Piriformis Syndrome A Pain in the Butt

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Piriformis Syndrome- A Pain in the Butt-

• Jody Miller

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The Sciatic Nerve
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What Is Piriformis Syndrome?

• Piriformis Syndrome was first described in 1928
  as a periarthritis of the anterior sacroiliac
  joint
  
• Piriformis Syndrome refers to irritation of the
  sciatic nerve as it passes through the piriformis
  muscle
  
• Despite the description, it has remained a
  controversial diagnosis. With some in the
  medical community claiming that the condition
  does not even exist.

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What is Sciatica?

• Radiculopathy or compression of a nerve root as
  it exits the spine
  
• Signs and symptoms are closely related, but the
  source of the irritation differs

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The Piriformis Muscle

• Origin
• Pelvic surface of the sacrum between (and lateral
  to) the first through fourth pelvic sacral
  foramina
  
• Margin of the greater sciatic foramen
• Pelvic surface of the sacrotuberous ligament
• Insertion
• Superior border of the Greater Trochanter of the
  femur
  
• Innervation
• Sacral plexus (L5, S1, S2)

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Anatomy

• There are multiple variations of the muscle
  structure
  
• Shape is variable
• In the majority of cadaver dissections, the
  sciatic nerve is found to run underneath the
  piriformis fibers
  
• Occasionally the nerve runs between the fibers of
  a bifid muscle

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Actions

• External rotation of the hip
• Abduction of the hip when the hip is flexed
• Some slight extension of the hip
• Example
• While balancing on the left foot, the piriformis
  moves the right leg directly sideways away from
  the body and rotates the right leg so that the
  toes are pointing towards the ceiling

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Symptoms of Piriformis Syndrome

• Piriformis Syndrome is characterized by pain and
  instability
  
• The location of the pain can be imprecise, but it
  is often present in the hip, coccyx, buttocks,
  groin, or distal part of the leg
  
• The symptoms most often reported are pain during
  running and walking

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Frequency

• In the US the female-to-male ratio is 61
• In about 15 of the population, the sciatic
  nerve runs through the piriformis muscle, rather
  than below it
  
• One author estimated that the incidence of
  piriformis syndrome in patients with sciatica is
  6

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Causes of Piriformis Syndrome

• Trauma to the buttocks or gluteal region is the
  most common
  
• Skiers, truck drivers, tennis players, and long
  distance bikers and runners are at high risk
  
• Morton foot may predispose you to piriformis
  syndrome
  
• Anatomic variations of the divisions of the
  sciatic nerve above, below, and through the
  piriformis may also be a factor

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Short or Long

• Commonly when the syndrome is present, the muscle
  is considered to be short
  
• Kendall reports that the symptoms of the syndrome
  can also be found in patients who have a
  lengthened piriformis muscle
  
• The length of the muscle needs to be carefully
  examined before intervention and treatment begin

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How Do You Get A Long Piriformis?

• In a faulty position where the leg is in
  adduction and internal rotation with an
  anteriorly tilted pelvis
  
• This position puts the piriformis in a stretched
  position
  
• The mechanism of this position thrusts the
  piriformis muscle and the sciatic nerve into
  close contact

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Diagnosing Piriformis Syndrome

• It is a diagnosis of exclusion
• The only true positive sign is considered to be
  tenderness over the gluteal region
  
• Pain can be reproduced with the maximum
  elongation of the muscle
  
• Weakness can be found with resistance to external
  rotation and abduction of the hip

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Red Flags

• Patients with Piriformis Syndrome are likely to
  have the following symptomatic history
  
• Chronic pain in the buttocks
• Pain with walking and running, climbing stairs,
  and squats
  
• Pain with bowel movements
• Pain in the labia majora in women and pain the
  the scrotum in men
  
• Pain when getting up from bed
• Pain with hip adduction and internal rotation
• Intolerance to sitting

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Stretching the Piriformis

• Have the patient lie on his/her back
• Use the leg on the affected side and cross the
  patients body
  
• Knee to opposite Ear
• Examiner can apply pressure in the similar
  direction to increase the stretch

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? Superior View
Inferior View ?
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More stretching

• Place the right knee on the ground roughly in
  line with your left shoulder
  
• The right foot should be just in front of the
  left knee
  
• Press your hips towards the ground so that your
  bodyweight is on your right leg
  
• As you move down the right knee comes closer to
  the left shoulder
  
• You should feel a gentle pull deep in the right
  hip/buttocks

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• If the muscle is tight, pain and a stretching
  sensation will be felt in the gluteal region
  
• If the muscle is irritating the sciatic nerve,
  pain may be present and will radiate through the
  buttocks and possibly down the leg

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Other Treatments

• Moist heat and/or ultrasound prior to stretching
• Muscle Energy Techniques
• Myofascial Release Techniques
• Stretch other muscles
• Iliopsoas, TFL, hamstrings, gluts

• Exercises to strengthen the piriformis
• NSAIDs
• Manual Manipulations
• Surgical intervention
• Release of the piriformis tendon
• Last resort treatment

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Prevention

• Recurrence of pain in the piriformis muscle can
  be prevented by continuing the stretching
  exercises and by avoiding known risks factors