Deep gluteal pain

Specialty: Musculoskeletal.

• piriformis syndrome
• deep gluteal space syndrome
• non-disc sciatica

Why it occurs

• Compression of the sciatic nerve by the hypertrophic or spastic piriformis muscle
• Entrapment of the sciatic nerve in the subgluteal space by fibrous bands or adhesions
• Tendinopathy of the obturator internus or superior/inferior gastrocnemius
• Sacroiliitis with referred gluteal irradiation
• Proximal insertion ischiotendinitis on the ischial tuberosity
• Ischiofemoral impingement syndrome (reduced space between the ischium and the lesser trochanter)

Initial workup

Physical provocation tests (Freiberg maneuver, Pace maneuver, FAIR test in flexion, adduction and internal rotation) | Magnetic resonance imaging of the pelvis (MR neurography to assess the anatomical status and signal intensity of the sciatic nerve and deep gluteal muscles) | Electromyography of lower extremities.

Standard management

• Pregabalin — 75-150 mg orally every 12 hours; indicated for the control of neuropathic pain caused by sciatic entrapment
• Cyclobenzaprine — 10 mg orally before bed; useful for its muscle-relaxing effect on the piriformis muscle
• Ultrasound-guided infiltration of the piriformis muscle with botulinum toxin type A (50-100 IU, reserved for refractory refractory cases) or depot corticosteroid.