Conditions & Treatments - Piriformis Syndrome

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Piriformis syndrome (click here for article for patients) is described as a peripheral neuritis of the sciatic nerve attributed to an abnormal condition of the piriformis muscle (1). Often times, it may not be diagnosed properly and may pose itself as another condition with similar symptoms such as lumbosacral radiculopathies, degenerative disc disease, compression fractures, spinal stenosis, sacroilitis, sacral iliac dysfunction, or diseases of the hip (1). The primary function of the piriformis muscle is to perform hip external rotation and assist with hip abduction when the hip is flexed. It originates at the anterior surface of the lateral sacrum and inserts at the greater trochanter of the femur, along its upper medial surface. The sciatic nerve enters the buttock adjacent to the piriformis muscle (2). Pirifromis syndrome involves compression of the sciatic nerve by the piriformis muscle resulting in sciatica (1, 2, 3).

Clinical symptoms of piriformis syndrome includes (1):
- Pain with sitting, standing, or lying longer than 15 to 20 minutes.
- Pain and/or paresthesia radiating from sacrum through gluteal area and down posterior aspect of thigh, usually stopping above knee
- Pain improves with ambulation and worsens with no movement
- Pain when rising from seated or squatting position
- Change of position does not relieve pain completely
- Contralateral sacroiliac pain
- Difficulty walking
- Numbness in foot
- Weakness in ipsilateral lower extremity
- Headache
- Neck pain
- Abdominal, pelvic and inguinal pain
- Dyspareunia in women
- Pain with bowel movements

Diagnosing piriformis syndrome can be challenging given the many other conditions it may pass for. A study by Fishman et al (2) examined the nerve conduction velocity of the H-reflex with a patient in the FAIR position (Hip Flexion, Adduction and Internal Rotation). They found that the H-reflex varied and tended to be delayed in piriformis syndrome patients in the FAIR position. Despite this finding, Hopayian et al (3), challenged the Fishman et al study as they reported that the study didn’t establish the accuracy of the H-reflex because it lacked the symptomatic controls (patients with sciatica, but not piriformis syndrome).

Other clinical signs that can present itself with piriformis syndrome can also include (1):
- Tenderness in region of SI joint, greater sciatic notch & piriformis muscle
- Tenderness over piriformis muscle
- Palpable mass in ipsilateral buttock
- Traction of affected limb provides moderate relief of pain
- Asymmetrical weakness in affected limb
- Piriformis sign positive
- Lasegue sign positive
- Freiberg sign positive
- Pace sign (flexion, adduction, and internal rotation test result) positive
- Beatty test result positive
- Limited medial rotation of ipsilateral lower extremity
- Ipsilateral short leg
- Gluteal atrophy (chronic cases only)
- Persistent sacral rotation toward contralateral side with compensatory lumbar rotation

Once piriformis syndrome has been confirmed, physical therapy can be helpful with relieving symptoms through improving range of motion, increasing strength, decreasing tissue irritability, improving/correcting posture and improving joint mobility. Below is the physical therapy protocol Fishman et al (2) followed in their study when working with subjects with piriformis syndrome (2):


Patient is placed in a contralateral decubitus and FAIR position.
1) ultrasound 2.0 to 2..5 W/cm2 applied in broad strokes longitudinally along the piriformis muscle from the conjoint tendon to the lateral edge of the greater scitic foramen for 10 to 14 minutes.
2) Wipe off ultrasound gel.
3) Hot packs or cold spray at the same location for 10 minutes.
4) Stretch the piriformis muscle for 10-14 minutes by applying manual pressure to the muscle’s inferior border, being careful not to press downward, rather directing pressure tangentially toward the ipsilateral shoulder.
5) Myofascial release at lumbosacral paraspinal muscles.
6) McKenzie exercsies.
7) Use lumbosacral corset when trating in the FAIR position.
Duration: 2 to 3 times weekly for 1 to 3 months.

Other interventions that are available for treating piriformis syndrome includes trigger point injections (steroids, lidocaine hydrochloride or botulinum type A), acupuncture, or surgical decompression (1). Through a better understanding of piriformis syndrome, therapists will be able to more effectively diagnose and treat this condition.


Last revised: September 24, 2013
by Chai Rasavong, MPT, MBA

 

References
1) Boyajian-O'Neill LA, et al. Diagnosis and Management of Piriformis Syndrome: An Osteopathic Approach. JAOA. 2008 Nov;108(11):657-664.
2) Fishman LM, et al. Piriformis Syndrome: Diagnosis, Treatment, and Outcome - a 10-Year Study. Arch Phys Med Rehabil. 2002 March;83:295-301.
3) Hopayian K, et al. The Clinical Features of Piriformis Syndrome: A Systematic Review. Eur Spine. 2010 19:2095-2109.

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