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Musculoskeletal and Sports Medicine

Elite Runner With Piriformis Syndrome Treated With Botulinum Toxin and Gait Retraining: A Case Report

Saturday, October 25, 2025
12:00 PM - 1:30 PM MT
Location: Kiosk 3

    Poster Presenter(s)

  • Katrina I. Coogan

    n/a
    n/a
    Newburyport, Massachusetts

    • Co-Author(s)

  • TT

    Tessa Taylor, PT

    Physical Therapist
    Spaulding Rehabilitation Hospital, MGB
    Rehoboth, Massachusetts

  • Joanne Borg-Stein, MD

    Chief, Sports Medicine. Associate Chair Harvard Medical School, Dept of PM&R
    Spaulding Rehabilitation Hospital
    Charlestown, Massachusetts

  • SK

    Sydney C. Karnovsky, MD

    Fellow Physician
    Mass General Brigham
    Brookline, Massachusetts

  • AT

    Adam S. Tenforde, MD

    Associate Professor, Harvard Medical School
    Spaulding Rehabilitation Hospital
    Milton, Massachusetts

Disclosure(s):
Katrina I. Coogan: No financial relationships to disclose
Adam S. Tenforde, MD: No relevant disclosure to display
Case Diagnosis: Piriformis syndrome in an elite runner.

Case Description or Program Description: A 23-year-old elite male runner with history of prior right ankle sprain presented with an 11-month history of right lower extremity pain. Symptoms limited both activities of daily living and running and were refractory to prior treatments including two steroid injections (piriformis and right L4-L5), physical therapy (PT), oral analgesics, and soft tissue modalities. Exam was notable for difficulty with tandem gait, strength impairments diffusely in the right L2-S1 distribution, and positive right-sided seated slump test and straight leg raise. Initial imaging included X-ray of the right hip and MRI of the lumbar spine without abnormality.

Setting: Outpatient Sports Medicine Clinic

Assessment/Results: Physical exam suggested extra-spinal sciatic neurologic pathology. Labs were negative for infectious, rheumatologic, or inflammatory disease and EMG was normal. Subsequent MRI of sacral plexus was suggestive of a focal right sciatic neuropathy with asymmetric muscle edema suggestive of denervation. Ultrasound demonstrated thickening of the sciatic nerve at the posterior ischial spine overlying the superior gemellus. Subsequently, he received two ultrasound-guided right sciatic perineural injections with partial improvement. A diagnostic and therapeutic CT-guided right piriformis intramuscular botulinum toxin injection(100 units) was performed, and PT modified to include gait retraining. Following injection, he was able to wean from oral medications and returned to running 80-100 miles per week by seven months.

Discussion (relevance): Piriformis syndrome is a challenging diagnosis due to anatomical variants in muscle anatomy in relation to the sciatic nerve. Prior treatments did not provide sufficient relief. While botulinum toxin is avoided in elite athletes due to concern for muscle weakness, the patient was able to achieve pain relief and return to a high volume of running.

Conclusions: We highlight the utility of botulinum toxin with gait retraining to diagnose and treat piriformis syndrome in an elite athlete and allow for successful return to sport.