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Implications of Delayed Diagnosis of Piriformis Syndrome Nathan Kenyon, MD; Mohammad Agha, MD University of Missouri, Department of Physical Medicine and Rehabilitation INTRODUCTION Piriformis originates anterior to S2-4 vertebrae and inserts on greater trochanter of femur Action: lateral rotator of hip Innervation: branches of L5, S1, S2 Estimated incidence of piriformis syndrome in patients with sciatica is 6% Left PSW/ Fibs Insertional Activity Recruitment Gluteus maximus 0 nl nl Vastus medialis 0 nl nl Gastrocnemius 1+ Increased Decreased Tibialis Anterior 0 nl nl Biceps femoris (Long head) 0 Increased nl Lumbar Paraspinals 0 nl nl Repeat EMG Results at 12 months CASE DESCRIPTION 50 year-old male presented to a spine clinic 12 month history of pain in left mid-buttock with radiation into the calf, no previous history of trauma or surgery at hip joint Previous treatments: gabapentin, prednisone, tramadol, hydrocodone, baclofen, physical therapy, intra-articular hip injection, epidural steroid injection, medial branch block Initially diagnostic ultrasound was performed which revealed obturator internus inflammation; a steroid injection was administered but did not decrease the patient’s pain. CLINICAL COURSE Considered ischio-femoral impingement (IFI) and obtained pelvis MRI which revealed abnormal signal in sciatic nerve. 1 month prior had normal lower extremity EMG. Repeat EMG revealed evidence of chronic denervation in left gastrocnemius, short head of biceps femoris. Referred to orthopedics and underwent left piriformis tendon release with complete resolution of pain CONCLUSION Our patient was prescribed several medications and procedures which failed to identify and treat the pain generator. Piriformis syndrome can be a challenging diagnosis and difficult to treat. Delay in recognition and treatment of piriformis syndrome may result in unnecessary treatments and prolong patient suffering.