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Background Anatomy: piriformis_syndrome.jpg

'Piriformis Syndrome' is tricky, because if not diagnosed and treated properly, it can become a recurring bout of painful low back pain, hip pain, or numbness and tingling in the legs or feet, depending on whether the sciatic nerve is impinged or not. Nerve damage may become permanent if not addressed soon enough. However, piriformis syndrome usually is reversible, but it takes a little care and time. 

Fortunately, for the majority of patients without any serious musculoskeletal or neurological deficits, chiropractic treatment is very effective. A chiropractor will generally be your best bet to treating piriformis syndrome... since it’s the chiropractor that can routinely do the most as far as diagnosis and treatment options are concerned. An accurate diagnosis is always the key to successful treatment to distinguish this syndrome from Sciatica (Sciatic Neuralgia), and, possibly Meralgia Paresthetica.

Click here for video, 'Piriformis Syndrome'.

The piriformis muscle is located deep in the buttock. It is a short, thick muscle that originates on the pelvic surface of the sacrum and the sacrotuberous ligament. It extends laterally through the greater sciatic foramen to its insertion point on the upper lateral end of the bony portion of the hip, the greater trochanter of the femur (thigh-bone).

This muscle's primary function is in external (outward) rotation of the hip and it helps with extension and taking the leg away from the body. As with all muscles sitting close to a joint, its main function is to provide stability for the thigh and hip through a static or isometric contraction. It works in conjunction with several other muscles in the buttock area such as the quadratus femoris, obturator internus, the superior and the inferior gemellus. It is almost impossible to isolate in muscle testing because of it, but it is easy to find and palpate if you know how.

Causes, Signs and Symptoms:

A distinguishing characteristic of this syndrome is that it is almost always worse with sitting.  This is because when we sit we do so right on top of the piriformis muscle. This muscle can also become injured from just about anything such as: walking, lying down, overuse; reacting to an injury of the sacroiliac joint; or, it can be injured with significant trauma. Whatever the cause, initially the muscle starts to spasm and tighten up, just like when any other muscle is injured. This can be a very painful condition and for some people is very disabling.

Anatomically, the sciatic nerve which is the thickest and longest nerve in the body, can run either over the piriformis muscle, under the piriformis muscle in the majority of people, and in less common cases (approximately 15% of the population) the nerve will pierce through the muscle belly.

Whatever the arrangement, with respect to piriformis syndrome, when the injured piriformis muscle tightens up in spasm and compresses and pinches the sciatic nerve, sciatic inflammation and neurological symptoms can be produced on the affected side such as:

  • Lower back and/or pain that radiates to the buttocks/hip and sometimes down the leg into the foot;
  • Possibly numbness or weakness in the back;
  • Pain in the groin or perineum (the area between the anus and the scrotum or vulva);
  • Pins and needles, or tingling;
  • Weakness due to compression of the sciatic nerve;
  • Dyspareunia (painful intercourse);
  • Pain in the rectum during defecation;
  • Deep and burning/electrical pain down the leg on the side of the affected muscle like sciatica and usually enough to cause a limp;
  • The affected side will classically develop a laterally deviated foot, when you look down at your feet when you are standing or lying down relaxed on your back, you will see the toe pointing outward on the affected side in a laterally deviated (rotated) foot.

The primary difference between piriformis syndrome and sciatica, besides for the cause of the pain, is that sciatica pain will usually extend all the way down the leg and into the foot. Whereas the pain from 'true' piriformis syndrome will usually only extend to the knee and rarely below the knee.

However, it is also important to note that the referred pain pattern from the piriformis muscle itself as it begins to tighten up and exert compression on the sciatic nerve as it passes by the muscle, is felt down the leg in a path along the sciatic nerve trajectory. It is therefore often mistaken for 'sciatica' when it is not.

Sciatica can have many causes and it has been shown in many studies that disc herniations can be non-symptomatic. This is where it is easy to get in to a muddle. Imagine if a disc herniation is visible on a MRI scan and the piriformis syndrome and referred pain has not been considered as a diagnosis. You have surgery for the disc... and low and behold, there is no improvement after surgery.

Quite often 'piriformis syndrome' is not even considered as a diagnosis when somebody has sciatica or leg pain. And, the cause of sciatica is often thought to be due to a disc injury. It is, of course as stated previously, imperative to have an accurate diagnosis in order to provide the right treatment.

Other causes of piriformis syndrome may include:

1. Inflexibility: A simple physiological principle is that we need to stretch to maintain functional muscle length. Short, tight muscles can cause a number of problems including joint dysfunction; circulation problems, poor posture, and as in the case of piriformis syndrome, nerve entrapment. Scroll down for the recommended treatment.

2. Muscle Weakness: Although piriformis syndrome is a condition of short, tight muscles, weak muscles... usually an antagonistic or synergistic group can also contribute significantly to this problem. In piriformis syndrome, the predisposing inactive and weak muscles are typically the gluteal muscles... the gluteus maximus and medius. Scroll down for the recommended treatment.

The gluteus maximus, the main muscle involved with walking, extends the hip and aids the piriformis in external rotation of the thigh. It can become 'lazy' and therefore other muscles have to compensate for its weakness such as the piriformis. A major cause for an inactive gluteus maximus is unwanted reciprocal inhibition from overactive hip flexors (psoas major, iliacus, and rectus femoris). As an external rotator (turning the leg outward), the piriformis muscle   contracts every time we take a step. Functionally, the piriformis works full-time when we are mobile as it prevents the leg from collapsing inward as we walk.

The gluteus medius holds our pelvis upright as we stand. When it gets weak, the piriformis muscle compensates to assist by contracting and thereby getting thicker. Consequently, the weak gluts indirectly lead to piriformis syndrome also.

3. Chronic Subluxation: A subluxation can involve a spinal vertebra or joint that is 'mis-aligned' producing dysfunction (abnormal motion) and a 'pinched' nerve producing symptoms of pain. As a result, chronic (long-term) subluxations can then lead to piriformis syndrome.

The involved joints are the sacroiliac joints (SIJs) which connect the pelvis to the sacrum on both sides of the body. The SIJs move every time we bend at the hip, such as during walking, running, sitting, or simply bending down to pick something up. When one or both of the SIJs subluxate (lock up), it forces the surrounding muscles like the piriformis to work harder and get shorter than if the joints were moving properly... resulting in the piriformis syndrome and/or sciatica due to the subluxations here and muscular imbalances created. Scroll down for the recommended treatment.

4. Foot Dysfunction: The final and perhaps most common cause of piriformis syndrome is foot dysfunction, primarily overpronation creating 'pes planus' (flat feet) which may lead to bunions and hallux varus. Overpronation is an excessive rolling-in of the feet (inversion) as a result of dropped arches. Remember that the main role of the piriformis muscle is to prevent inward collapse of the legs during walking. Therefore, when overpronation is present, the piriformis works overtime to counter the inward movement of the leg during the gait cycle (ambulation). This results in an overworked and fatigued piriformis muscle, with all the other ingredients that come along with it. Scroll down for the recommended treatment.

The Chiropractic Examination:

The examination primarily addresses some of the following questions for answers:

  1. Is your problem stemming from the piriformis muscle or is it coming from the spine and/or its joints (degenerative changes such as a herniated disk, osteoarthritis, etc.)... the origin of the problem will determine the treatment plan;
  2. What is the actual causative factor? In the case of piriformis syndrome, the chiropractor will try to determine if a foot dysfunction is present, if it’s just a tight or weak muscle, if spinal or joint subluxations are present.

The chiropractic approach to diagnosing this syndrome includes a full evaluation of your spine and pelvis, and the related musculature. A functional, orthopaedic and neurological examination is also performed which may reveal:

  • Direct palpation (touch) of the piriformis muscle reveals a taut and tender muscle, often with soft-tissue swelling and trigger points present causing referred pain locally or down the leg;
  • A possible sign of a tight piriformis muscle is having one foot pointing outwards more than the other when you lie relaxed on your back.
  • Dysfunction in the sacroiliac joints is one contributory factor, which can lead to neuromuscular dysfunction causing weakness in the other muscles in the area;
  • Several activities are said to aggravate the pain in a piriformis syndrome such as: walking, sitting, climbing stairs, performing squats and running, but they are so general and therefore unreliable for diagnostic purposes;
  • Either resisted external rotation or passive internal rotation of the hip may increase the pain;
  • Resisted muscle testing can be used to see if a tendinitis is present. But since the piriformis works in conjunction with several other muscles in the buttock area such as the quadratus femoris, obturator internus, superior  and inferior gemellus... it is difficult to be specific;
  • If there are neurological signs and symptoms present, several tests are performed to rule out a disc injury. Some of these tests are modified to find out if the sciatic nerve is being affected and irritated by the taut piriformis muscle, such as Bonnet’s test.

The diagnosis is usually quite straight forward from the clinical tests, unless there is suspect of other musculoskeletal or neurological factors such as discopathy (disc herniations, degenerative disc disease) and arthropathies (arthritis, degenerative joint disease). A recommendation for diagnostic high-definition digital spinal or joint x-rays may also be prescribed on a 'case-by-case' basis if indicated.

When neurological symptoms are present, the chiropractor will do a full neurological examination in order to identify the cause of the symptoms. Disc herniations are the most common cause, but sometimes although rarely, more sinister causes have to be excluded. In those cases an MRI scan is requested thru the patient's medical practitioner.

Once a specific and accurate diagnosis has been made ruling out any contraindication to care, the treatment can start.

Chiropractic Treatment and Prevention:

Several rehab techniques for piriformis problems are available, none of which requires expensive equipment or great time commitments. Selecting the best exercise approach for each patient's hip problem is not difficult. A closely monitored home exercise program allows the doctor of chiropractic to provide cost-efficient, yet quite effective rehabilitation care.

1. Inflexibility: One solution to piriformis syndrome caused by inflexibility is to immediately and regularly begin stretching and passive mobilization, even in the early stages after an injury or with chronic pain. Muscle imbalance inhibits normal joint function and limits functional range of motion. 

Two stretches in particular are superb for relieving piriformis syndrome... the supine piriformis stretch, and a yoga pose called pigeon. To do the supine stretch, you need to lie on the floor on your back with knees bent. Crossing one leg over the other, push the lever side (which is the side not being stretched) actively toward your chest. By default, the bent leg will also move closer toward your chest, stretching the piriformis muscle. This stretch is excellent, especially for people that have poor flexibility to begin with. For those a bit more flexible, the pigeon stretch will be much more effective.

2. Muscle Weakness: Weak or lazy muscles are often the result of other tight muscles creating a 'domino' effect which can then lead to further tight muscles ultimately causing dysfunction and pain. This is referred to a 'dysfunctional' chain involving more than one muscle.

The way to correct the muscle weakness leading to piriformis syndrome is to strengthen the weak muscles quickly with isotonic resistance exercises. Since the hip joint functions as part of a closed kinetic chain during most daily and sports activities, weight-bearing exercises that require the co-contraction of accessory and stabilizing muscles are most effective. Examples of closed-chain exercises for the piriformis muscle include: partial squats, lunges (forward, back and to the side), and step-ups or stair climbing. Initially, the patient's own body weight will be sufficient. Resistance can be increased gradually and progressively with the use of hand weights or a weight bar. A closed-chain exercise available at many gyms is the leg-press machine; however, this machine does not retrain the co-contraction of accessory hip support muscles as fully as do weight-bearing exercises.

It is important for athletes, whether recreational or competitive, to regain the fine neurological control (proprioception and coordination) necessary for accurate hip and lower-extremity movements. Stimuli from articular and muscle mechanoreceptors must be modulated with efferent responses to maintain "dynamic joint stability." This means that some time (five to 10 minutes each day) should be spent exercising on one leg, with the eyes closed, while standing on a mini-trampoline or using a special wobble/rocker board.

3. Chronic Subluxation: If subluxations are present, then a chiropractor can administer manipulative adjustments aimed at restoring the function of the pelvic and spinal joints, which are often the cause, with particular attention paid to the knees, ankles, feet and SIJs to improve their mechanical motion and balance. Remember that only a chiropractic doctor can detect and correct subluxations... you won’t get that essential treatment in a MDs or physical therapist's office.

The scope of conservative chiropractic care management may also include combinations of:

  • Low-level laser therapy (LLLT) to promote soft-tissue healing, pain management, reducing inflammation and swelling;
  • Needle-insertion acupuncture for pain management and energy (Chi) balancing;
  • Electronic muscle stimulation (TENS, IFC, EMS) to reduce muscle spasm, pain, inflammation and swelling;
  • Rest;
  • Ultrasound;
  • Cryrotherapy (ice pack) application to reduce pain and swelling;
  • Trigger point pressure therapies (Shiatsu);
  • Kinesiology taping (KT) for joint stability and circulatory support;
  • Rehabilitation involving therapeutic stretching (myofascial release to bring length and relaxation to the involved muscle), and, strengthening exercises to strengthen core and weak muscles;
  • Instruction for individualized 'self-directed' home care; and
  • Coach postural, ergonomic and lifestyle modification which are important to ensure a quick recovery and prevent symptoms from coming back.

4. Foot Dysfunction: Since biomechanical alignment problems are frequently found in association with chronic piriformis complaints, patients must be screened for excessive pronation and/or leg-length discrepancies. When the lower extremities are aligned properly, when the piriformis muscles are strengthened and lengthened, and when the hip joints work smoothly, patients will be able to enjoy the benefits of independent mobility well into their elder 'golden' years.

A pronated foot (fallen arch) may cause rotation of the leg which can put extra strain on the piriformis muscle, can also be addressed with active 'functional alignment' through wearing custom-made, stabilizing orthotics and/or heel lifts frequently is a necessary part of a comprehensive piriformis rehabilitation program. This is followed by trigger point therapy, massage, and specific stretching and strengthening exercises for the pelvis, hips and feet.

Leg-length discrepancies and foot pronation problems are frequently found in association with piriformis syndrome. Studies have found osteoarthritis is much more common in the hip joint of a longer leg. The use of custom-made,

Orthotics are shoe inserts that correct foot dysfunction by creating the natural and missing arch common in overpronaters (flat feet, pes planus). By doing so, not only is the biomechanical fault responsible for piriformis syndrome corrected, but so are many other dysfunctions related to overpronation. The wearer gets relief from any and all pain conditions related to their mechanical foot dysfunction, including low back pain, knee pain or shin splints, amongst others. That’s the idea anyway. Let it be known that orthotics offer no protection sitting unworn in the closet; so the only useful orthotic is the worn orthotic.

Piriformis Syndrome Self-Care:

While waiting at home before seeing your sports chiropractor, you can do a few things to help relieve the pain associated with piriformis syndrome. To begin with you can ice the area to reduce inflammation.

You can also roll up a towel in the shape of a doughnut, or toilet seat, and use that as a cushion to sit on. This maneuver is especially useful for people who must sit at a desk at home or work for extended periods. Remember as stated previously, a characteristic sign of piriformis syndrome is that pain is worse while seated. Since many sufferers of piriformis syndrome are in their current state precisely because they must sit so much, a rolled up towel might go a long way in bringing pain relief.

Click here for article, 'How to Use Tennis Ball to Relieve Your Sciatic Nerve and Back Pain'.

Once again, stretching the piriformis muscle is imperative to relieve the pain and sciatica of the syndrome. Two major stretches one can do was explained previously... the 'supine piriformis stretch' and the yoga pose called 'pigeon'. Strengthening weak gluteals will also be important if this is your problem, but you’ll need to get these exercises from a trained professional.

What is the Prognosis?

The prognosis for piriformis syndrome is normally good as it is usually reversible, but it takes a little care and time. On the other hand, sciatic nerve damage may become permanent if not addressed early on. Once the underlying problems and symptoms have been addressed, you can usually resume your normal activities. In some cases, stretching for flexibility and strengthening exercise routines may need to be modified in order to reduce the likelihood of recurrence or worsening.

Prevention... What should you do?

These are all risk factors for developing recurring and chronic back pain:

  • Poor fitness levels and spinal stability (core muscle strength);
  • Poor posture;
  • Previous episodes of back pain; and
  • Pain for more than 8 days

So, the longer you have put up with the pain the more likely you are to become a chronic and recurrent sufferer.

The general recommendation is to make sure you get the problem diagnosed properly, have a chiropractor evaluate your core stability, have treatment if necessary and do the right type of exercise to help your problem recover as best as it can.

So don’t delay... if you or someone you know is needlessly suffering from low back, hip, buttock or leg pain; if you have numbness and tingling going into your leg or foot; if it hurts to sit, walk, lie down... then call Dr. Pisarek today for an appointment to come into Advanced Healthcare and have Dr. Pisarek assess you and develop a customized treatment protocol.

Let’s make sure your piriformis syndrome is past history and not a recurring pain in the butt without the use of drugs, needles or surgery... that will have you on the 'recovery' road to living pain free today!

References

  1. Papadopoulos SM, McGillicuddy JE, Albers JW. Unusual cause of "piriformis muscle syndrome." Arch Neurol 1990;47:1144-1146.
  2. Pace JB, Nagle D. Piriformis syndrome. West J Med 1976;124:435-439.
  3. Souza TA. Differential Diagnosis and Management for the Chiropractor: Protocols and Algorithms, 3rd ed. Sudbury, MA: Jones and Bartlett Pub., 2005.
  4. Neel SS, Jheeta GS. Piriformis syndrome. ACA J of Chiro 1986;23(12):32-35.
  5. Barton PM. Piriformis syndrome: a rational approach to management. Pain 1991;47(3):345-352.
  6. Vandertop WP, Bosma NJ. The piriformis syndrome: a case report. J Bone and Joint Surg 1991;73A(7):1095-1097.
  7. Sayson SC, Ducey JP, Maybrey JB, et al. Sciatic entrapment neuropathy associated with an anomalous piriformis muscle. Pain 1994;59(1):149-152.
  8. Fishman LM, Zybert PA. Electrophysio-logical evidence of piriformis syndrome. Arch Phys Med Rehabil 1992; 73(3):59-64.
  9. Laskowski ER, Newcomer-Aney K, Smith J. Refining rehabilitation with proprioception training. Phys Sports Med 1997;25:89-102.
  10. Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in length inequality. Spine 1983:643-645.

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