Piriformis Syndrome

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Clinically relevant anatomy

 

The Piriformis muscle is one of the small muscles deep in the buttocks that rotates the leg outwards. It runs from the base of the spine (the sacrum) and attaches to the greater trochanter.

The sciatic nerve runs very close to this muscle and in some people (around 10% of the population) it passes straight through the muscles’ fibres. If the piriformis muscle becomes tight it can cause compression of the sciatic nerve causing pain which can radiate down the leg, commonly known as sciatic pain. It has been suggested that this condition would be better referred to as piriformis impingement due to the impingement of the sciatic nerve.

 

Landmarks to identify the Piriformis (picture with tape)

If you draw a line from the greater trochanter to the PSIS  piriformis trigger points can often be found half way between the two.

Epidermiology/Aetiology

 

A common cause of Piriformis syndrome is having tight adductor muscles (inside your thigh). This means the abductors on the outside cannot work properly and so put more strain on the Piriformis.

 

Clinical Characteristcs and presentation.

  • Tenderness in the area of the muscle.
  • Pain in the buttocks.
  • Pain which radiates down the back of the leg, usually into the hamstrings and sometimes even the calf muscles.
  • It is common for pain to initially be confused with a hamstring strain or hamstring origin tendinopathy. However there will be no area in the hamstrings which is tender to touch.
  • Reduced range of motion of the hip joint, especially into internal hip rotation.

 Differential diagnosis

(Table goes here)

 

Examination:

Useful tip: “The above and below rule. Pain can be referred so it is always useful to assess the joints either side of the painful area to gain a holistic approach to your clinical impression”

 

See full examination of the back and hip here.• It is important to assess the hip holistically. Pain in the buttock and posterior thigh can also be referred from the back so check ROM of the back.

  • Hip ROM
  • Assessing tissue lengths of the Piriformis and Adductor muscles with give you information of ROM (ie when performing a piriformis stretch those with piroformis spasm may complain of localized pain in the pirifiromis region. Assessing strength through ranges will indicate contractile limitations. Ie  Spasm of the piriformis may mean that ER of the hip is weak due to pain inhibition.
  • Palpation -Patients with piriformis  spasm often have multiple trigger points and can be extremely sensitive. Start with a light pressure and build up slowly. Good explanation to the patient will put them at ease. It is important to ask the patient if the  pain stays locally or travels down the leg. This helps to confirm that the pain is likely to be coming either from the trigger point of compression of the sciatic nerve within the muscle.

 

Clinical Experience “I have found that trigger point release within the Piriformis often has an immediate result however can be very uncomfortable. I usually apply compression(ischemic pressure) to the trigger point for 30 seconds and explain that it is likely to be uncomfortable for 30 seconds and then relax off. If the trigger point has not eased after this period I will try soft tissue massage and then try again. I find using the phrase ‘ What is your pain out of ten? Can you tolerate this pressure?’ allow me to work within the patients limitations.”

Management

Advice to patient for independent management

  • Apply heat to relax the muscle. This should only be done if you are sure there is no acute injury. (In the acute period there may be inflammation which is contraindicated in the use of heat).
  • Stretch the Piriformis muscle and other external rotators of the hip joint.
  • Stretch the groin (adductor) muscles.
  • Strengthen the Piriformis muscle and hip abductors.
  • See a sports injury professional who can advise on treatment, rehabilitation and prevention

 

What can a healthcare professional or physiotherapist do?

  • Trigger Point release.
  • Clinical massage.
  • Soft Tissue Release.
  • PNF
  • Stretch the Piriformis muscle using Muscle Energy Techniques.
  • Apply ultrasound.
  • Acupuncture
  • Advise on strengthening and rehabilitation to avoid injury recurrence.

 

 

Click here for case studies on this.

Click here for exempler notes for assessment and treatment.

“Formulating your treatment plan can help you organize your thoughts. One way to do this is by writing a problem list and then considering the treatment approaches which may be beneficial in treating this problem. See below for an example of this for Piriformis Syndrome.

 

PHYSIOTHERAPY MANAGEMENT

Physiotherapy problems.

  1. 1. Pain in Piriformis muscle +/- radiating symptoms into posterior thigh.
  2. 2. Reduced Internal rotation AROM/PROM of the hip joint.
  3. 3. Tight adductor muscles

 

The key in reducing symptoms is to find the CAUSE and eliminate it. If you treat only the symptom but leave the cause the symptom will reoccur.

 

Physiotherapy Treatments

In conjunction with the doctors management.

 

Problem 1.

Potential causes:

Tight muscle compressing nerve

Muscle imbalance creating pressure on nerve.

Muscle tightness

Potential treatments:

  •  NSAIDS (prescribed by doctor)
  • Trigger point release of piriformis
  • Piriformis stretch
  • Heat
  • Ice
  • Muscle Energy Techniques
  • U/S
  • Interferential
  • TENS

 

Problem 2.

Potential causes:            

Tight piriformis and external hip rotators.

Potential Treatments:

  • Piriformis Stretches
  • Strengthen external rotators to improve muscle balance

 

Problem 3.

Potential causes:

  • Overdeveloped  adductor muscles
  • Muscle imbalance

 

Potential Treatments:

  •  Adductor stretches
  • Muscle energy techniques
  • PNF
  • Electrotherapy

 

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