pain syndrome (painful and somewhat isolated trigger points in the big muscle in your lower back between your pelvis and lower rib,) cluneal nerve disorder (see just below), and osteitis condensins ilii (usually seen in pregnant women as their pelvis reshapes and this can cause sciatica-like pain).

What are the cluneal nerves? Are they the cause of your Piriformis syndrome?

The cluneal nerves are sensory, not motor nerves. This means that the messages that travel through them sense your environment but not how to react or move because of it. So the sensation of pain would be a primary function of the cluneal nerves. The cluneal nerves are divided into three branches. The inferior branch, the medial branch, and the superior branch. The inferior branch can be affected by piriformis syndrome and send out pain signals.

A March 2018 paper in the journal Neurospine (6) gives further detail: “Low back pain is encountered frequently in clinical practice. The superior and the middle cluneal nerves are cutaneous (sensation to the skin) nerves that are purely sensory. They dominate sensation in the lumbar area and the buttocks and their entrapment around the iliac crest can elicit low back pain.

  • The reported incidence of superior cluneal nerve entrapment in patients with low back pain is 1.6%–14%.
  • Both superior cluneal nerve and middle cluneal nerve entrapment produce leg symptoms in 47%–84% and 82% of low back pain patients, respectively.
  • In such patients, pain is exacerbated by lumbar movements, and the symptoms mimic radiculopathy due to lumbar disorder. As patients with failed back surgery or Parkinson’s disease also report low back pain, the differential diagnosis must include those possibilities. “

In essence, the inferior branch of the cluneal nerve may be involved in piriformis syndrome. Possibly affects about one in seven low back pain patients. About four in five patients may have pain radiating down their legs. Patients who underwent back surgery and continued to have pain radiating down their legs may have had the wrong surgery.

Our colleagues, James Inklebarger, MD & Nikforos Galanis, MD, wrote this in the Journal of Prolotherapy (7) about cluneal nerve entrapment.

“The diagnosis of cluneal nerve entrapment may be challenging. Pain over the medial portion of the iliac crest and in the gluteal or lumbosacral area are often attributed to a facet syndrome, lower lumbar disc problem, or an iliolumbar syndrome (involvement of the iliolumbar ligament).

 Clinical symptoms of cluneal nerve entrapment have been described as low back pain, which may radiate to the ipsilateral leg (the leg on the same side). Clinical signs include tenderness at the iliac crest rim just above the dimple at the buttock and decreased touch sensation of the buttock just below the iliac crest. A diagnosis of medial cluneal nerve entrapment is made by palpation of the iliac crest or long posterior sacral ligament resulting in marked local tenderness and pain relief after local anesthetic injection.”

What are we seeing in this image below?

A lot of cross conditions, symptom makers, and other problems clearly demonstrate that piriformis muscle syndrome is rarely a problem in isolation.

Here are some explanatory points of what is going on in this image

  • You are leaning forward ready to lift something
  • The gluteus maximus and piriformis (where it attaches to the sacrum) stabilize the sacrum.
  • Anterior innominate rotation is a dysfunction of the anterior superior iliac spine (the back of the pelvic bone just below the iliac crest or “wing,” of the pelvis) where the pelvis is unstable and this instability causes vertical (up and down pressure) shear that causes the gluteus maximus to pull away from the iliac crest and create a painful situation across the buttocks, through the ball area or trochanter area of the hip to the side of the knee.
  • This can cause piriformis syndrome which is easily mistaken for sciatica.

The point of this illustration is to suggest in some people, there is much more going on beyond piriformis syndrome.

Part 2: Treatments for Piriformis Syndrome

Making sense of why treatment focused only on the Piriformis muscle is not helping you

When a patient visits the sports medicine physician, chiropractor, or other health care provider for treatment, it may be suggested to them that the symptoms and pain they are dealing with are being caused by the tight piriformis muscle. The patient and doctor would then work to loosen up the piriformis muscle, through exercises, manipulation, massage, and physical therapy.

Doctors at the Spinal Surgical Service, Weill Medical College of Cornell wrote in The Orthopedic Clinics of North America (8) journal of the typical expectations of treatment a patient may receive. This will likely sound very familiar to you:

  • Physical therapy is the mainstay of conservative treatment of Piriformis muscle syndrome as it aims at stretching the muscle and reducing the vicious cycle of pain and spasms.
  • Physical therapy is usually enhanced by local cortisone injections or in some instances Botulinum toxin (Botox).
  • Surgery should be reserved as a last resort in case of failure of all conservative modalities.

Corticosteroid injections for piriformis syndrome

A 2020 study (9) comes to us from the National and Kapodistrian University of Athens, University General Hospital in Greece. Here the doctors assessed cortisone injection effectiveness in piriformis syndrome patients who were not responding to conservative care management. In this study, twenty patients were examined who had a previous cortisone injection for their piriformis syndrome diagnosis. The doctors found that in these 20 patients, pain symptoms were significantly reduced. Two of the patients had a second injection within 10 days after the first. The doctors noted that ultrasound-guided cortisone injections seem to be “a feasible, efficacious, and safe approach for pain reduction and mobility improvement in patients with symptomatic piriformis syndrome.”

Many of you reading this article may have had initial success with cortisone. That you are reading this article is indicative that this “success” was off and you are now seeking other treatment methods.

Shockwave therapy and corticosteroid injection

A January 2023 study in the Journal of Bodywork and Movement Therapies (10) compared the effects of shockwave therapy and corticosteroid injection in the treatment of piriformis syndrome.

  • Thirty-five patients with piriformis syndrome were randomly divided into two groups; 18 in the shockwave group and 17 in the corticosteroid group.
  • The Shockwave group underwent three sessions of shockwave therapy per week and the corticosteroid group underwent an injection of 40 mg methylprednisolone with 1 mL of 1% lidocaine under ultrasound guidance.
  • All patients were assessed with standard self-reporting outcome surveys.
  • At the end of the study, (12-week assessment) both groups had a significant improvement in pain and quality of life compared to before the intervention. “It seems that shockwave therapy and corticosteroid injection are both effective in the treatment of piriformis syndrome. (12 week post-treatment assessment).  There was no significant difference between the two groups in the quarterly follow-up. Because shockwave therapy is a relatively non-invasive treatment with fewer side effects, it can be useful to improve pain and the quality of life of patients with piriformis syndrome.”

Botulinum toxin injection can help. How much help? Not sure.

A July 2022 paper in the Journal of Clinical Orthopaedics and Trauma (11) suggests botulinum toxin injection can help. How much help? Not sure. The researchers write: “There is fair quality of evidence to suggest botulinum toxin is safe to reduce pain in piriformis syndrome. There is insufficient data to quantify pain reduction and to describe other functional outcomes. The optimal dose of botulinum toxin A remains unclear.”

A December 2022 paper in the journal Healthcare (12) compared the effectiveness of ozone and BTX to lidocaine injection in treating piriformis syndrome that was resistant to medication and/or physical therapy.

  • Eighty-four subjects diagnosed with piriformis syndrome were randomized in a comparative study to receive an ultrasound-guided injection of lidocaine (control group), botulinum toxin A, or local ozone (28 patients in each group) in the belly of the piriformis muscle. The majority (58.3%) of patients were male, while (41.7%) were female.
  • Pain condition evaluated by the visual analog score (0 – 10 pain score) was used as a primary outcome, and the Oswestry Disability Index (ODI) as a secondary outcome, before, at one month, two months, three months, and six months following the injection.
  • At one month, a highly significant decrease occurred in pain and disability scores in the lidocaine and ozone groups compared to the botulinum toxin group.
  • At six months, there was a highly significant decrease in pain and disability scores in the botulinum toxin group compared to the lidocaine and ozone groups.

Conclusion: “Botulinum toxin may assist in the medium- and long-term management of piriformis syndrome, while lidocaine injection and ozone therapy may help short-term treatment in patients not responding to conservative treatment and physiotherapy.”

Dry Needling

An August 2023 paper in the journal Cureus (13) evaluated the effectiveness of dry needling therapy and exercise programs on pain, neuropathic pain, physical function, and disability in patients with Piriformis muscle syndrome.

  • Forty-four patients with Piriformis muscle syndrome were divided into two groups, those who were treated with dry needling three times once per week under ultrasound guidance and those who had an exercise program for three weeks.  Pain and disability patient self-reported survey scores were used to assess results.
  • The group comparisons showed no statistically significant differences in decreasing pain, reducing disability, and increasing functional status scores among the groups at post-treatment first-month and third-month assessments.

Conclusion: Both treatment modalities are beneficial in reducing pain and disability, and increasing the functional status of the patients with Piriformis muscle syndrome. in three months of follow-up. In patients who cannot adapt to exercise programs, dry needling treatment under ultrasound guidance should be kept in mind as a minimally invasive treatment modality with no adverse effects.

Hydro-dissection for Piriformis syndrome

Two case histories presented in The American Journal of Case Reports in February 2022 (14)  found that “Hydro-dissection by ultrasound-guided injection of a very low concentration of local anesthetic is effective and has a lower risk of adverse effects, thus making it more convenient for the treatment of piriformis syndrome than conventional treatments, such as local anesthetics, steroids, and botulinum toxin injection.”

For many of you reading this article, you have found that these treatments were not effective and you are facing the surgical recommendation, the “last resort.”

Yet other researchers agree with this treatment methodology. Writing in the journal Practical Neurology (15) doctors say: “Owing to a lack of clinical trials and a lack of consensus on diagnosis, treatment of piriformis syndrome largely utilizes conservative methods, such as stretching, manual techniques, injections, NSAIDs, muscle relaxants, ice and activity modifications. The mainstay of treatment is piriformis stretching, which focuses on relaxing tight muscles to relieve nerve compression.”

Indeed, for some, these treatments may be effective. If you are reading this article, it is probable that they were not effective for you.

Osteopathic manipulative treatment

An August 2023 update in the internet publication STATPearls housed at the National Library of Medicine (16), compares and discusses outcomes of Osteopathic manipulative treatment and conservative care. The update authors write: “Although muscle relaxants, NSAIDs, and steroid injections are possible options to treat the piriformis muscle, the use of counterstrain and muscle energy on patients is an effective and conservative alternative or adjunct to other treatment modalities.” As with many treatments, Osteopathic manipulative treatment “approach must be repeated with other osteopathic sessions because if the problem derives from a chronic condition, it is necessary to have sufficient time to change the texture of the tissue and the related neurological reflexes. Additional sessions will depend on the patient’s physiological response and the cause of the dysfunction.”

The problem of finding any comfortable sleep position with Piriformis syndrome

Another thing we are accustomed to hearing from our patients is that they are spending a lot of time trying to find answers on how to sleep better. They are “side sleepers,” they move around at night in bed with all sorts of pillows jammed between their legs, under their backs, basically wherever a pillow needs to be. They cocoon themselves up in a ball of blankets trying to maintain sleep while in their back sleeping position. You know what happens next, you wake up an hour or two later with pain in your hip and you have rolled yourself up back in a fetal position.

So these people go online and look for all sorts of piriformis syndrome sleep aids and exercises and what they run into is a piriformis syndrome vs sciatica debate. This is what a patient will explain to us and why their first treatments centered on sciatica pain management to help them sleep better.

  • The patient went to the doctor concerned about a burning pain and numbness sensation in his/her buttocks, legs, and feet. Often the pain woke them up in the middle of the night as we just described.
  • They decided to go to the doctor because his/her own pain management plan of aspirin, anti-inflammatories, heat, ice, yoga, stretching, resting, and back braces had not helped. (Please refer to our article Why physical therapy and yoga did not help your low back pain.)
  • His/her problems have probably gone on for some time and symptoms are getting worse as you begin to suffer from severe spasms in the lower leg and calf muscles.

Surgery: endoscopic piriformis release with a sciatic nerve neurolysis

When all conservative treatments fail, a recommendation may then be made for an MRI or CAT scan to confirm that what this person needs is surgery. A surgery that most patients do not want when they are told of the four-month recovery time. This is when these people will contact our office seeking a surgical alternative and a treatment that will help them compete or get back to work again.

A January 2022 review study published in the journal Arthroscopy, Sports Medicine, and Rehabilitation (17) asked patients about their satisfaction following endoscopic piriformis release with a sciatic nerve neurolysis.

Before the surgical procedure, the patients had suffered an average 34 months with symptoms associated with piriformis syndrome.

  • Thirty-seven of forty-six cases (82.2%) had an EMG that showed sciatic compression around the piriformis muscle.
  • The average preoperative Pain Visual Analog Scale pain score was 7.4 (on a scale of 0 – 10). The average Pain Visual Analog Scale score at the time of the survey was 1.9 showing significant improvement.
  • The researchers found that the outcomes at the time of the survey were:
    • excellent in 23 patients (24 cases, 53.4%),
    • good in 10 (22.2%),
    • fair in 3 (6.7%), and
    • poor in 8 (17.7%). Three patients with poor results had a wrong diagnosis of piriformis syndrome and ended up needing treatment for a different diagnosis.

What is causing Piriformis syndrome-related problems?

The sciatic nerve runs between the two heads of the piriformis muscle. When the piriformis muscle is spastic, the sciatic nerve may be pinched. Lumbosacral and hip joint weaknesses are the two main causes of piriformis muscle spasms. Stretches and physical therapy directed at the piriformis muscle to reduce spasms help temporarily, but do not alleviate the real problem.

The iliotibial band/tensor fascia lata extends from the pelvis over the hip joint to the lateral knee. Its job is to help abduct the leg (taking a step to the side), especially during walking so the legs do not cross when walking.

When this band/muscle is tight, it puts a great strain on the sacroiliac and lumbosacral ligaments. Stretching this muscle is beneficial to many people with chronic hip/back problems. Stretching and massages feel good to people with chronically “tight IT bands.” Take this one step further to understand why the bands/muscles become tight in the first place, which is joint instability generally in the hip or the knee. This instability needs to be properly identified and treated for the chronic tightness to be eliminated, along with the need to regularly stretch or massage the area in order to feel relief. Once the joint becomes stable, the continual tightness subsides.

Understanding treatment: The piriformis muscle does not just tighten up on its own

The piriformis muscle does not just tighten up on its own. We have found that in many patients with this condition, a sacroiliac ligament injury or a hip ligament injury is the cause. Basically, the sacroiliac or hip ligaments are stretched out and loose. Consequently, when the piriformis muscle tries to contract, it can’t, so it starts to spasm. When the piriformis spasms, it pinches the sciatic nerve, which causes pain, tingling, and numbness that the person experiences.

Trying to loosen the piriformis muscle is not going to work to alleviate the patient’s symptoms. For these patients, in our opinion, the symptoms of piriformis syndrome can only be alleviated by treating the underlying cause of the problem which is loose sacroiliac and/or hip ligaments.

The patient is a long-distance runner, who developed sacroiliac joint pain, iliotibial band problems, piriformis syndrome, patella femoral syndrome, and pain all along her entire right side.

In the Journal of Prolotherapy a case history of successful treatment with Prolotherapy (see below on what Prolotherapy is) is presented:

  • The patient is a long-distance runner, who developed sacroiliac joint pain, iliotibial band problems, piriformis syndrome, patella femoral syndrome, and pain all along her entire right side.
  • The patient had sought extensive chiropractic and physiotherapy. Unfortunately, these treatments were all minimally successful at best, providing no real relief.

An acute episode occurred when during a run the patient “heard a crack and felt searing pain through the inner thigh and groin.”

After visiting numerous doctors the patient was advised she had a “pulled groin muscle,” and to “stop running.” Since the patient was already experiencing extreme difficulties in simply walking, the doctor’s advice was of no help.

According to the patient: “Months of dedicated, daily physiotherapy treatments proved mostly futile until finally the physiotherapist, a marathoner herself, informed me of a treatment called Prolotherapy. She believed this would address the laxity of the ligaments of my right SI joint, which had culminated in what was, in fact, a fracture of the inferior pubis ramus resulting from multiple biomechanical problems, and laxity of the ligaments of the SI, exacerbated by many miles of running.”

Prolotherapy injections for Piriformis syndrome

Prolotherapy involves injections of dextrose, a simple sugar, into damaged ligaments. The treatment causes an inflammatory response which causes the growth of new and stronger ligaments. After the initial treatment, the patient was informed to refrain from all vigorous activity for 48 hours so as to not add any additional stress during that healing period, followed by no impact activities for two weeks.

The patient reported: “After two weeks of refraining from running, I gently eased back into my routine, seeing increased strength and decreased pain. Several months later, I had trained for and completed a half marathon, although with some SI pain. Another Prolotherapy treatment and several more months of smarter training, and I registered for and completed the marathon that I had fractured out of and was sidelined from almost exactly one year earlier. Arguably, 42.2 kms of impact is about as good a test as you will find anywhere to demonstrate the efficacy of a treatment.

In the two years since that pelvic fracture and subsequent Prolotherapy treatments, I have run four marathons, and competed in numerous other road races of varying distances, as well as several triathlons. After a year of continuous training, I required one isolated Prolotherapy treatment for the same SI joint. Considering the amount of stress I have put on it with my running if a minor tune-up is called for in order to keep me moving and being an active participant in my own life, then so be it.”

Prolotherapy may be an excellent treatment to help cause permanently strong tissue to form where a weakened sports injury exists. Prolotherapy stimulates the healing process and, therefore, decreases the length of time it takes for soft tissue sports injuries to heal. Prolotherapy, because it triggers the growth of normal collagen tissue, causes stronger ligaments and tendons to form. Consequently, the athlete returns to his or her game stronger. After Prolotherapy treatments, not only is the athlete able to return to the sport but often the particular area that was injured will be stronger than before the injury and performance will be enhanced.

Platelet Rich Plasma Injections for Piriformis Syndrome

  • PRP treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets from your blood into areas of chronic joint and spine deterioration.
  • Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma. Platelets play a central role in blood clotting and wound/injury healing.

An August 2021 paper in the Journal of Back and Musculoskeletal Rehabilitation (18) describes patient outcomes following PRP injections for Piriformis syndrome.

“Piriformis syndrome is the common entrapment neuropathy causing buttock pain. Patients are conventionally treated with lifestyle modification, exercise, non-steroidal anti-inflammatory drugs, corticosteroid, or botulinum toxin injections. However, some patients may not respond to these conventional treatment methods.”

The researchers noted that Platelet-rich plasma (PRP) injection has been shown to be beneficial in various muscular injuries, but its effects have not yet been investigated in piriformis syndrome. The aim then of this study was to explore the effect of PRP on pain and functional status in patients with piriformis syndrome.

To do this, the study authors selected 60 patients with piriformis syndrome and randomly separated them into two groups (PRP and control groups).

  • All patients received one session of either PRP or saline injection performed under ultrasound guidance.
  • The researchers found: “Ultrasound-guided PRP injection provided greater improvements in both pain and functional status in patients with piriformis syndrome, starting in the early period after treatment. A repeat injection might be needed for a long-term effect.”

For more information on the combined use of PRP and Prolotherapy please see Prolotherapy treatments for lumbar instability and low back pain.


The various treatment options for Piriformis syndrome are presented here. Many patients have found success with conservative care options other than surgery. If you have read this article is very likely that you have not yet found your success. If you have questions about Piriformis muscle syndrome treatment, get help and information from our Caring Medical Staff

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This page was updated February 13, 2024


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