so this is a good point worth looking at. my schools OMM manual actually says internally or externally rotate (which ever lowers “the tenderness” more)
I tried to look up that Uworld QID and it looks like Uworld threw it out (my guess is enough people complained about ABD+IR as an answer) so that particular ID isn’t a resource we can rely on unfortunately.
I did check Savarese and it only lists ER
AMBOSS lists ER on their chart but their treatment video does verbalize (IR or ER as tx option)
I think the best option would be to change the wording in the extra to “May also be placed in internal rotation (less common)”
I agree that leaving it as an external rotation is good enough. The main thing to remember is the “peeing dog” position for the piriformis, which mainly involves flexion and abduction of the hip to shorten the piriformis as much as possible. The role of the piriformis in performing ER is mainly when the hip is in extension, which makes sense in terms of the treatment position but ER only is a minor modifier compared to flexion and abduction.