1.  With the patient standing up with the back in forward flexion and hands/arms supported by the examination table, the clinician stands directly behind the patient.

2.  Locate the S2 median sacral crest and the lateral aspect of the femoral trochanter.

3.  Identify the point of maximal tenderness over the piriformis muscle. This will be one-third to one-half of the distance from the sacral crest.

4.  At that site, press firmly on the skin with the retracted tip of a ballpoint pen. This indention represents the entry point for the needle.

5.  After the landmarks are identified, the patient should not move.

1.  Prep the insertion site with alcohol followed by the povidone–iodine pads.

2.  Achieve good local anesthesia by using a topical vapocoolant spray.

3.  Position the needle and syringe perpendicular to the skin with the tip of the needle directed anteriorly.

4.  Using the no-touch technique, introduce the needle at the insertion site (Fig. 8.6).

5.  Advance the needle until you feel that there is an increase in resistance in the muscle due to spasm and/or fibrosis. If the patient experiences sudden shooting pain down the leg, the sciatic nerve has been contacted. Withdraw the needle a few millimeter until there is no pain.

6.  Aspirate to ensure no blood return and inject the volume of the syringe into the soft tissues. The injected solution should flow smoothly. If increased resistance is encountered, advance or withdraw the needle slightly before attempting further injection.

7.  Following injection of the corticosteroid solution, withdraw the needle.

8.  Apply a sterile adhesive bandage.

9.  Instruct the patient to move his or her hip through its full range of motion. This movement distributes the steroid solution throughout the course of the piriformis muscle.

10.  Reexamine the piriformis muscle in 5 min to confirm pain relief.