An Alternative Treatment Approach to Piriformis Syndrome

1
An Alternative Treatment Approach to Piriformis
Syndrome

• Korey Pieper, DPT, OCS
• Marie Potter, DPT, OCS, ATC
• Rick J Rafael, DPT, OCS, CSCS
• Jason Tonley, DPT, OCS
• Kaiser Permanente West Los Angeles Orthopaedic
  Residency Program
• September 2008

2
Piriformis SyndromeDefined

• Neuritis of the branches of the sciatic nerve,
  caused by pressure of an injured or irritated
  piriformis muscle1.

3
Symptoms

• Radiating pain from the low back down over the
  sacrum into the buttocks and hip region, as well
  as down the posterior portion of the upper leg to
  the popliteal region1.

Image from bp1.blogger.com
4
Anatomy
image from www.tpmassageball.com
5
Possible Causes of Piriformis Syndrome

• Anatomical variation
• L/S dysfunction
• Muscle tightness and/or spasm
• Overuse
• Post surgical injury
• SIJ dysfunction
• Trauma/fall

6
Differential Diagnosis

• Differential Diagnosis of Hip pain7,8
• Intra-articular Extra-articular (Often Managed
  Operatively)
• Labral Tears
• Loose Bodies
• Femoroacetabular Impingement (FAI)
• Hypermobility
• Capsular Laxity
• Ligamentum Teres Tear
• Chondral Damage
• Snapping Hip Syndrome
• IT Band Syndrome
• Greater Trochanteric Bursitis
• Gluteal Tendon Injury

7
Differential Diagnosis

• Differential Diagnosis of Hip pain7,8
• Extra-articular Causes (Often Managed
  Non-Operatively)
• Femoral Neck Stress Fracture
• Adductor Strain
• Piriformis Syndrome
• Sacroiliac Joint Syndrome
• Tendonitis (hip flexors, abductors, adductors)

8
Differential Diagnosis

• Other Competing Diagnosis
• Lumbar Facet Syndrome
• Lumbar Disc Herniation
• Nerve entrapment
• Ischial Tuberosity Bursitis
• Lumbar radiculopathy
• Spinal stenosis
• Spondylolisthesis
• Osteoarthritis

9
Common Treatment Options

• Treatment Options2,3,4,5,6
• Injections
• L/S stabilization exercises
• Mobilization/manipulation L/S
• Mobilization/manipulation SI joint
• Foot orthotics
• Soft tissue mobilization
• Strengthening
• Stretching
• Surgical / arthroscopic release
• Ultrasound
• 
  
  
  
  
  

10
Common assumption guidingtreatment approaches

• The piriformis is shortened or in spasm and is
  compressing the sciatic nerve

11
Purpose of study

• To create a case series using an alternative
  treatment approach to piriformis syndrome

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Inclusion Criteria Objective Exam

• Unilateral pain from lower lumbar/buttock region
  to the leg
• Symptoms not reproduced from lumbar, SI joint,
  and/or hip joint examinations

13
Inclusion Criteria Objective Exam

• Lumbar Exam
• Negative AROM with OP
• Negative PA exam
• Neurological testing negative for nerve root
  lesion
• SIJ Exam
• Negative cluster
• Hip Exam
• Negative ROM, excluding quadrant

14
Inclusion Criteria Objective Exam

• Reproduction of symptoms with
• Palpation of piriformis muscle
• Piriformis stretch test
• FAIR Test
• Demonstrates movement dysfunction of ADD and/or
  IR and reproduction of symptoms with step down
  test
• Decreased reproduction of symptoms with corrected
  movement during step down test

15
Objective Exam

• Patient to fill out disability questionnaires
• Oswestry Disability Index
• Lower Extremity Functional Scale

16
Treatment Approach

• Isolated strengthening for hip extensors,
  abductors, and external rotators
• Functional movement re-education for decreasing
  hip adduction and internal rotation
• NO!!!!!
• Stretching
• Soft tissue massage
• Modalities

17
Treatment Approach Examples

• Hip strengthening
• Clams
• Bridging
• Prone hip extension
• Quadruped hip extension
• Hip abduction

18
Treatment Approach Examples

• Movement Re-education
• Postural correction
• Sit to stand transitions
• Single leg sit to stands
• Lunges
• Plyometrics if indicated

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Patient Data

• 7 Patients
• Age mean 56 (range 31 - 69)
• Duration of symptoms 197 days (range 45
  730)
• of visits 5 (range 2-8)
• Duration of visits 9 weeks (range 3-16)

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Average LE Functional Scale
Range initial (37-70) discharge
(54-80)
21
Average VAS (Pain Scale)
Range initial (6-10/10) discharge
(0-4/10)
22
Analysis

• Movement assessment allowed proper physical
  therapy diagnosis and treatment
• Patients can have multiple positive tests, but
  movement reproduces primary pain complaint
• Ceiling effect of questionnaires affects data
  analysis

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Future Research

• Prevalence of movement dysfunction in patients
  diagnosed with piriformis syndrome
• Most effective treatment modality for movement
  dysfunction strength training vs. movement
  re-education

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Conclusion

• Movement re-education and strengthening can be a
  successful way to treat piriformis syndrome when
  a patient presents with a coordination deficit.

25
References

• Edwards, F.O. Piriformis syndrome. Academy of
  Applied Osteopathy. Yearbook, 1962, pp 39-41.
• Parizale JR, Hudgins TH, Fishman LM The
  Piriformis Syndrome. Am J. Orthrop,
  199625819-823.
• Parizale JR, Hudgins TH, Fishman LM The
  Piriformis Syndrome A Review. Paper. The. Am J
  of Orthop. 2002251-11
• Bird JW Piriformis Syndrome. Oper Tech Sports
  Med 2005 13 71-79
• Mayrand N, Fortin J, Descarreaux M, Normand MC.
  Diagnosis and management of posttraumatic
  piriformis syndrome a case study. J.
  Manipulative Physiol Ther. 2006
  Jul-Aug29(6)486-91
• Keskula DR, Tamburello M Conservative Management
  of Piriformis. Syndrome. J Athl Train. 1992
  27(2)102, 104, 106-107, 110
• Lisa M Tibor, Jon Sekiya. Differential Diagnosis
  of Pain Around the Hip Joint. The Journal of
  Arthroscopic and Related Surgery. 2008191-15
• Michael K Shindle, Benjamin G Domb, Bryan T
  Kelly. Hip and Pelvic Problems in Athletes. Oper
  Tech Sports Med. 2007 15 195-203.