Successful Ultrasound-Guided Management of Persistent Right Buttock Pain in a Patient with Piriformis Syndrome

Background:

A patient presented to our clinic with persistent right-sided buttock pain, which began in 2022 without any clear history of trauma or injury. The pain was particularly aggravated by walking—especially up hills—and prolonged standing, with some discomfort when sitting. Mornings were especially challenging, requiring walking in a bent position initially. There was no associated back pain and no pain radiating to the leg.

Past History:

Previously, the patient experienced lateral hip pain which improved significantly after an ultrasound-guided steroid injection into the right trochanteric bursa. The patient had already been evaluated by physiotherapists and the Orthopaedic team, who ruled out any complications related to bilateral total hip replacements (performed over 20 years ago). Imaging and examination confirmed no prosthesis loosening, but there was tenderness over the right piriformis muscle and mild residual tenderness over the right trochanteric region.

The medical history was otherwise unremarkable, and there was no regular analgesic use. Living independently, the patient remained generally active, but the ongoing pain significantly impacted the ability to carry out household chores and pursue her hobbies.

Diagnosis and Initial Treatment:

Given the examination findings and prior physiotherapy opinion, piriformis syndrome was suspected. As a first step, Dr Krishna performed an ultrasound-guided injection of local anaesthetic and steroid into the right piriformis muscle. This procedure was both diagnostic—confirming the piriformis as the likely pain generator—and therapeutic, providing meaningful pain relief for a few weeks.

Definitive Treatment with Botox:

As the benefits of the initial injection gradually diminished, Dr Krishna recommended  an ultrasound-guided injection using Botulinum Toxin (Botox) targeted precisely into the piriformis muscle. Botox works by reducing muscle spasm and tension over several months, allowing sustained pain relief and facilitating rehabilitation.

The patient responded extremely well to this treatment, with significant improvement in buttock pain, increased walking tolerance, and an enhanced ability to manage daily activities without relying on a stick. She was able to enjoy her hobbies, including going for long walks.

Piriformis Pain – Often Underdiagnosed and Undertreated:

Piriformis syndrome remains one of the more under-recognised causes of buttock and leg pain. Many patients with this condition are either misdiagnosed or left to manage persistent pain without a definitive solution, as traditional treatments often fail to address the root cause.

Failure to correctly diagnose the condition can lead to significant patient dissatisfaction, repeated consultations with different specialists (“doctor shopping”), unnecessary investigations, and ineffective treatments—prolonging suffering and delaying recovery. However, with precise ultrasound-guided injections, the diagnosis can be confirmed and highly effective treatment can be delivered directly to the source of pain, offering a real chance of long-term relief rather than merely managing discomfort.

The Role of Ultrasound Guidance:

This case illustrates how accurate, real-time ultrasound-guided injections can be invaluable in both diagnosis and treatment of musculoskeletal pain conditions. The precision ensures that medication is delivered exactly to the intended target, maximising therapeutic benefit and minimising risks.

At Pain Spa, Dr Krishna has extensive expertise in using ultrasound guidance for targeted pain interventions, enabling highly accurate and effective treatments for patients with chronic pain conditions.

Conclusion:

For patients with suspected piriformis syndrome, a stepwise approach using an initial diagnostic steroid injection followed—if necessary—by a therapeutic Botox injection can provide excellent results. In this case, the combination not only confirmed the diagnosis but also delivered long-term functional improvement and pain relief.

For more details please visit www.painspa.co.uk.