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Treatment algorithm:
1. pharmacological optimisation
a. small doses of NSAIDs for a short duration, weak opioids: dihydrocodeine, tramadol or Tramacet SR
b. small doses of gabapentinoids: gabapentin 100 mg tds or pregabalin 25-50 mg bd
c. muscle relaxants, baclofen 5mg bd-tds
2. injection-based treatment with local anaesthetic/depo steroid combination under image guidance, which is minimally invasive, is not destructive and can be repeated on recurrence of symptoms
3. physiotherapy with iliopsoas muscle stretches and core stability work which needs to follow the injection treatment
4. occupational therapy advice and lifestyle changes, as we need to treat the patient within their environment; correct the walking aids to avoid stooped posture, advise patients to sit on high standing chairs and avoid saggy sofas, install stair rails to aid mobility and prevent accidents
Follow up: At 4 months - 32% have full resolution of symptoms, 51% have 50% reduction of symptoms, 12% have 30% reduction of symptoms, but 5% will have no reduction of symptoms.
Iliopsoas syndrome is still under- recognised and under-treated. It is one of the few chronic pain conditions with good to excellent clinical outcomes for the patient and the treating physician alike.
Piriformis syndrome
Anatomy and physiology: The piriformis muscle (pear shaped muscle) is situated deep in the buttock stretching between the sacrum and the greater trochanter of the hip. It is the external rotator of the hip. The piriformis muscle is in close vicinity
to the sciatic nerve as it exits the pelvis. It is close to the pudendal nerve at its proximal part.
Diagnosis: This is clinical. Patients’ symptoms may include limping gait, pain on walking, sitting or standing, and lying down flat or on the affected side. Patients may be unable to sit on the affected
side or shift position from one buttock to another. Pain may radiate down the leg to the heel. Patients may be unable to cross the leg and one patient described the experience as if ‘sitting on iron balls’.
Figure 3: Piriformis muscle (red arrow) after retraction of gluteus muscle (blue arrow)
Treatment algorithm: This follows the one for iliopsoas syndrome:
1. pharmacological optimisation for musculo-skeletal, neuropathic and visceral pain should be started/ modified/optimised; short course
of NSAIDs, weak opioids as dihydrocodeine, Tramacet, tramadol, tapentadol, gabapentinoids in small doses (gabapentin100 mg tds, pregabalin 25-50 mg bd), muscle relaxants e.g.baclofen 5 mg bd-tds
or their combination will be decided according to the presenting symptoms
2. injection-based treatment under image guidance needs to follow in short succession and can be carried out as a day-case procedure; a combination of local anaesthetic/depo steroid initially is diagnostic, therapeutic and prognostic, and can be repeated on recurrence
3. intense physiotherapy with piriformis muscle stretches and sacroiliac joint mobilisation should follow in quick succession
4. occupational therapy issues must
be discussed with the patient and implemented with minimal delay; these include sitting on well-padded chairs, cushions on car seats, not sitting down for long, and not provoking the symptoms
Follow up: At 4 months - 87.5% of patients have full functional restoration with 80% reduction of pain.
Summary
Piriformis and iliopsoas syndromes present as myogenic neuropathic pain with visceral components in different proportions.
Accurate diagnosis and treatment lead to good or excellent clinical outcomes.
Self-management strategies are easy to implement and follow by patients.
EDUCATIONAL OFFERINGS
Dr Tzvetanka Ivanova-Stoilova MD PhD FRCA FFPMRCA
Consultant in Pain Medicine
St Joseph’s Hospital, Newport and Fitzrovia Hospital, London,
E: drivanova.stoilova@gmail.com
EDUCATIONAL OFFERINGS
Figure 4: Symptom distribution in piriformis syndrome
The pain phenotypes in these patients may be
1. neuropathic pain – described as ‘hot poker’, pins and needles, shooting, exploding
2. visceral pain - pelvic pain, deep vaginal or/and rectal pain
The patient symptoms could have started after falling on the buttock,
hip arthroplasty, any pelvic surgery (gynaecological, urological, lower gastro- intestinal tract), radiotherapy for pelvic tumours, recto-vaginal fistulas, or pelvic fractures.
The patient is usually unable to sit on the affected side and may limp. There is no true sciatica, tendon reflexes are normal, and sciatic stretch is negative.
The patient may experience severe pain on passive adduction of the hip, as this stretches the affected piriformis muscle.
Clinical examination: There may be tenderness on the sciatic notch at the buttock. The contours of the affected buttock may be different from the healthy one and atrophic change may be visible if the condition has been longstanding.
The sacroiliac joint on the affected side may be tender as well.
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