Ultrasound-guided dry needling decreases pain in patients with piriformis syndrome

Analysis of Research Trends in Ultrasound-Guided Acupuncture and Dry-Needling: A Scoping Review

Background: This study aimed to summarize the current status of research on ultrasound-guided acupuncture and dry-needling treatment and the specific treatment methods applied to patients. Methods: A scoping review was conducted, surveying three English databases (PubMed, Embase, and the Cochrane Library) for studies published up to May 2024. All studies related to ultrasound-guided acupuncture and dry-needling treatment were considered. Literature was selected using selection and exclusion criteria, and extracted and organized using EndNote. Results: A total of 107 eligible studies were included. Among the 107 studies, non-comparative studies accounted for the largest proportion (n = 47, 43.9%), followed by randomized controlled trials (RCTs; n = 41, 38.3%). Diseases of the musculoskeletal system or connective tissue (15 diseases of the musculoskeletal system or connective tissue) accounted for most (n = 48, 55.8%) of the 86 diseases studied, followed by symptoms, signs, or clinical conditions not otherwise classified (n = 17, 19.8%). Conclusions: Ultrasound-guided acupuncture and dry-needling have been actively studied and applied for the treatment of various diseases. However, higher-quality studies are needed for further applications in research and clinical practice.

Efficacy of trigger point dry needling on pain and function of the hip joint: a systematic review of randomized clinical trials

OBJECTIVE

The objective of this study was to assess the evidence for the impact of dry needling (DN) on hip pain and function.

METHODS

Medline/PubMed, Embase, Scopus, Web of Science and Cochrane CENTRAL databases were searched systematically through June 2022 for randomized clinical trials (RCTs) investigating the impact of DN on hip pain and function. Version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2) was used to assess risk of bias. Descriptive analysis was conducted to explain the outcomes and adverse events of DN in hip joint diseases. Meta-analysis was not feasible due to significant heterogeneity.

RESULTS

A total of seven eligible studies (including 273 patients) were included out of 2152 screened records. Five studies were in participants with hip osteoarthritis (OA; n = 3), greater trochanteric pain syndrome (GTPS; n = 1) or piriformis syndrome (n = 1); the other two studies were conducted in healthy athletes (n = 2). Two articles assessed changes in participants' short-term visual analog scale (VAS) scores (<1 week), one of which showed that DN significantly reduced pain (P < 0.05). One-week VAS scores were analyzed in three studies, all of which demonstrated reduced scores following DN (P < 0.05). Hip range of motion (ROM) and muscle force were also improved following DN. No serious side effects were reported.

CONCLUSION

DN may be safe and effective at relieving hip pain and improving hip function. DN performs significantly better than several different types of control intervention (including sham DN, no treatment, corticosteroid injections and laser). Strong evidence (high degree of certainty around the results) is lacking, and future studies should ideally use longer follow-up periods and larger sample sizes.

REVIEW REGISTRATION NUMBER

CRD42022297845 (PROSPERO).

Could dry needling change the kinematics of gait in individuals with piriformis muscle syndromes? Secondary analysis of a randomized controlled trial

INTRODUCTION

Piriformis muscle syndrome (PMS) is a condition that can lead to symptoms including gluteal pain, local tenderness, and limitation of hip joint motion in daily activities, and it may have a major impact on some daily functions such as gait. We proposed that dry needling (DN) can improve the gait of individuals with PMS.

METHODS

Thirty-two individuals with PMS were assigned equally and randomly to the treatment group or the wait-list control group. Subjects in the treatment group received three sessions of DN of the piriformis muscle. All participants in both groups were educated to correct their lifestyles. The outcome measures were the gait-related parameters (walking speed, peak hip flexion, peak hip extension, time to peak internal and external hip rotation, and knee sagittal range of motion), which were evaluated at baseline and after treatment. To compare different outcomes, analysis of covariance (ANCOVA) was used, with baseline as the covariance and groups as a factor.

RESULT

After DN sessions, peak hip extension during gait showed a statistically significant difference [adjusted MD 1.9 (3.7-0.08), p < 0.05, d = 0.56 (0.1-1.28)] in favor of the DN group. Peak hip flexion, on the other hand, exhibited a marginal statistically significant difference [adjusted MD -3.2 (-6.51 to 0.01), p = 0.053, d = 0.44 (1.16 to -0.02)] compared to the control group.

CONCLUSION

The findings suggest that participants in DN showed significantly greater peak extension angle of the hip during walking in individuals with PMS than in the control group.

Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Needling Therapies for Chronic Primary Low Back Pain in Adults

PURPOSE

Evaluate benefits and harms of needling therapies (NT) for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline.

METHODS

Electronic databases were searched for randomized controlled trials (RCTs) assessing NT compared with placebo/sham, usual care, or no intervention (comparing interventions where the attributable effect could be isolated). We conducted meta-analyses where indicated and graded the certainty of evidence.

RESULTS

We screened 1831 citations and 109 full text RCTs, yeilding 37 RCTs. The certainty of evidence was low or very low across all included outcomes. There was little or no difference between NT and comparisons across most outcomes; there may be some benefits for certain outcomes. Compared with sham, NT improved health-related quality of life (HRQoL) (physical) (2 RCTs; SMD = 0.20, 95%CI 0.07; 0.32) at 6 months. Compared with no intervention, NT reduced pain at 2 weeks (21 RCTs; MD = - 1.21, 95%CI - 1.50; - 0.92) and 3 months (9 RCTs; MD = - 1.56, 95%CI - 2.80; - 0.95); and reduced functional limitations at 2 weeks (19 RCTs; SMD = - 1.39, 95%CI - 2.00; - 0.77) and 3 months (8 RCTs; SMD = - 0.57, 95%CI - 0.92; - 0.22). In older adults, NT reduced functional limitations at 2 weeks (SMD = - 1.10, 95%CI - 1.71; - 0.48) and 3 months (SMD = - 1.04, 95%CI - 1.66; - 0.43). Compared with usual care, NT reduced pain (MD = - 1.35, 95%CI - 1.86; - 0.84) and functional limitations (MD = - 2.55, 95%CI - 3.70; - 1.40) at 3 months.

CONCLUSION

Based on low to very low certainty evidence, adults with CPLBP experienced some benefits in pain, functioning, or HRQoL with NT; however, evidence showed little to no differences for other outcomes.

Evaluation of the Efficacy of Ultrasound-Guided Dry Needling Therapy and Exercise in Piriformis Muscle Syndrome

BACKGROUND

 Piriformis muscle syndrome (PMS) is characterized by symptoms of buttock pain and numbness radiating to the back of the thigh due to irritation of the sciatic nerve. This study aimed to evaluate the efficacy of dry needling (DN) therapy and exercise programs on pain, neuropathic pain, physical function, and disability in patients with PMS.

METHODS

 Forty-four patients with PMS were included in the study. Patients were divided into two groups, those who were treated with DN three times once per week under ultrasound guidance and those who had an exercise program for three weeks. To identify the outcomes of the treatment modalities, pre-treatment and post-treatment first-month and third-month visual analog scale (VAS), Oswestry Disability Index (ODI) questionnaire, Lower Extremity Functional Scale (LEFS), and Douleur Neuropathique 4 (DN4) questionnaire scores were used.

RESULTS

 There was no statistically significant difference between the groups in baseline scores of VAS (p = 0.548), DN4 (p = 0.446), and LEFS (p = 0.880), but in the DN group, baseline ODI scores were significantly higher than in the exercise group (p = 0.001). The group comparisons showed no statistically significant differences in decreasing pain, reducing disability, and increasing functional status scores among the groups at post-treatment first-month and third-month assessments (p > 0.05).

CONCLUSION

Both treatment modalities are beneficial in reducing pain and disability, and increasing the functional status of the patients with PMS in three months of follow-up. In patients who cannot adapt to exercise programs, DN treatment under ultrasound guidance should be kept in mind as a minimally invasive treatment modality with no adverse effects.

A human donor (cadaveric) observation study of three needle placements in the piriformis muscle

OBJECTIVE

To compare the safety and accuracy of three dry needling locations in the piriformis muscle using human donors.

DESIGN

Observational dissection study of embalmed human donors.

METHODS

A licensed physical therapist of 17 years clinical experience and 5 years teaching dry needling placed three needles in a medial, midpoint, and lateral location of 14 piriformis muscles of seven embalmed human donors. Block dissection allowed for observation of tissues the needles traversed and recording of the structures that the needles pierced.

RESULTS

The lateral needle pierced piriformis in 3/14 trials, and contacted sciatic nerve in 0/14 trials. The medial needle pierced both piriformis and sciatic nerve in 11/14 trials. The midpoint needle pierced the piriformis in 11/14 trials, and contacted sciatic nerve in 3/14 trials. Fisher's Exact test (p < 0.001) found a nonrandom association between dry needle placement, and dry needle contact.

CONCLUSIONS

When dry needling the piriformis, a lateral approach can avoid the sciatic nerve, but cannot accurately pierce the piriformis tendon. Furthermore, while a midpoint and medial approach finds the piriformis muscle with the same accuracy, the midpoint location avoided the sciatic nerve more often.

Effectiveness of ultrasound guided dry needling in management of jumper's knee: a randomized controlled trial

Jumper's knee is highly prevalent condition in athletes. Very limited evidence is available on clinical effects of tendon dry needling. Therefore, the objective of this study is to compare the effects of ultrasound-guided dry needling (UG-DN) combined with conventional physical therapy and conventional physical therapy alone in patients with jumper's knee. A total of 96 patients with pre-diagnosed jumper's knee were randomly assigned to experimental group (UG-DN + CPT) and conventional group (CPT alone) with 48 participants each. Pain intensity and functional disability were recorded using visual Analogue Scale (VAS), Victorian Institute of Sports Assessment-Patellar Tendinopathy (VISA-P) questionnaire, Lysholm Scale, Knee Injury and Osteoarthritis Outcome Score (KOOS) respectively at baseline, at 1st, 2nd, and 4th week. Whereas ultrasonographic features of patellar tendon were measured through musculoskeletal ultrasound (MSKUS) at baseline and 4th week. Total 8 sessions of treatment were provided. Mann Whitney U test and Friedman test were used to compute between and within group differences respectively. P value was significant at 0.05. Results showed that patients in both groups had improvement in signs of jumper's knee but the improvement in UG-DN + CPT group was more significant (p ≤ 0.05). Significant difference was seen after 4 weeks of intervention in UG-DN + CPT group in VAS (Median ± I.Q.R = 3 ± 1, p = 0.000), VISA-P (Median ± I.Q.R = 83.5 ± 7, p = 0.000), KOOS (Median ± I.Q.R = 83.5 ± 8, p = 0.000), , Lysholm (Median ± I.Q.R = 84 ± 5, p = 0.000) than CPT group VAS (Median ± I.Q.R = 1.5 ± 1, p = 0.000), VISA-P (Median ± I.Q.R = 92 ± 2, p = 0.000), KOOS (Median ± I.Q.R = 92 ± 3, p = 0.000), Lysholm (Median ± I.Q.R = 92 ± 4, p = 0.000) and ultrasonographic features of jumper's knee were more significant in experimental group(p-value ≤ 0.05). The Ultrasound guided dry needling with conventional physical therapy of patellar tendon had been found an effective treatment for jumper's knee and helps in reducing pain intensity, improving function and ultrasonographic features in patients with jumper's knee. UG-DN + CPT group showed more significant results as compared to CPT.Trial registration: (IRCT20210409050913N1). Dated: 17.04.2021.

Validity and reliability of dry needle placement in the deep lumbar multifidus muscle using ultrasound imaging: an in-vivo study

OBJECTIVES

To use ultrasound (US) imaging to determine the validity and reliability of needle placement of two dry needling (DN) protocols for the lumbar multifidus (LM) in individuals with a high body mass index (BMI).

METHODS

Twenty-one participants with a BMI higher than 25 kg/m² completed the study. A US scanner was used to determine the location of needle placement after a 100 mm long needle was inserted in the LM at L4 and L5 following two DN protocols for the deep LM muscle. US images were saved and viewed 6 months later to determine the intra-tester reliability.

RESULTS

The probability of reaching the deep LM muscle was high (85-95%) at L4 and L5. Although the needle reached a bony landmark 85-100% of the time, it only reached the vertebra lamina as intended 70-75% of the time. The intra-tester reliability of needle placements based on analysis of real-time and recorded US images was poor-to-moderate.

CONCLUSIONS

Although the bony drop may not indicate that the needle has reached the vertebra lamina as the protocol intended, reaching a bony drop is still meaningful as it coincided with reaching the LM in the majority of participants.

Ultrasound-guided dry needling versus traditional dry needling for patients with knee osteoarthritis: A double-blind randomized controlled trial

Objective

To compare the effect of ultrasound (US)-guided dry needling (DN) with traditional DN in the treatment of pain and dysfunction for patients with knee osteoarthritis (KOA).

Design

A double-blind, randomized controlled trial.

Methods

Patients (25 male and 65 female), age 50–80 years diagnosed with KOA were recruited and randomly assigned to one of three groups in a 1:1:1 ratio for intervention: real US-guided DN with exercise therapy (G1), placebo US-guided DN with exercise therapy (G2), and exercise therapy solely (G3). G1 and G2 were blinded to the application of real or placebo US guidance by turning the monitor of US imaging out-of-view from participants’ vantage points. The effectiveness of blinding was evaluated by asking the participants whether they had received real-US guided DN. The responses were assessed by Chi-square test. Visual Analogue Scale (VAS), Knee injury, and Osteoarthritis Outcome Score (KOOS) subscales (KOOS-pain, KOOS-symptoms, KOOS-quality-of-life (QoL)) were collected at baseline, 4 weeks, and 8 weeks by a blinded assessor. Data were analyzed by mixed model analysis of variance (ANOVA) with Bonferroni correction.

Results

Eighty-four participants (61.26±5.57 years) completed the study. G1 achieved significant improvement in VAS at 8 weeks compared to G2 and G3 (G1 vs. G2: MD = -15.61, 95% CI [-25.49, -5.51], p = 0.001; G1 vs. G3: MD = -19.90, 95% CI [-29.71, -10.08], p< 0.001). G1 achieved significant improvement in KOOS-pain at 8 weeks compared to G2 and G3 (G1 vs. G2: MD = 9.76, 95% CI [2.38, 17.14], p = 0.006; G1 vs. G3: MD = 9.48, 95% CI [2.31, 16.66], p = 0.010). KOOS-symptoms and KOOS-QoL were not statistically significant between groups. G2 had no significant difference of the perceptions as G1 with p = 0.128. G2 were successfully blinded to placebo US-guided DN.

Conclusion

US-guided DN with exercise therapy may be more effective than traditional DN with exercise therapy or exercise therapy alone in reduce pain of KOA.

Effects of ultrasound-guided platelet rich plasma injection in patients with piriformis syndrome

BACKGROUND

Piriformis syndrome (PS) is the common entrapment neuropathy causing buttock pain. Patients are conventionally treated with lifestyle modification, exercise, non-steroidal anti-inflammatory drugs, corticosteroid or botulinum toxin injections. However, some patients may not respond to these conventional treatment methods. Platelet rich plasma (PRP) injection has been shown to be beneficial in various muscular injuries, but its effects have not yet been investigated in PS.

OBJECTIVE

The aim of this study was to explore the effect of PRP on pain and functional status in patients with PS, and to identify any correlations between clinical changes and demographic features.

METHODS

A total of 60 patients with PS were randomly separated into two groups (PRP and control groups). All patients received one session of either PRP or saline injection performed under ultrasound guidance. The pain was measured with a visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were noted at three intervals in both groups: before treatment, 1 week after treatment and 1 month after treatment.

RESULTS

The VAS and ODI scores were improved in both groups. The improvement was more obvious in the PRP group in the first week, and the results were similar for both groups when measured 1 month after the treatment.

CONCLUSION

Ultrasound-guided PRP injection provided greater improvements in both pain and functional status in patients with PS, starting in the early period after treatment. A repeat injection might be needed for a long-term effect.

Ultrasound-guided injections in pelvic entrapment neuropathies

Pelvic entrapment neuropathies represent a group of chronic pain syndromes that significantly impede the quality of life. Peripheral nerve entrapment occurs at specific anatomic locations. There are several causes of pelvic entrapment neuropathies, such as intrinsic nerve abnormality or inflammation with scarring of surrounding tissues, and surgical interventions in the abdomen, pelvis and the lower limbs. Entrapment neuropathies in the pelvic region are not widely recognized, and still tend to be underdiagnosed due to numerous differential diagnoses with overlapping symptoms. However, it is important that entrapment neuropathies are correctly diagnosed, as they can be successfully treated. The lateral femoral cutaneous nerve, ischiadic nerve, genitofemoral nerve, pudendal nerve, ilioinguinal nerve and obturator nerve are the nerves most frequently causing entrapment neuropathies in the pelvic region. Understanding the anatomy as well as nerve motor and sensory functions is essential in recognizing and locating nerve entrapment. The cornerstone of the diagnostic work-up is careful physical examination. Different imaging modalities play an important role in the diagnostic process. Ultrasound is a key modality in the diagnostic work-up of pelvic entraptment neuropathies, and its use has become increasingly widespread in therapeutic procedures. In the article, the authors describe the background of pelvic entrapment neuropathies with special focus on ultrasound-guided injections.

Is Dry Needling Applied by Physical Therapists Effective for Pain in Musculoskeletal Conditions? A Systematic Review and Meta-Analysis

OBJECTIVE

The main objective of this systematic review and meta-analysis was to determine the short-, medium-, and long-term effectiveness of dry needling (DN) applied by physical therapists to myofascial trigger points for the treatment of pain.

METHODS

PubMed, Scopus, SportDiscus, and Web of Science databases were searched from their inception to February 2020. Randomized controlled trials that compared DN with other treatments or placebo and measured pain with a visual analog Scale or another numerical pain rating scale were included. Two authors used a personalized form to collect the following data relevant to the objectives of the review from each article independently: study design, purpose, sample size, diagnosis, characteristics of DN intervention, characteristics of placebo intervention, outcome measures, period of assessment, body region, DN technique, and number of sessions. The initial search identified 1771 articles. After the selection, 102 articles were assessed for eligibility; 42 of these articles measuring pain were used for the meta-analysis. Four meta-analyses were performed according to the follow-up period from the last reported treatment.

RESULTS

This meta-analysis found a large effect to decrease pain within 72 hours (standardized mean difference [SMD] = -0.81; 95% CI = -1.21 to -0.40), a moderate effect in 1 to 3 weeks (SMD = -0.69; 95% CI = -1.02 to -0.35), a large effect in 4 to 12 weeks (SMD = -0.85; 95% CI = -1.30 to -0.40), and a large effect in 13 to 24 weeks (SMD = -0.81; 95% CI = -1.64 to -0.03). The risk of bias was generally low; however, the heterogeneity of the results downgraded the level of evidence.

CONCLUSIONS

Low-quality evidence that the immediate to 72-hour (large) effect, 4- to 12-week (large) effect, 13- to 24-week (large) effect, and moderate-quality 1- to 3-week (moderate) effect suggested that DN performed by physical therapists was more effective than no treatment, sham DN, and other therapies for reducing pain.

IMPACT

DN is commonly used by physical therapists to treat musculoskeletal pain, and it is very important for physical therapists to know the clinical conditions and time periods for which DN is effective in reducing pain in their patients.

Surgical and Non-surgical Treatment Options for Piriformis Syndrome: A Literature Review

Context

Piriformis syndrome is a solely clinical diagnosis that often eludes the practitioner and goes underdiagnosed. PS is a pain syndrome and for those it affects, causes persistent pain and limits daily activity and work capacity. It is a form of deep gluteal syndrome that needs to be considered on the differential of low back pain as it comprises between 0.3% - 6% of all low back pain cases and is frequently underdiagnosed. Piriformis syndrome may be primary due anatomic anomalies or secondary, though the majority of cases are secondary to some insult. The objective of this manuscript is to provide a description of the epidemiology and presentation of piriformis as well as both non-operative and operative treatment options. We review all of the recent clinical evidence regarding the aforementioned therapies.

Evidence Acquisition

Literature searches were performed using the below MeSH Terms using Mendeley version 1.19.4. Search fields were varied until further searches revealed no new articles. All articles were screened by title and abstract. Decision was made to include an article based on its relevance and the list of final articles was approved three of the authors. This included reading the entirety of the article. Any question regarding the inclusion of an article was discussed by all authors until an agreement was reached.

Results

Medical management and physical therapy show some promise; however, when conservative treatment fails minimally invasive methods such as steroid injections, botulinum toxin injections, dry needling are all efficacious and there is substantial clinical evidence regarding these therapies. In those patients in which minimally invasive techniques do not result in an adequate relief of pain and return of function, endoscopic release can be considered. Endoscopic release is far superior to open release of the piriformis syndrome given the higher success and lower rate of complications.

Conclusions

Piriformis syndrome is an important differential diagnosis in the work up of lower back pain and should not be ruled out with proper examination and testing. Clinicians should consider medical management and conservative management in the initial treatment plan for piriformis syndrome. There are many options within the conservative management and the literature shows much promise regarding these. Physical therapy, steroid injections, botulinum toxin injections, and dry needling are all potentially effective therapies with few adverse effects. Surgical options remain as gold standard, but only when conservative management has failed and the symptoms are significant to affect daily living activities. Endoscopic decompression of the sciatic nerve with or without release of the piriformis muscle has a reported high likelihood of success and a low complication rate. Current literature supports the preference of the endoscopic approach over the open approach due to improved outcomes and decreased complications. Further research is to well define the metrics for the diagnosis of piriformis syndrome and may include a need to develop diagnostic criteria.

Benefits of Adding Gluteal Dry Needling to a Four-Week Physical Exercise Program in a Chronic Low Back Pain Population. A Randomized Clinical Trial

OBJECTIVE

To determine if adding dry needling to a four-week exercise program has an additional benefit compared with adding sham dry needling to the same exercise program in subjects with chronic low back pain.

DESIGN

Randomized clinical trial.

SETTING

Physiotherapy and Pain Clinic of Alcala University.

SUBJECTS

Forty-six patients with chronic low back pain.

METHODS

Subjects were randomized to two groups: the dry needling group (N = 23) or sham dry needling group (N = 23). Both groups received a four-week exercise program and before the exercise started a session of dry needling or sham dry needling. Pain (visual analog scale), disability (Roland-Morris Questionnaire), and fear avoidance beliefs (Fear Avoidance Beliefs Questionnaire) were assessed at baseline, after treatment, and at three-month follow-up. Pressure pain thresholds (algometer) were measured at baseline, after the dry needling or the sham dry needling, and after treatment.

RESULTS

Both groups showed significant improvements for all variables. In the between-group comparison, the dry needling group improved significantly in pain at three-month follow-up and pressure pain thresholds at the end of treatment for all measures, and at three-month follow-up there was no improvement in gluteus medium.

CONCLUSIONS

In chronic low back patients, adding dry needling to a four-week exercise program has an additional benefit in pain and sensitivity compared with adding sham dry needling to the same exercise program.

Short-term effect of myofascial trigger point dry-needling in patients with Adhesive Capsulitis

BACKGROUND

Adhesive Capsulitis (AC) is a common disabling musculoskeletal pain condition of unknown etiology related to the shoulder joint. Literature reported the restricted range of motion (ROM) and pain could be the result of myofascial trigger points (MTrPs) in the muscles of the shoulder girdle. Hence, the objective of this study was to assess the short-term effectiveness of MTrP dry needling (DN) in improving ROM, pain, pressure pain threshold (PPT), and physical disability among patients having AC.

METHODS

In a single group pre-post experimental study design, a total of 70 clinically diagnosed patients (both male & female, age group between 40 and 65 years) with AC were recruited from three multi-specialty hospitals. The informed consent forms were received from each patient before participating in the study. Each patient received DN for the MTrPs of shoulder girdle muscles for alternative six days. In addition to DN, each patient had received conventional physiotherapy for continuous twelve days which includes electrotherapy modalities and exercises. The pain intensity (visual analog scale), shoulder ROM (Goniometer), disability (shoulder pain and disability index) and PPT (Algometer) were the outcome measures assessed at the baseline and twelfth day of the intervention.

RESULTS

There was a statistically significant (p < 0.05) improvement in shoulder ROM, pain intensity, shoulder disability, and PPT at the end of the twelve days of intervention as compared to baseline assessment.

CONCLUSION

MTrPs-DN techniques may improve the pain, ROM, disability and PPT along with conventional physiotherapy management among patients with AC.

Ultrasound-guided trigger point injection for piriformis syndrome in the emergency department

Piriformis syndrome, a myofascial pain disorder characterized by deep gluteal pain that radiates to the ipsilateral lower back and/or posterior thigh, is an underreported cause of low back pain frequently misdiagnosed in the emergency department (ED). Often refractory to oral pain medications, this syndrome can be debilitating. Ultrasound-guided trigger point injection of the piriformis muscle can treat piriformis syndrome, but no previous reports exist in the emergency medicine literature. This case series describes 2 patients who presented to our emergency department with low back pain and were diagnosed with piriformis syndrome. Both patients received an ultrasound-guided trigger point injection of the affected piriformis muscle with a significant reduction of pain at 15 minutes and 48 hours after the procedure.

Lower extremity entrapment neuropathies

Entrapment neuropathies are frequently encountered by rheumatologists, not only because they are common but also because of their association with certain rheumatological and systemic disorders. Recognizing entrapment neuropathy early can help avoid progressive neurological deficits, as well as facilitate appropriate treatment measures, which can effectively minimize a patient's symptoms. Entrapment neuropathies may be distinguished from other musculoskeletal causes of lower extremity pain by identifying characteristic patterns of weakness and/or sensory loss, so a focused bedside neurological examination is key for diagnosis. In this chapter, we review the most common entrapment neuropathies that occur in the lower extremities, review the relevant neuroanatomy, outline a diagnostic approach to distinguish them from other mimics, and highlight appropriate management options.

Short-Term Effects of PENS versus Dry Needling in Subjects with Unilateral Mechanical Neck Pain and Active Myofascial Trigger Points in Levator Scapulae Muscle: A Randomized Controlled Trial

Procedures such as dry needling (DN) or percutaneous electrical nerve stimulation (PENS) are commonly proposed for the treatment of myofascial trigger points (MTrP). The aim of the present study is to investigate if PENS is more effective than DN in the short term in subjects with mechanical neck pain. This was an evaluator-blinded randomized controlled trial. Subjects were recruited through announcements and randomly allocated into DN or PENS groups. Pain intensity, disability, pressure pain threshold (PPT), range of motion (ROM), and side-bending strength were measured. The analyses included mixed-model analyses of variance and pairwise comparisons with Bonferroni correction. The final sample was composed of 44 subjects (22 per group). Both groups showed improvements in pain intensity (ηp2 = 0.62; p < 0.01), disability (ηp2 = 0.74; p < 0.01), PPT (ηp2 = 0.79; p < 0.01), and strength (ηp2 = 0.37; p < 0.01). The PENS group showed greater improvements in disability (mean difference, 3.27; 95% CI, 0.27-6.27) and PPT (mean difference, 0.88-1.35; p < 0.01). Mixed results were obtained for ROM. PENS seems to produce greater improvements in PPT and disability in the short term.