Piriformis Syndrome?

[takajokomo]

I have a patient with symptoms suggestive of piriformis syndrome. after 2 weeks of treatment with illiopsoas and piriformis stretching, utrasound to piriformis, and hip extensor strengthening on the affetecd side, symptoms have improved a bit but continue to persist.

She also presents with right anterior groin pain when the bladder is full, has excessive hip external rotation at rest and a mild pes cavus on weight bearing (possibly from the external hip rotation).

Could this be a genuine case of piriformis syndrome? Or are there other differential diagnoses I should consider?

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[nmbulan]

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[linbin]

hi friend
as you might be aware-various biomechanical alterations can lead to pain in the buttock area.
our thinking should the the basic principles
1)
structures that are beneath-likely source
structures that can refer pain to that site-somatic refered/visceral refered


2)
looking for cause of pain rather than source-shirley sharmann approach-movement impairment syndromes

3)
for mangement
-take into consideration -concept of regional interdependence
problem in one area causing maifestation in another area-so treatmentdirecteed to an area-reduce symptoms in area of pain.there is clear cut explanation for this phenomenon.

[ginger]

Takajokomo
So called piriformis syndrome occurrs when this muscle's normal pattern of recruitment is affected by irritation at the nerve root, specifically at L4. Before any treatment can be effective and long term at the site of pain, it is first necessary to restore a non irritated state to this nerve root. This is done by turning off protective behaviour at at around the L4 facet joint and it's corresponding nerves and muscles. Without this ,it will usually not be possible to restore a normal state of tone to Piriformis.

[linbin]

Hi,
As far as i know,prififormis syndrome arises when the sciatic nerve or braches(tibial/common peroneal) being impinched/irritated by piriformis muscle.as a name syndrome implies there are multiple factors which leads to it.
I wonder how L4 facet joint and corresponding nerve become the main culprit.I dont understand the rationale behind it.Is there any literature back up for this claim??

[ginger]

In many cases effective treatment ( by mobilising L4 unillateraly till protective paravertebral tone is normalised ) at the lumbar spine will eliminate the so called piriformis syndrome without attention to lateral thigh structures at all. In the light of these changes it can be said that many times the symptoms felt at the lateral thigh ( including the oft misunderstood ITB ) were entirely referred , rather than the result of some misbehaviour of the pirifrmis muscle.

[physiofixme]

I agree with Ginger. Review your anatomy on somatic referred and radicular referred pain patterns and you will see how L4 could be part of the cause of pain if not the sole cause of pain!!

[thabiso]

Thanks.
I see the sense in it and agree,but the mind should also be open to the other possibility always. I have managed a few cases which responded to targeted treatment to piriformis (trigger point treatment, ultrasound and stretches).

[physiofixme]

Absolutely and I guess this is where sound clinical reasoning can distinguish one from the other!!!!

[takajokomo]

I am also in total support of remaining open to other differential aetiologies. For example, I have attended to one case where piriformis shortening & irritation was secondary to excessive supination of the hindfoot. I have also heard of a few cases where weakened gluteals present a very important aetiology.

But I will not be quick to dismiss Ginger's postulation that L4 is important in Piriformis Synd; it sounds quite logical.

[Hallamshire Physiotherapy]

Hi
Lets be controversial: I think the 'piriformis' muscle is the not the seat of all musculoskeletal evil and should be set free. I see many people with 'piriformis' syndrome and have stopped rubbing it many years ago as it 1.does not work (in my experience) 2.only causes the patient further pain 3. Hurts my thumbs
Look for the cause and don't blame that little muscle. Ill start the "Piriformis is innocent campaign".

Steve
Hallamshire Physiotherapy

[Physio Dace]

Praise be to Steve. I too am sick of hearing about this particular muscle. It seems to cop the blame for most lower quadrant and limb pain. In my mind most changes in local muscle tone and sensitivity (hence acting as pain generator) are a sequelae of some other dynsfunction elsewhere e.g. joint OA, neural irritation, immobilisation, maladaptive movement patterns etc etc. Further on treatment of the muscle has very short acting but short lived results. If it is necessary to "release" a muscle group as part of treatment program then I would be teaching the patient or their partner/family member to complete the ischaemic release so that it can done daily "for free".

[takajokomo]

Hey Steve. Should you wish to engage a campaign manager, I'm here.

[Hallamshire Physiotherapy]

Thanks takajokomo

After 'free piriformis' we could address the equally dubious 'tendonitis' and the even more ridiculous 'bursitis'!

Steve
Hallamshire Physiotherapy

[thabiso]

Okaaay......

Now its time for me to leave this forum! Now we are going to get some picketing and toyi-toying!

Out of interest of interest though(and hopefully without getting anyone too fired up) whats so wrong with the tendonitis and bursitis labels.

[ginger]

As indicated by the comment from thabiso, the world of physiotherapy treatments and understanding about the cause and physiology of common complaints is very variable. I agree that a thread on "bursitis " and "tendonitis " would be valuable. A way to reveal the neurological contributions to these often misunderstood issues at the very least. Who'll start it off, ?

[Hallamshire Physiotherapy]

Thabiso

I have no problem with the term 'bursistis' or 'tendonitis', but I think it is not as prevalent in our patients are people seem to think and the terms stops physiotherapists thinking.

'Bursitis' of the shoulder or hip, in my opinion, is not that common and I would say 49 out of 50 patients I see with the label 'bursitits' have other problems which change rapidly with movement/corrective exercise. I do not think we can change true 'bursitis' as a physio (I have stopped using ultrasound/interferential etc many years ago).
A patient I saw this week had the bursitis label and told by her Dr that physio would not help. It would not help if the diagnosis was correct (she even had full shoulder movement!), but she wanted a second opinion and the problem originated in her neck. She rapidly improved once treatment addressed the origin of the problem.

This is not uncommon the label of bursitis does more harm than good.

[CFSupport]

Nerve root "flossing" may help (or exacerbate) symptoms, but a single session to gauge response is appropriate.

[thabiso]

Nerve root "flossing" may help (or exacerbate) symptoms, .

Hi, Hope I dont appear really silly here. My first time for me to hear about this. What is flossing?

[CFSupport]

Flossing, as described, by McGill in Low Back Disorders is a technique that is meant to increase mobility around the point of an inpingment, in this case the periformis. Have the patient sit on a table with the legs bent at the knee and hanging freely. The patient then fully flexes the cervical spine (i.e. tucks chin), then in a coordinated manner, fully extends the knee, and cervical spine. repeat 5 ot 6 controlled reps. This techniques essentially moves the nerve root as a unit (dosent stretch it), literally flossing through possible areas of inpingment between the cervical SC region and the lower leg (sciatic nerve root flossing). i am by no means an expert in this technique but it is meant to relieve symptoms of impingment of the sciatic......let me know how it goes

[sheri]

back to the original point....
1) how is your patient going, takajokomo
2) you needed far more description of the patient if you required a decent response ie: more postural information, nerve testing, neural length testing, muscle length and strength testing...i am sure you did do all these things but in order to appraise it online we need more info!
3) you definitely do need to assess the lumbar joints and movements to rule out disc and facet problems. if these are all clear you need to look closely at the pelvis and work your way through the issues there (a topic i am slowly coming to grasp...textbooks on the way as we speak...). the groin pain and hip external rotation are sending alarms in my head. . .
4) this certainly does not seem like a condition where ultrasound will be of ANY benefit whatsoever so i suggest take that five or so minutes in each session to reassess and prescribe exercises.

keep us posted
Additional Comment I forgot:
message to thabiso

i see you are from botswana. i studied in south africa and since moving to and working in australia i realise how the universities in south africa (not sure of botswana) are quite backward in their research. no need to apologise for your questions. just hit those journals man!

good luck!

[thabiso]

Zimbabwe actually. thanks for encouragement

[takajokomo]

Thanks Sheri. But that patient has since recovered and has been symptom free for months now.

I attended a course on "dry needling" in the interim, and that patient was one of my first trials. Of course the patient was recovering gradually with stretches and myofascial release, but a combination of piriformis needling and stretches did the trick in days. Amazing!

I would also recommend dry needling for all physiotherapists out there. It's quite a useful technique.