Piriformis muscle injections are done with the help of fluoroscopic guidance. The fluoroscope is an x-ray machine that allows the doctor to actually see an x-ray image while doing the procedure. This allows the doctor to watch where the needle goes as it is inserted. This makes the injection much safer and much more accurate. Once the needle is in the right location, a small amount of radiographic dye is injected. This liquid dye shows up on the x-ray image and the doctor can watch where it goes. The medication used for the injection will go in the same place, so the doctor wants to make sure that the medication goes to the best place to do the most good. Once the correct position is confirmed, the medication is injected and the needle is removed.
You will then be taken out of the procedure room to the recovery area. You will remain in the recovery area until the nurse is sure that you are stable and have not had an allergic reaction to the medications. The anesthetic may cause some temporary numbness and weakness. You will be free to go when these symptoms have resolved.
After Care
What happens after the procedure?
If everything goes as planned, you will be able to go home soon after the injection, probably within one hour. As with most types of pain injections, you will likely not have any restrictions on activity or diet following the procedure.
Seeing as the piriformis injection is mainly a diagnostic injection, your healthcare professional will be interested in how much the pain is reduced while the anesthetic, or the numbing medication, is working. You may be given a pain diary to record what you feel for several hours after the injection. You should rate your pain on a scale of 0-10 during this time, with 0 being no pain, and 10 being the worst pain you have ever felt. Tracking your comfort level while the anesthetic is still working is important for making decisions regarding the next steps in treatment for your pain, so keep close track of any discomfort as best you can.
Most doctors will arrange a follow-up appointment, or phone consult, within one or two weeks after the procedure to see how you are doing and what effect the procedure had on your symptoms.
It is recommended that you begin to see a physiotherapist at Interactive Health Physiotherapy & Massage after your injection (if you haven’t seen one before), or return for further treatment with your usual therapist if you have already been working with one.
Post-injection Rehabilitation
Treatment at Interactive Health Physiotherapy & Massage after a piriformis injection can begin as soon as your doctor allows it. Each doctor will set their own time frames for beginning therapy based on their personal experience, and also based on how your body has reacted to the injection.
If the injection has relieved some or all of your discomfort then, if possible, it is useful to begin treatment at Interactive Health Physiotherapy & Massage during the period where you are in less pain. This time frame allows your physiotherapist to take advantage of the pain-free period to stretch your piriformis muscle and to set you up on an individualized home exercise program of stretching and strengthening.
In order to help lengthen and relax a tight or contracted piriformis muscle your therapist may use hands on massage or stretching techniques as well as warm hot packs and electrical modalities such as ultrasound, interferential current, or electrical muscle stimulation. In some cases of lingering pain, ice may also be useful. If your therapist practices a type of needling, such as acupuncture or intramuscular stimulation, then they may also use this technique to assist with your pain and to help release any muscle tension.
Your physiotherapist will prescribe a series of stretching exercises for your hip, buttocks, thigh, low back and, if necessary, your calf. They will also assess the motion of your hip joint. Any tightness in the muscles around the hip and knee or restricted motion in the hip joint itself can affect the biomechanics of the trunk and lower limb, including the tension in the piriformis muscle, so this will need to be addressed. In particular your therapist will encourage you to specifically stretch your piriformis muscle by sitting in a chair or on the ground and crossing the ankle of your affected side over your other knee. By applying gentle pressure downwards on the inside of your thigh of the affected side, while simultaneously sitting up tall (gently tilting your pelvis forward) you will be stretching your piriformis. Your therapist can advise you depending on your individual situation about how often you should be stretching your piriformis muscle and for how long you should hold each stretch. In general doing a long, steady hold of the piriformis stretch will improve flexibility of the piriformis muscle as well as improve the external rotation motion at your hip.
The cause of the initial spasm of your piriformis muscle will need to be investigated by your therapist. In order to assess this they will want to look at your overall posture in standing and sitting and may ask you to do activities like walk, jump, go up or down stairs, or squat on one leg in order to determine your particular pattern of motion and to assess which muscles may be weak or overbearing. In particular the alignment of your pelvis and lower limb will be assessed. Your hip joint, including the piriformis muscle along with the deep gluteal muscles, help to control the position of your lower limb as well as your pelvis. If your muscles are tight or weak they can alter your alignment and biomechanics and if your biomechanics or alignment are off, this can affect the tension in your piriformis muscle.
Your physiotherapist will also assess the motion in your lumbar spine and pelvis as well as the ability of your core muscles to control the trunk. Due to the close proximity of the piriformis muscle to the low back area as well as the relation of the spinal nerves leaving the low back and then forming the large sciatic nerve (which, as explained above, passes near or through the piriformis muscle) this area needs to closely be assessed for its contribution to your dysfunction in the piriformis muscle. If your low back is stiff or degenerating at the joints this can irritate the nerves in the low back or alter the biomechanics of the spine causing the piriformis muscle to become tight. Alternatively a loose (hypermobile) low back joint can also alter the biomechanics of the low back and trunk causing the piriformis to tighten. Often by changing the overall biomechanics of the trunk and lower extremities the piriformis muscle is relieved of excess strain and your pain eases. You therapist will provide advice regarding your individual biomechanics and how you can improve them in your daily activities of work and play.
Having a weak core muscle area can have a similar effect on the lumbar and trunk biomechanics as a stiff or loose lumbar spine and can also lead to pain in the piriformis muscle. Core-strengthening exercises will be crucial to your rehabilitation after a piriformis injection. Your therapist may start these exercises by first just teaching you how to activate the deep muscles that support the spine and trunk. This is done by gently pulling the muscles inwards as you sit or lie on the bed. Pain and injury can make these muscles much less effective and difficult to activate so learning to use them may not be easy at first; the feedback from your physiotherapist regarding technique will be crucial.
As you improve in your control of your core muscles then more difficult exercises such as ones where you are moving your arms or legs while you keep your trunk steady, will be prescribed in order to challenge this area. Lastly, improving the endurance of your core area will be of focus.
Generally the rehabilitation we provide at Interactive Health Physiotherapy & Massage after piriformis injections goes very well. If, however, your therapy is not progressing as your therapist believes it should, we may send you back to your doctor for another consult regarding further management of your pain. It is important to remember, however, that injections are not usually a cure for your pain; they are only a part of your overall pain management plan.
Interactive Health Physiotherapy & Massage provides services for physiotherapy in Crowfoot NW.
Complications after piriformis injection
What might go wrong?
Piriformis injection procedures are safe and unlikely to result in a complication, but no procedure is 100% foolproof. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Complications are uncommon, but you should know what to watch for if they occur.
Allergic Reaction
Like most procedures where medications are injected, there is always a risk of allergic reaction. The medications that are commonly injected include lidocaine, bupivicaine, radiographic dye, and cortisone. Allergic reactions can be as simple as developing hives or a rash. They can also be life threatening and restrict breathing. Most allergic reactions will happen immediately while you are in the procedure room so that help is available immediately. Most reactions are treated and cause no permanent harm. You should alert your doctor if you have known allergies to any of these medications.
Infection
Several types of infections are possible complications of piriformis injections. Any time a needle is inserted through the skin, there is a possibility of infection. Before any injection is done, the skin is cleansed with a disinfectant and the health care provider doing the injection uses what is called sterile technique. This means that the needle as well as the area where the needle is inserted remains untouched by anything that is not sterile. The provider may also use sterile gloves.
Infections can occur just underneath the skin, in the muscle, or in the deep tissues of the buttock. Signs of infection are increasing redness, swelling, pain, and fever. Almost all infections will need to be treated with antibiotics. If an abscess forms, then a surgical procedure may be necessary to drain the pus in the abscess as well as antibiotics to treat the infection.
Increased pain
Not all injections work as expected. Sometimes injections cause more pain. This may be due to increased spasm in the muscles around the injection site. The increased pain is usually temporary, lasting a few hours or a few days. Once the medication has a chance to work, the injection may actually perform as expected and reduce your pain. Increased pain that begins several days after the injection may be a sign of infection so if this occurs, alert your health care professional.
Portions of this document copyright MMG, LLC
