A Case Report of Deep Gluteal Syndrome Secondary to Piriformis Enthesopathy Successfully Treated With Ultrasound-Guided Dextrose Prolotherapy

Background: Piriformis syndrome is a neuromuscular disorder caused by compression of the sciatic nerve by the piriformis muscle, leading to buttock pain radiating to the lower extremity. Pharmacological management generally includes nonsteroidal anti-inflammatory drugs and drugs for neuropathic pain, but long-term use may result in adverse effects. Therefore, nonpharmacological management such as acupuncture may be considered. Case: A 28-year-old male presented with right buttock pain radiating to the right calf for 2 years, aggravated by prolonged sitting, standing, and walking. FAIR, Pace, Freiberg, and Beatty maneuvers were positive. The patient was treated on an outpatient basis using manual acupuncture on body points and ear acupuncture using Battlefield Acupuncture points twice weekly for six sessions. Outcome measures included the Numeric Rating Scale (NRS), the Oswestry Disability Index (ODI), and hip abduction range of motion (ROM). Results: After six sessions of therapy, NRS improved from 5 to 0, ODI from 24.4% to 0%, and hip abduction ROM from 18° to 45°. Conclusions: Manual acupuncture and auricular acupuncture may contribute to symptom improvement in piriformis syndrome. However, the observed benefit in this case cannot establish clinical efficacy because a single case report does not determine causality, and symptom improvement may also have been influenced by avoidance of aggravating activities.

The sciatic gliding space.

Effectiveness of Integrated Neuromuscular Inhibition Technique (INIT) and ELDOA Technique on Piriformis Syndrome

Background: Piriformis syndrome is a painful condition caused by compression or irritation of the sciatic nerve by the piriformis muscle. This study aims to determine the effect of the addition of Integration Neuromuscular Inhibition Technique (INIT) on reducing pain in piriformis syndrome patients. Research Method: is a quasi-experimental design with a pre-test and post-test control group, the sampling technique uses purposive sampling with criteria. A total of 42 respondents were divided into two groups, namely 21 respondents in the treatment group and 21 samples in the control group. The level of pain was measured using NRS. Results: the study showed that the average pain in the treatment group decreased from 7.95 ± 1.36 to 5.05 ± 1.65, while in the control group decreased from 7.71 ± 1.19 to 6.10 ± 1.44. The paired t-test showed a significant decrease in pain in both groups with a p value = 0.000. The results of the independent t-test showed a significant difference between the two groups (p = 0.015). Conclusion: The addition of INIT to TENS and Ultrasound significantly reduced pain in piriformis syndrome at Pandeglang Regional Hospital.

IntroductionPiriformis syndrome is the compression or the irritation of the sciatic nerve by the adjacent piriformis muscle. Among surgical options, endoscopic (minimally invasive) and open techniques are the most commonly employed. However, debate persists regarding the superiority of one approach over the other in terms of clinical outcomes, pain relief, recovery time, and complication rates.MethodsA comprehensive literature search was conducted through databases including: Scopus, ScienceDirect, PubMed, and relevant gray literature to identify studies comparing endoscopic and open surgical techniques for the treatment of piriformis syndrome. The search strategy utilized a combination of keywords, including: “piriformis syndrome”, “minimally invasive”, and “open surgery”. The Joanna Briggs Institute (JBI) Critical Appraisal Tool was used to evaluate the quality and potential bias. Data extraction and quality assessment were performed independently by two reviewers to ensure objectivity. The analyzed primary outcomes were reductions in pain (Visual Analogue Scale) and improvements in function (Harris Hip Score and International Hip Outcome Tool). Additionally, complication rates were recorded as a secondary outcome.ResultFrom total of 163 studies, nine studies with total of 683 patients (455 Patients with piriformis syndromes) were included, consisting of nine cohort studies and ten case reports. In the endoscopic surgery, with 415 pyriformis syndromes patients, the VAS score decreased in seven studies (Mean decreased VAS 5.10 (95% CI: 4.65 - 5.55)), the HHS score increased in four studies (Mean increased HHS 23.70 (95% CI: 40.30 – 7.30)), and the iHOT score increased in one study. In open surgery, with 40 pyriformis syndromes patients, explained the decrease in VAS score decreased and complete resolution at the end of follow-up. However, the evidence on functional improvement was more limited. The overall quality of evidence was good.ConclusionEndoscopic surgery appears to be an effective and safe treatment option for patients with piriformis syndrome. It demonstrates favourable outcomes in terms of pain reduction and functional improvement, while also being associated with fewer complications compared to open surgery. These findings support the growing preference for endoscopic approaches in managing this challenging condition.Keywords: Piriformis Syndrome, Endoscopic Surgery, Visual Analogue Score, Harris Hip Score

Comparative Effects of Neural Mobilization of Sciatic Nerve Versus Stretching Among Patients with Piriformis Syndrome: A Randomized Clinical Trial

INTRODUCTION. Piriformis syndrome is one of the most common nosologies encountered by doctors of various specialties. It significantly reduces patients’ quality of life and leads to the formation of an suboptimal motor stereotype accompanied by persistent pain. Early diagnosis and adequate manual and physiotherapeutic correction are difficult due to the lack of generally recognized morphological diagnostic criteria. AIM. To determine the possibilities of a therapeutic and diagnostic algorithm involving the method of functional (manual) muscle testing based on the developed methodology for examining patients with lower back pain, including those afflicted with various myofascial pain syndromes in the lower extremities. MATERIALS AND METHODS. Between July 2024 and June 2025 37 patients were under observation (F = 1.04, p 0.01) — 18 (48.65 ± 4.86 %) women and 19 (51.35 ± 5.14 %) men aged 18 to 52 (34.64 ± 3.46) years with the final clinical diagnosis “piriformis syndrome. G57.0”; The history of the disease ranged from 0.12 to 1.24 (0.51 ± 0.06) years. Each patient was supposed to assess his or her pain syndrome on a visual-analog scale (VAS) of pain from 0 to 10 points. The doctor consistently performed: 1) visual diagnosis of the patient’s postural balance; 2) flexion test; 3) functional (manual) muscle testing of the indicator muscle (anterior [clavicular] portion of the deltoid muscle) in the patient; 4) assessment of the functional state of muscle contraction (hypo-, normal- or hyperreaction); 5) selection of aromatherapy to achieve normoreaction muscle contraction in the patient; 6) functional (manual) muscle testing of the piriformis muscles on both sides of the patient; 7) following the establishment of the side of the fascial shortening of the piriformis muscle, the patient was positioned supine with flexion of the shin in the knee joint. Thereafter, its postisometric relaxation was performed according to Professor V.P. Veselovsky’s methodology. RESULTS AND DISCUSSION. Hyporeaction was detected in 59.45 ± 5.95 %, and hyperreaction in 40.54 ± 4.05 % of cases. After correction, normoreaction of muscle contraction of the tested muscles was achieved in all observed patients and pain reduction during postisometric relaxation of the affected muscle in 86.49 ± 8.65 % of cases. CONCLUSION. The use of functional (manual) muscle testing as an express method of early detection of muscle tissue dysfunction has shown its effectiveness in all subjects diagnosed with piriformis syndrome, who have subsequently developed neuropathies.

Introduction: The present review of literature has been undertaken to discover the “effect of Active Release Technique (ART) in improving the fl exibility in patients with piriformis syndrome”. Piriformis syndrome is a musculoskeletal ailment that causes discomfort. The piriformis muscle spasms and becomes infl ammed as a result of long sitting positions, causing a persistent mechanical defect that eventually compresses the sciatic nerve and causes aches that radiate down the leg. Aim: To identify the effect of active release technique to improve fl exibility in patients with piriformis syndrome. Materials and Methods: Using PubMed, Google Scholar, Research Gate, and Scopus, database searches were performed. The keywords: Piriformis, piriformis syndrome, pain, ART in piriformis syndrome, prevention and intervention of piriformis syndrome, range of motion, fl exibility were searched. Articles released within the year 2019-2025 were selected. Languages apart than English were not included. The study encompassed both male and female sexual groups. Data is extracted from proportion of clients in various systematic review and randomised controlled trials. Result: Numerous studies have been conducted individually and on comparison to see the effect of active release technique in reducing pain and improving fl exibility in piriformis syndrome. This technique plays a signifi cant role in reducing pain, improving fl exibility, increasing the functional range of motion and promoting long term relief. However, it is often recommended to combine the use of ART with other physical therapy techniques such as stretching, strengthening, and posture correction. Conclusion: ART has proven to be signifi cantly better when compared to other techniques in reducing pain, improving the fl exibility and range of motion.

Piriformis syndrome (PS) is a sciatic nerve entrapment condition caused by compression by the piriformis muscle, often presenting with symptoms that mimic lumbar radiculopathy and gluteal and buttock pain. This narrative review explores its diagnostic challenges and highlights the role of advanced imaging techniques in improving diagnostic accuracy. Literature suggests that PS may account for 5% to 8% of low back pain cases, frequently manifesting as buttock pain exacerbated by sitting or hip motion. Traditional imaging often fails to detect PS due to nonspecific findings, but magnetic resonance neurography can reveal sciatic nerve inflammation. A multimodal approach combining clinical assessment with targeted imaging enhances diagnostic precision and guides effective management of PS.

Rationale:Piriformis syndrome (PS) is a neuromuscular condition in which irritation or dysfunction of the piriformis muscle leads to compression of the sciatic nerve, resulting in radiating pain in the buttock and lower limb. Accurate diagnosis is often complicated by the clinical overlap between PS and other neurologic conditions such as lumbar radiculopathy or sciatica, as these disorders may present with similar symptomatology.Patient concerns:This case report describes the diagnosis and treatment of PS in a 37-year-old male military pilot. The patient had a history of lumbar disc herniation and experienced an acute tingling sensation in his left lower extremities following a high gravitational force (G-force) flight sortie.Diagnoses:PS was diagnosed based on ultrasonographic findings, which revealed a piriformis muscle thickness of 1.03 cm.Interventions:The patient initially underwent a blinded trigger point injection targeting the left piriformis muscle, which yielded partial pain relief. Nevertheless, due to ongoing radiating pain in the lower extremity, the patient was referred to a tertiary outpatient clinic, where an ultrasound-guided injection into the piriformis muscle was subsequently performed.Outcomes:An ultrasound-guided piriformis injection was administered, leading to a significant decrease in pain and enabling the patient to resume flight sorties.Lessons:This case highlights the importance of accurately diagnosing and treating PS in patients with lumbar disc herniation and suggests that ultrasound-guided piriformis injection can be an effective treatment method.

Comprehensive Management of Piriformis Syndrome With Endoscopic Release and Sciatic Neurolysis Provides Favorable Outcomes and Low Complication Rate.

Piriformis Syndrome (PS) is caused by the sciatic nerve compression in the gluteal region causing pain, tingling and numbness in the buttock and the nerve pathway down to lower thigh and into leg. Diagnosing PS is quite difficult and is often misinterpreted. So, there is a need to identify various clinical diagnostic tests and their accuracy. To explore different clinical diagnostic tests, criteria and their psychometric properties for diagnosing PS. Total 516 fulltext published articles were identified from PubMed, Scopus and Science Direct from 2012-2024. Only full text prevalence/incidence, review articles and observational studies on individual with PS were included. After duplicate deletion from Mendeley, 225 articles were left to screen at title and abstract level. Finally, 26 full text articles related to research topic were further analysed at full-text level. Out of which only 5 articles were selected and included in the review for analysis. Various clinical diagnostic tools including FAIR, Beatty test, Hand on Hip sign, SLR, active piriformis and seated Piriformis stretch test are available defined to be reliable and valid measures for the study.The SLR had sensitivity of 0.15, specificity of 0.95, Active piriformis test had sensitivity of 0.78, specificity of 0.80, Seated piriformis stretch test had sensitivity of 0.52, specificity of 0.90, the FAIR test had sensitivity and specificity of .88 and .83, HHS was found to have a sensitivity of 86% and a specificity of 75%. We found two clinical criteria also in which one is utilising clinical symptoms and diagnostic imaging to diagnose PS while another one took into account clinical symptoms, clinical diagnostic tests, aggravating and relieving factors to diagnose PS. The scoping review concludes that various clinical diagnostic tests, like Flexion, Adduction, Internal Rotation (FAIR), Beatty maoeuver, Straight Leg Raise (SLR), active piriformis test and seated piriformis stretch test are sensitive and specific tools in diagnosing PS.

Background and aimSciatica is commonly attributed to nerve root compression due to disc herniation, foraminal stenosis, or spondylolisthesis, which are well-recognized causes of the condition. However, non-discogenic causes, such as inflammatory disorders, including axial spondyloarthritis, remain underrecognized and contribute significantly to the pathophysiology of sciatica. "Rafe’s sciatica," proposing a distinct subtype of sciatica linked to spondyloarthritis (SpA), is one such example. Other types of sciatica share clinical characteristics with this condition, such as piriformis syndrome, which can also involve sacroiliitis and sciatic nerve entrapment. This study aimed to identify and characterize Rafe’s sciatica as a novel, non-discogenic sciatica subtype associated with SpA, and to explore its diagnostic and clinical implications.MethodsA prospective case series of 41 patients with sciatica and suspected SpA was conducted at the Government Employees' Hospital in Dhaka, Bangladesh, from November 2022 to July 2023. The purposive sampling technique was applied to recruit patients who met the inclusion criteria. No blinding was applied. Data were collected through structured interviews and medical records. The Assessment of Spondyloarthritis International Society (ASAS) and Amor criteria guided SpA diagnosis. Enthesitis was assessed clinically and via ultrasound. Sacroiliitis was diagnosed using X-ray and magnetic resonance imaging findings, including bone marrow edema, synovitis, and subchondral sclerosis. Metabolic causes were excluded biochemically. Ethical approval for the study was obtained from the Institutional Review Board of the Government Employees’ Hospital, and informed consent was obtained from all participants prior to inclusion.ResultsThe average age of the patients was 39 years, with a predominance of females (31, 75.6%). Imaging studies revealed that 35 (85.4%) patients had sacroiliitis, a key feature of SpA, and 12 (29.3%) patients tested positive for the human leucocyte antigen (HLA)-B27 genetic marker, which is commonly associated with inflammatory disorders. Clinically, 35 (85.4%) patients reported persistent low back pain and exhibited sacroiliac joint tenderness, while morning stiffness lasting more than 30 minutes was observed in 28 (68.3%) patients. Additionally, dactylitis was present in 21 (51.2%) patients. Almost all patients had positive results from the FAIR (flexion, adduction, and internal rotation), modified FAIR, and piriformis stretch tests, which further indicated a link to SpA.ConclusionRafe’s sciatica appears to represent a novel, non-discogenic sciatica subtype associated with SpA. Recognition of this condition may improve diagnostic accuracy and patient management by emphasizing the role of clinical markers and imaging in identifying inflammatory causes of sciatica. While our findings highlight its potential clinical relevance, further validation through larger, comparative studies is essential to refine diagnostic criteria and develop effective treatment strategies.

Effect of ultrasound-guided acupotomy nerve stimulation combined with sinomenine injection in site-directed interventional treatment of piriformis syndrome: a randomized controlled study

Background/Objective: Piriformis syndrome (PS) causes sciatic nerve entrapment and chronic pain. In refractory cases, pulsed radiofrequency (PRF) and endoscopic piriformis release (EPR) are used, but comparative evidence is limited. Methods: This retrospective cohort study compared PRF and EPR in patients treated from 2018 to 2024 at a tertiary hospital using propensity score matching (PSM). Patients with PS, unresponsive to conservative treatment (≥3 months), were included. PRF targeted the sciatic nerve under imaging guidance; EPR involved endoscopic decompression. Primary outcomes were Numeric Rating Scale (NRS) scores at 3 and 6 months. Secondary outcomes included patient satisfaction, reintervention rates, complications, and the Oswestry Disability Index (ODI), where available. After PSM, 115 patients were analyzed per cohort. Multivariate regression identified the predictors of pain improvement. Results: From 465 eligible patients (PRF 350; EPR 115), after PSM, 230 patients were analyzed (115 per cohort). The baseline NRS score was 7.4 ± 1.4 (PRF) vs. 7.5 ± 1.3 (EPR). At 3 months, EPR showed a lower NRS score (2.6 ± 1.3) compared to PRF (3.2 ± 1.6; p = 0.032). At 6 months, the EPR NRS score was 2.2 ± 1.1 vs. 2.9 ± 1.5 for PRF (p = 0.018). EPR had a higher rate of ≥50% NRS score reduction (78% vs. 65%; p = 0.041). EPR patients reported higher satisfaction and fewer reinterventions but more complications. Regression analysis identified EPR (OR = 2.15), higher baseline NRS scores, and shorter symptom duration as predictors of improvement. Conclusions: EPR provided superior pain relief compared to PRF at 3 and 6 months, although with a higher risk of complications. PRF remains a safer initial option.

BackgroundDeep gluteal syndrome (DGS) involves extrapelvic entrapment or irritation of the sciatic nerve (SN) within the deep gluteal space, often mimicking S1 radicular syndrome. Accurate differentiation between DGS and true nerve root pathology is essential for effective treatment. This study aimed to distinguish DGS from nerve root affections and identify the causes of symptoms in individuals with suspected DGS using a comprehensive multi-modal evaluation, including advanced diagnostic techniques.MethodsNineteen subjects (13 females, 6 males, mean age of 36.8±10.9 years, range 23–65 years) with unilateral gluteal pain radiating to the S1 dermatome for at least three months and symptoms exacerbated by prolonged sitting were evaluated. All underwent 3T magnetic resonance imaging (MRI) (Siemens MAGNETOM VIDA) for standard spine and pelvis imaging, diffusion tensor imaging (DTI) of the lumbosacral plexus (LSP) and SN, electromyography (EMG) of the H-reflex circuit with positional maneuvers, and clinical tests targeting DGS.ResultsNerve root contact was demonstrated in only two subjects on the pathology side. Morphological findings on standard MRI with the potential to cause DGS symptoms were inconsistent. Surprisingly, narrowing between the ischium and lesser trochanter of the femur was found in 42% on the symptomatic side. Statistically significant higher mean diffusivity (MD) (P=0.023), radial diffusivity (RD) (P=0.038), and axial diffusivity (AD) (P=0.026) values were observed on the symptomatic side of the SN, indicating edema and microstructural changes. No significant differences were noted in fractional anisotropy (FA) (P=0.913) and normalized quantitative anisotropy (NQA) values (P=0.778). No changes in diffusivity were observed at the LSP level. Twelve subjects (63%) showed increased latency (>1.2 ms) or complete disappearance of the H-reflex when using modified muscle position/activation on the symptomatic side. Clinical tests showed inconclusive results.ConclusionsAdvanced diagnostic tools such as DTI and EMG combined with positional maneuvers can help identify DGS when standard imaging and clinical tests are inconclusive. Elevated diffusivity values in the symptomatic SN suggest possible edema and structural changes, supporting the utility of a multimodal approach for accurate diagnosis and treatment of DGS.

Background: Piriformis syndrome is a neuromuscular disorder causing pain and mobility limitations due to sciatic nerve compression. This study compares post-isometric relaxation and strain counterstrain techniques to determine which approach provides superior pain relief, mobility improvement, and functional recovery in affected patients. Objective: To evaluate the comparative effects of the post-isometric relaxation technique and strain counterstrain in patients with piriformis syndrome. Methodology: Single-blinded, randomised clinical trial with clinical trial ID No. IRCT2024718062453N1 was conducted. Participants were selected from the outdoor patient department of Allied Hospital, National Hospital, Faisalabad, from February to June 2024. The study included 66 participants using convenient sampling, both male and female, between the ages of 30-50 years. Group A received post-isometric relaxation therapy while Group B received strain counterstrain therapy three times a week for four consecutive weeks. Both groups also received conventional therapy, which included the application of a hot pack to the gluteal area for 15 minutes. Pain was assessed by the Numeric Pain Rating Scale, while hip abduction and internal rotation range of motion were measured through a universal goniometer and functional activity was assessed by the Lower Extremity Functional Scale before and after four weeks of treatment. Within and between-group analysis of pain and range of motion was done using the Wilcoxon Signed-Rank and Mann-Whitney U tests respectively. Results: Overall, the findings of the randomized clinical research highlight the advantages of post-isometric relaxation against strain counterstrain in the treatment of piriformis syndrome. Patients who had post-isometric relaxation treatment showed significant decreases in pain, increased range of motion, and reduced impairment (p<0.05). Conclusion: Post-isometric relaxation demonstrated superior efficacy in reducing pain, improving range of motion, and enhancing functional recovery in patients with piriformis syndrome compared to strain counterstrain. These findings support post-isometric relaxation as an effective therapeutic approach for managing musculoskeletal impairments associated with piriformis syndrome.

Background: Piriformis syndrome is characterized by pain due to compression of the sciatic nerve by the pressure of the piriformis muscle, leading to discomfort in the buttocks, sciatica, or a combination of both. Physical therapy is regarded as a crucial intervention for individuals experiencing piriformis syndrome. Objective: To evaluate the effectiveness of myofascial release technique in addition to conventional physical therapy on the pain, range of motion and functional disability in patients with piriformis syndrome. Methodology: A total of 46 patients (20 males and 46 females) who had been pre-diagnosed with piriformis syndrome by an orthopedic physician were evaluated at Surriya Azeem Surgical Hospital in Pattoki. After meeting the inclusion criteria, the participants were assigned randomly to two groups; one received standard physical therapy while the other was given myofascial release techniques in addition to conventional physiotherapy. The exclusion criteria encompass any injury of the lower extremity, lumbar radiculopathy, any systemic disease, sacroiliac joint dysfunction, lower extremity fractures, any congenital deformity, and any cognitive issues. The outcome measures like range of motion, pain, and functional disability were evaluated utilising the numerical pain rating scale, a goniometer, and the Lower Extremity Function Test, respectively. Data collection occurred at baseline, following six sessions, and again after twelve sessions. The non-parametric Friedman test was used for between-group analysis, and the Mann-Whitney U test was used for within-group analysis. Results: The average rank for the numeric pain rating scale at baseline, 6th and 12th sessions was 2.50, 2.35, and 1.15, respectively (p=0.00). The average rank of external rotation and abduction for baseline were 4.55 and 6.87 for the 6th session, 6.32 and 8.21, and for the 12th session were 6.32 and 8.21, respectively, (p=0.00). The average rank for LEFS at baseline, 6th and 12th sessions was 6.95, 9.08, and 10.19 (p=0.000). Based on the results, conventional physical therapy demonstrated a significant difference in pain, range of motion and functional disability at different sessions. Conclusion: Myofascial release, along with conventional physical therapy, is notably effective in relieving pain, enhancing the range of motion, and decreasing functional disability.

Background: Piriformis Syndrome is a neuromuscular disorder characterised by pain and/or numbness in the buttock area caused by the compression or irritation of the sciatic nerve by piriformis muscle tightness. Early diagnosis and treatment of piriformis tightness are crucial to preventing long-term complications and improving the quality of life for individuals. Objective: to determine the prevalence of piriformis tightness and to determine the impact of piriformis tightness on physical activity and quality of life among undergraduate City University students. Methodology: The study was a cross-sectional design conducted at City University, Peshawar, Pakistan, with a sample size of 329 participants selected through non-probability convenient sampling. Ethical approval was obtained from the Research Committee of City University of Science and Information Technology. Inclusion criteria included undergraduate students aged 18-26 and those who are willing to participate, while exclusion criteria covered recent trauma, surgery in low back and lower limbs, psychological issues, lower limb disability, and lumbar radiculopathy. Tools used in the study were piriformis stretch test, numeric pain rating scale, and international physical activity questionnaire. Data was analyzed using SPSS version 26. Qualitative variables were calculated as frequency and percentages. Chi-square test was used to analyze the correlation between variables. The p-value ≤0.05 was considered statistically significant. Results: In a sample size of 329, 165 (50.2%) were males and 164 (49.8%) were females. The pain intensity among these participants was also distributed into different categories such as no pain, mild pain, moderate pain, and severe pain. The mild pain category had the highest frequency with 123 participants representing 37.4%% of the total sample. According to IPAQ score of the participants, the participants who are performing moderate physical activity had the highest frequency accounts for (54.4%). The mean sitting hours of the participants is 10.79±3.12. Conclusion: In conclusion, the prevalence of piriformis tightness and its impact on physical activity and quality of life are high among undergraduate university students, as a significant association was found between piriformis tightness and physical activity.