Dry Needling for Piriformis Syndrome

What is piriformis syndrome

Refers to a series of symptoms mainly including sciatic nerve pain caused by the stimulation or compression of the sciatic nerve and other sacral plexus nerves, as well as buttock blood vessels, caused by acute or chronic damage to the piriformis muscle, resulting in swelling, spasms, hypertrophy, and other symptoms related to the piriformis muscle.

Local anatomy

the piriformis muscle originates from the upper surface of the pelvic area of the lateral side of the anterior foramen of the 2nd, 3rd, and 4th sacrum, and terminates at the greater trochanter of the femur.

Tender point treatment

Fixed point: the patient is in a lateral position with the lower extremity straight and the affected limb flexed upwards. The body is slightly tilted forward to make the affected knee rest on the bed, and the deep tenderness point is found in the projection area of the piriformis muscle on the body surface.

Take a point about 1.5cm above and below the midpoint of the line connecting the posterior superior iliac spine and the coccyx tip, respectively. The area formed by the triangle composed of these two points and the tip of the greater trochanter of the femur is the projection area of the piriformis muscle on the body surface.

The common tender points are as follows: 

1. the midpoint of the line connecting the posterior superior iliac spine and the tip of the coccyx,

2. a point located at the middle third of the line connecting the above point to the tip of the greater trochanter,

3. a point located at the outer third of the above line,

4. the attachment point of the piriformis muscle at the greater trochanter.

Indeed, the second and third points are located based on specific symptoms of the patient, and finding the tender points can provide a more accurate diagnosis and treatment for piriformis syndrome.

Direction

Dry needling should be in line with the course of the sciatic nerve, and the needle body should be perpendicular to the buttocks plane. 

Procedure

Release the starting point of the piriformis muscle: at the projection of the outer side of the sacrum where the piriformis muscle is located, use dry needling to penetrate to the outer edge of the sacrum and then loosen the piriformis muscle close to the anterior surface of the sacrum with a shovel-like movement. As the thickness of the piriformis muscle is up to 2-2.5cm, nerves are less likely to be damaged. 

1. Release the tender point or treatment point most commonly found: located in the middle of the piriformis muscle (GB30), usually reaching a cord-like enlarged and hardened area deep in the gluteus, and pain radiating down the lower limb. After the needle tip pierces the skin, the needle is inserted by touching the skin, and electric or avoidance reactions may occur if the needle touches nerves or blood vessels, so the needle should be lifted up 2-3cm and inserted again towards a slightly different angle until the needle reaches the lesion site in the piriformis muscle.

2. Release the midpoint of the line connecting the ischial spine and the tip of the coccyx: insert the needle into the dorsum of the sacrum, penetrate along its edge for about 0.5cm, reach the piriformis muscle bundle, cut off part of the tense muscle fibers. Then tilt the needle body towards the lateral side, insert the blade about 0.3cm close to the inner side of the sacrum, and longitudinally clear and peel it off. 

3. When the piriformis muscle is adhered to the hip joint capsule, dry needling can be performed at the painful area one-third outward from the piriformis muscle's surface projection area. The needle is inserted by touching the skin. When the patient complains of acid and swelling under the needle, the needle is usually entering the joint capsule, and it can be peeled off longitudinally and transversely until the needle is removed. 

4. When there is tenderness at the attachment of the piriformis tendon to the tip of the greater trochanter, dry needling can be performed there. Insert the needle perpendicular to the bone surface at the tip of the greater trochanter, reach the bone surface, clear and peel it off longitudinally, and swing the needle body horizontally. If necessary, the angle of the needle can be adjusted to make it perpendicular to the direction of the tendon fibers, and part of the tendon can be cut off.

Dry needling treatment: The patient lies prone with a pillow under the abdomen, the lumbar spine is extended, and a fixed point is located 2 inches outside the posterior superior iliac spine. The area is routinely disinfected, draped with a surgical sheet, and subjected to local anesthesia. After the skin is opened at the fixed point, a long dry needle is selected and bluntly relieved along the direction of the piriformis muscle in the superficial fascia layer, and the external oblique muscle of the ilium is relieved vertically. 

The needle is then retreated subcutaneously and bluntly relieved towards the deep layer of the piriformis muscle, guided by nerve feedback.

Finally, cupping is applied at the needle site and a post-operative patch is applied.

Massage treatment for the piriformis muscle

Pressure and massage are applied to the starting and ending points of the piriformis muscle, and can also be applied while stretching the piriformis muscle.

Stretching the piriformis muscle

The patient lies supine, the hip and knee joints on the treatment side are flexed, the therapist holds the knee and maximally flexes the hip joint while externally rotating it 45 to 60 degrees, and gently presses down to prevent the hip from lifting; the other hand is placed at the end of the muscle and pulls the piriformis muscle towards the muscle belly. 

Note

Although the piriformis muscle has external rotation function, it does not internally rotate the hip during stretching, mainly because the piriformis muscle becomes an internal rotator when the hip joint is flexed more than 90 degrees (according to analysis based on the starting and ending points of the piriformis muscle).