Piriformis syndrome Optimum rehab ?

[sdkashif]

Piriformis syndrome is characterized by pain and instability. The location of the pain is often imprecise, but it is often present in the hip, coccyx, buttock, groin, or distal part of the leg. The piriformis muscle can either irritate or compress the proximal sciatic nerve due to spasm and/or contracture, and this problem can mimic diskogenic sciatica (pseudosciatica). This condition is identical in clinical presentation to LBP with associated L5, S1 radiculopathy due to diskogenic and/or lower lumbar facet arthropathy with foraminal narrowing.

Aetiology:

The different causes of the piriformis syndrome can be categorized as under:

Trauma to the buttocks or gluteal region is the most common cause. Skiers, truck drivers, tennis players, and long-distance bikers are at high risk. Blunt injury may cause hematoma formation and subsequent scarring between the sciatic nerve and short external rotators

In Morton foot, the prominent head of the second metatarsal causes foot instability and a reactive contraction of the external rotators of the hip during gait.

Spinal stenosis can lead to bilateral piriformis tenderness.

Anatomic variations of the divisions of the sciatic nerve above, below, and through the belly of the piriformis muscle may be causative factors.

Hyperlordosis

Muscle anomalies with hypertrophy

Fibrosis (due to trauma)

Partial or total nerve anatomical abnormalities

Pseudoaneurysms of the inferior gluteal artery adjacent to the piriformis syndrome

Bilateral piriformis syndrome due to prolonged sitting

Total hip arthroplasty

Myositis ossificans

Vigorous physical activity

Functional biomechanical deficits: These may include the tight piriformis muscle,tight hip external rotators and adductors, hip abductor weakness, lower lumbar spine dysfunction, Sacroiliac joint hypomobility. As a result functional adaptations to these deficits include the ambulation with thigh in external rotation, functional limb length shortening, shortened stride length.

Management:

A suitable management programme will be followed as under:

Acute Phase:

Rest & avaoidance of provocative activities:

The patient should be instructed to rest from offending activities. Professions that involve prolonged sitting can worsen symptoms, and patients should avoid sitting for long periods. Patients should be instructed to stand and walk every 20 minutes. Patients should make frequent stops when driving to stand and stretch.

Modalities & Stretching:

Physical therapy modalities often are beneficial forms of treatment when used in conjunction with stretching and manual therapy. The use of moist heat and/or ultrasound treatment (~2 W/cm2 for 5-10 min) often is recommended prior to stretching of the piriformis muscle. Prior to performing piriformis stretches, the hip joint capsule should be mobilized anteriorly and posteriorly to allow for more effective stretching. Soft tissue therapies of the piriformis muscle can be helpful, including longitudinal gliding with passive internal hip rotation, as well as transverse gliding and sustained longitudinal release with the patient lying on his/her side. The piriformis muscle is stretched with flexion, adduction, and internal rotation of the hip adductors and the knee while the patient lies supine. This stretching is performed by bringing the foot of the affected side across and over the knee of the other leg. To enhance the stretch of the piriformis muscle, the physical therapist may perform a muscle-energy technique. This is completed by having the patient abduct the limb against light resistance provided by the therapist for 5-7 seconds, and then is repeated 5-7 times. In addition to stretching the piriformis, the patient also should be instructed to stretch the iliopsoas, tensor fascia latae, hamstrings, and gluteal muscles. Cold packs and, occasionally, electrical stimulation are applied after exercise or manual therapy. Cold modalities help to decrease pain and inflammation that may have been further triggered by stretching or massage. Remember to stress to patients the importance of light and gradual stretching techniques for the piriformis muscle to avoid overstretching and possible further irritation to the sciatic nerve.

Myofascial Therapies:

The Spray and Stretch myofascial treatment and ultrasound modality can be used to restore the original length of the muscle. In addition ischemic compression, lewit technique can also be used

Soft Tissue Massage:

Soft tissue massage to the gluteal and lumbosacral regions may help to decrease tightness of the affected musculature and reduce irritation of the sciatic nerve. Some physical therapists may be trained in performing myofascial release techniques for the piriformis muscle as well. Friction massage as described by James Cyriax can be used effectively.

Manipulation:

The patient is placed in a lateral recumbent position on the unaffected side. The therapist faces the patient and rotates the patient’s upper body away by laterally pulling on the lower arm. The therapist places his or her cephalad hand most superiorly on the paravertebral muscles. The patient’s top leg is brought over the edge of the table. The therapist places her caudal hand over the patient's hip in the line of the lowered leg. Force is applied in the direction of the lowered leg but perpendicular to the muscle fibers. When tension is reduced, a thrust (high-velocity low-amplitude) technique can be applied.

Addressing sacroiliac joint and low back dysfunction also is important.

Homes Activities Modifications:

(1)Before arising from bed, roll side to side and flex and extend the knees while lying on each side. This exercise can be repeated for a total of 5 minutes.

(2) Rotate side to side while standing with the arms relaxed for 1 minute every few hours.

(3) Take a warm bath with the full body (to the shoulders) immersed; the buoyancy effect is effective.

(4) Lie flat on the back and pedal the legs as if riding a bicycle by raising the hips with the hands.

(5) Perform knee bends, with as many as 6 repetitions every few hours. A countertop can be used for hand support.


Recovery Phase:

Modalities:

Therapeutic modalities are continued through this phase to enhance the benefits of rehabilitation.

Strengthening and Resumption of Activities:

The patient may begin gradual strengthening activities for the piriformis and gluteal muscles.. As the patient becomes asymptomatic, he or she may initiate light sport-specific activities and functional training.

Addressing posture and faulty pelvic mechanics is important when resuming activity. Some athletes may need to change their footwear or undergo an orthotic consultation to correct their pelvic alignment and avoid further stress on the piriformis muscle.

Maintenance Phase:

During the maintenance phase of rehabilitation, the patient should continue performing a home exercise program for increasing flexibility and strength. Athletes may gradually increase their training volume as tolerated. Runners should be cautious when resuming speed training and hill running, doing so in a gradual fashion with proper warm-up and cool-down periods. Compliance to a daily stretching program is crucial to avoid recurrence of this syndrome. Return to play is dependent on many factors (eg, severity of condition, how soon treatment was initiated, level of patient compliance to program).

[topbluenose]

the stretch quoted above of flexion, adduction and internal rotation makes sense.
However, bringing the foot of the affected side, over the opposite knee is external rotation.

Wonder if someone could clear this up please?

[ginger]

my guess is that sdkashif is fond of pasting pieces out of outdated and poorly written texts.
What text was it kashif?

[wkriski]

I've been suffering with lower back pain since early 2002 and over time it's been eventually diagnosed as piriformis syndrome. I've had physio, acupuncture, active release therapy, stretching, core strengthening, IMS, prescription drugs, chiropractic, tennis ball/trigger point massage, and it has degraded to a daily pain cycle. During ART I actually started getting spasms which are horrifically painful and emotionally draining.

You get to a point after spending thousands of dollars and hours getting ongoing physio and other treatments where you need a more effective solution.

Also, there doesn't seem to be a very good systematic process for diagnosing back pain and escalating treatments along a path. It is very haphazard and is usually because there is no one overseeing specialist that tracks the progress. At least that's my experience in Calgary. I am hopefully getting botox soon. One surgeon thought it was an cycle of inflamed joint and muscle tightness/spasm so to me the treatment should be to reduce inflammation at joint and relax the muscle so that it has time to break out of the cycle.

We're at 7 years now with this and the last 2 years have been brutal. At some point I think more aggressive/effective treatments need to be sought.

[IceMan]

the stretch quoted above of flexion, adduction and internal rotation makes sense.
However, bringing the foot of the affected side, over the opposite knee is external rotation.

Wonder if someone could clear this up please?

For the purpose of keeping things simple lets assume you're stretching the right piriformis. If you're in a hook/crook lying position and bring your right foot up (flex the right hip) and across the left knee/distal thigh and just let the knee "hang out" laterally yes the hip would be externally rotated. Using the left hand to pull the right knee internally rotates and adducts the hip and stretches the piriformis.

[john lee]

Please Help....I have been having this lower back pain and leg pain for over 3years now. The lower back pain has stopped. But the last year I have been having this leg type pain which is hard to identify. Whenever I put weight on the one leg it gives me this sharp pain inside the leg. Not all the time though. Just certain weird movements will aggravate this sharp pain down the leg. It seems to switch from right leg to left leg. Just the other day. After sitting on the computer....I try getting up and one leg I can't put any weight on it without having this sharp pain down the leg. I have tried many things. chiropractor for 3years...back inverter, etc. The best way I can describe it is: Certain bending movements is hard to get up. So, if anyone can please advise and help. I would really appreciate anything. Thanks in advance

[ATTIreland]

Please Help....I have been having this lower back pain and leg pain for over 3years now. The lower back pain has stopped. But the last year I have been having this leg type pain which is hard to identify. Whenever I put weight on the one leg it gives me this sharp pain inside the leg. Not all the time though. Just certain weird movements will aggravate this sharp pain down the leg. It seems to switch from right leg to left leg. Just the other day. After sitting on the computer....I try getting up and one leg I can't put any weight on it without having this sharp pain down the leg. I have tried many things. chiropractor for 3years...back inverter, etc. The best way I can describe it is: Certain bending movements is hard to get up. So, if anyone can please advise and help. I would really appreciate anything. Thanks in advance

Hi John,
The first thing that springs to mind is that you may have a lumbar disc bulge. This would explain the back pain, radiating pain and the difficulty with bending movements. Due to the severity and duration of symptoms I would recomend an MRI of your lower back to investigate it fully.

Have you gotten a diagnosis of what was wrong before (I take it the chiropractor explained what he thought it was)?