Piriformis Syndrome - clinical pattern sheet PDF

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Condition Piriformis Syndrome Definition / Description Piriformis syndrome is a painful musculoskeletal condition, characterized by a combination of symptoms including buttock or hip pain. Piriformis syndrome is defined as a peripheral neuritis of the branches of the sciatic nerve caused by an abnormal condition of the piriformis muscle, such as an injured or irritated muscle. There are two types of piriformis syndrome; Primary piriformis syndrome Primary piriformis syndrome has an anatomical cause, with variations such as a split piriformis muscle, split sciatic nerve, or an anomalous sciatic nerve path. Among patients with piriformis syndrome, fewer than 15% of cases have primary causes. At present, there are no accepted values for the prevalence of the anomaly and little evidence to support whether the anomaly of the sciatic nerve causes piriformis syndrome or other types of sciatica. These findings suggest that piriformis and sciatic anomalies may not be as important to the pathophysiology of piriformis syndrome as previously thought. Secondary piriformis syndrome Secondary piriformis syndrome occurs because of a precipitating cause, including macrotrauma, microtrauma, ischemic mass effect, and local ischemia. Piriformis syndrome is most often (50% of the cases) caused by macrotrauma to the buttocks, leading to inflammation of soft tissue, muscle spasms, or both, with resulting nerve compression. Muscle spasms of the PM are most often caused by direct trauma, postsurgical injury, lumbar and sacroiliac joint pathologies or overuse. PS may also be caused by shortening of the muscles due to altered biomechanics of the lower limb, low back and pelvic regions. This can result in compression or irritation of the sciatic nerve.

Variations in the relationship of the sciatic nerve to the piriformis muscle shown on the diagram above: (A) the sciatic nerve exiting the greater sciatic foramen along the inferior surface of the piriformis muscle; the sciatic nerve splitting as it passes through the piriformis muscle with the tibial branch passing (B) inferiorly or (C) superiorly; (D) the entire sciatic nerve passing through the muscle belly; (E) the sciatic nerve exiting the greater sciatic foramen along the superior surface of the piriformis muscle. The nerve may also divide proximally, where the nerve or a division of the nerve may pass through the belly of the muscle, through its tendons or between the part of a congenitally bifid muscle. Populations / Risk Factors There are more women diagnosed with Piriformis syndrome than men, with a female–to–male ratio of 6:1. This ratio can be explained by the wider quadriceps femoris muscle angle in the os coxae of women. A fraction of the population is at high risk, particularly skiers, truck drivers, tennis players and long-distance bikers. Other causative factors are anatomic variations of the divisions of the sciatic nerve, anatomic variations or hypertrophy of piriformis muscle, repetitive trauma, sacro-iliac arthritis and total hip replacement. Symptoms Patients with piriformis syndrome have many symptoms that typically consist of;  persistent and radiating low back pain  (chronic) buttock pain  Numbness/paranesthesia  difficulty with walking and other functional activities such as pain with sitting, squatting, standing, with bowel movements and dyspareunia in women.  pressure pain on the buttock on the same side as the piriformis lesion and point tenderness over the sciatic notch in almost all instances  The buttock pain can radiate into the hip, the posterior aspect of the thigh and the proximal portion of the lower leg  pain with activity; prolonged sitting or walking, squatting, hip adduction and internal rotation and maneuvers that increase the tension of the piriformis muscle Clinical Signs A complete neurological history and physical assessment of the patient is essential for an accurate diagnosis. The physical assessment should include the following points: 

an osteopathic structural examination with special attention to the lumbar spine, pelvis and sacrum, as well as any leg length discrepancies

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diagnostic tests deep-tendon reflex testing, strength and sensory testing

Palpation The patient reports sensitivity during palpation at the greater sciatic notch, in the region of sacroiliac joint or over the piriformis muscle belly. It is possible to detect the spasm of the PM by careful, deep palpation. With deep digital palpation in the gluteal and retro-trochanteric area, there may be tenderness and pain with an exacerbation of tightness and leg numbness. FAIR/ Piriformis Test Painful Flexion Abduction Internal Rotation. Patient in side lying on edge of bed, affected leg on top. Flex hip to 60 degrees with knee flexed. Stabilise hip and apply downward pressure to the knee. Localized pain indicated piriformis tightness. Radiating pain indicates sciatic nerve involvement. Pace sign Pace’s sign consists of pain and weakness by resisted abduction and external rotation of the hip in a sitting position. A positive test is occurring in 46.5% of the patients with piriformis syndrome. Lasèque sign / Straight Leg Raise Test The patient reports buttock and leg pain during passive a straight leg raise performed by the examiner. Freiberg sign Involves pain and weakness on passive forced internal rotation of the hip in the supine position. The pain is thought to be a result of passive stretching of the piriformis muscle and pressure placed on the sciatic nerve at the sacrospinous ligament. Positive in 56,2% of the patients. Beatty’s maneuver An active test that involves elevation of the flexed leg on the painful side, while the patient is lying on the asymptomatic side. The abduction causes deep buttock pain in patients with PS, but back and leg pain in patients with lumbar disc disease. History      

PMH include previous injury, trauma, predisposing conditions related to PS Could have a previous diagnosis of ‘sciatica’ Any MOI – may not be one Aggravating/Easing factors Pain distribution patterns, hx of sciatic pain Activities relating to aggravation of pain i.e. sports/manual work

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Any pattern of acute flare up’s Hx of chronic pain

Investigations Radiographic studies have limited application to the diagnosis of piriformis syndrome. Although standard antero-posterior radiographs of the pelvis and hips, lateral views of the hips and either CT or MRI of the lumbar spine are recommended to rule out the possibility that the symptoms experienced by the patients originate from the spine or the hip joint. Electromyography (EMG) may be also beneficial in differentiating piriformis syndrome from other possible disorders, such as intervertebral disc herniation. Interspinal nerve impingement will cause EMG abnormalities of muscles proximal to the piriformis muscle. In patients with piriformis syndrome however, EMG results will be normal for muscles proximal to the piriformis muscle and abnormal for muscles distal to it. Electromyography examinations that incorporate active manoeuvres, such as the FAIR test, may have a greater specificity and sensitivity than other available tests for the diagnosis of piriformis syndrome.

Atypical Presentations                 

Dysfunction, lesion and inflammation of sacroiliac joint Pseudoaneurysm in the inferior gluteal artery following gynaecologic surgery Thrombosis of the iliac vein Painful vascular compression syndrome of the sciatic nerve, caused by gluteal varicosities Herniated intervertebral disc Post-laminectomy syndrome or coccygodinia Posterior facet syndrome at L4-5 or L5-S1 Unrecognized pelvic fractures Lumbar osteochondrosis Undiagnosed renal stones Lumbosacral radiculopathies Osteoarthritis (lumbosacral spine) Sacroiliac joint syndrome Degenerative disc disease Compression fractures Intra-articular pathology in the hip joint: labral tears, femuro-acetabular impingement (FAI)[14] Lumbar spinal stenosis

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Tumors, cysts Gynaecological conditions Diseases such as appendicitis, pyelitis, hypernephroma, uterine disorders, prostate disorders and malignancies in pelvic viscera. Psychgenic disorders: physical fatigue, depression, frustration Sacroiliitis

Management Options and Levels of Evidence Medical management Conservative treatment for piriformis syndrome includes pharmacological agents (non-steroidal anti-inflammatory agents (NSAIDs), muscle relaxants and neuropathic pain medication), physical therapy, lifestyle modifications and psychotherapy. Injections of local anaesthetics, steroids, and botulinum toxin into the PM muscle can serve both diagnostic and therapeutic purposes. Piriformis syndrome often becomes chronic and pharmacological treatment is recommended for a short period. Surgical management Surgical interventions should be considered only when nonsurgical treatment has failed and the symptoms are becoming intractable and disabling. Classic indications for surgical treatment include abscess, neoplasms, hematoma, and painful vascular compression of the sciatic nerve caused by gluteal varicosities. Surgical release with tenotomy of the piriformis tendon to relieve the nerve from the pressure of the tense muscle has resulted in immediate pain relief. The postoperative management consists of partial weight-bearing using crutches for 2 weeks and unrestricted range of motion exercises.

Physiotherapy Management The most commonly reported physiotherapy interventions include ultrasound, soft tissue mobilization, piriformis stretching, hot or cold therapy and various lumbar spine treatments (evidence level 2A). To achieve a 60 – 70% improvement, the patient usually follows 2 – 3 treatments weekly for 2-3 months. Stretching; Before stretching the piriformis muscle, treat the same location with hot or cold therapy for 10-15 minutes. The use of hot and cold before stretching is very useful to decrease pain. After that, begin with stretching of the piriformis which can be executed in a variety of ways. Stretch the piriformis muscle by

applying manual pressure to the muscle’s inferior border. It is important not to press downward, rather directing pressure tangentially, toward the ipsilateral shoulder. When pressing downward, the sciatic nerve will compress against the tendinous edge of the gemellus superior. However, when applying tangential pressure, the muscle’s grip will weaken on the nerve and relieve the pain of the syndrome. Another way to stretch this muscle is in the FAIR position. The patient lies in a supine position with the hip flexed, adducted and internally rotated. Then the patient brings his foot of the involved side across and over the knee of the uninvolved leg. We can enhance the stretch, by letting the physical therapist perform a muscle–energy technique. This technique involves the patient abducting his limb against light resistance, which is provided by the therapist for 5-7 seconds, with 5-7 repetitions After stretching, continue with myofascial release at the lumbosacral paraspinal muscles and McKenzie exercises. When the patient lies in the FAIR position, the lumbosacral corset can be used. The therapist can also give several tips to avoid an aggravation of the symptoms. This includes:      

Avoid sitting for a long period Stand and walk every 20 minutes Make frequent stops when driving to stand and stretch Prevent trauma to the gluteal region Avoid further offending activities. Daily stretching is recommended to avoid the recurrence of the piriformis syndrome.

The patient can also perform several exercises and treatments at home including:     

Rolling side to side with flexion and extension of the knees while lying on each side Rotate side to side while standing with the arms relaxed for 1 minute every few hours Take a warm bath Lie flat on the back and raise the hips with your hands and pedal with the legs like you are riding a bicycle Knee bends, with as many as 6 repetitions every few hours.

Useful Resources http://www.physio-pedia.com/Piriformis_Syndrome#Definition.2FDescription

Boyajian- O’ Neill L.A. et al. Diagnosis and Management of Piriformis syndrome : an osteopathic approach. The journal of the American and osteopathic association Nov 2008; 108(11): 657-664. (2A) Jankovic D, Peng P, van Zundert A. Brief review: piriformis syndrome: etiology, diagnosis, and management. Can J Anaesth. 2013 Oct;60(10):100312. doi: 10.1007/s12630-013-0009-5. Epub 2013 Jul 27. PubMed PMID: 23893704 (2A)...