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Pyriformis Syndrome

Wallet Sciatica

Piriformis syndrome is a neuromuscular disorder wherein stretching of the piriformis muscle entraps and compresses the sciatic nerve. This rare, often controversial condition is characterized by persistent and radiating pain in the buttocks, the posterior part of the thigh and the lower leg.


Presentation

The primary mode of presentation of piriformis syndrome is a persistent pain in the buttocks that may radiate to the hip, the posterior part of the thigh and the proximal part of the lower leg [1]. This may be associated with prolonged low back pain and sensory deficits in the form of numbness and paresthesia over the affected regions [2] [3]. Pain may also be present in the coccyx, groin or the distal parts of the leg [4]. The patient may have difficulty in walking and may present with a limp [5].

The pain may be aggravated by activity or during sitting, squatting or standing. A certain number of patients may exhibit pain with bowel movements or during sexual intercourse [6]. The pain might only be relieved by lying down or by bending the knee while walking. Some patients are unable to find pain relief in any position. However, walking does seem to provide them the maximum degree of relief.

This condition may be recognized by the short and externally rotated limb seen in a supine patient. This external rotation, also called splayfoot or a positive piriformis sign, is due to contraction of the piriformis muscle [7]. On examination, point tenderness is often found at the sciatic notch where the sciatic nerve passes under the piriformis. Certain maneuvers that may stretch the piriformis muscle and compress the sciatic nerve further may be performed to elicit the pain. These include FABER (flexion, abduction, external rotation), FAIR (flexion, adduction, internal rotation), Freiburg and the Pace maneuvers [8] [9].

Some patients may present with leg swelling and sexual dysfunction. Motor deficits, in the form of muscle weakness and decreased/ absent reflexes, are usually not seen in piriformis syndrome. This is in contrast to the other causes of low back pain.

Weakness
  • It usually presents with sciatic pain and hypoaesthesia and a limp caused by weakness of the gluteus maximus muscle. Peroneal nerve innervated muscles and hamstrings are also usually affected.[ncbi.nlm.nih.gov]
  • Motor deficits, in the form of muscle weakness and decreased/ absent reflexes, are usually not seen in piriformis syndrome. This is in contrast to the other causes of low back pain.[symptoma.com]
  • Weak Gluts and Piriformis Syndrome Hi there all you runners!![precision-chiropractic.co.uk]
  • "If those hip muscles are weak and you continue to add mileage, it can become an overuse issue."[active.com]
  • Other causes of leg pain, numbness, tingling, burning, and weakness include peripheral neuropathy, vascular disease, and piriformis syndrome.[rothmaninstitute.com]
Severe Pain
  • Piriformis syndrome is a condition in which you suffer severe pain starting in the center of your buttocks and, often, radiating down the back of your leg.[livestrong.com]
  • For more severe pain, your provider may recommend electrotherapy such as TENS. This treatment uses electrical stimulation to reduce pain and stop muscle spasms.[medlineplus.gov]
  • It can cause severe pain and discomfort in those who suffer from it.[disability-benefits-help.org]
  • Other conservative methods include: Rest, ice and heat packs Muscle relaxants Weight loss Rolling it on lacrosse ball ART / Graston technique Platelet Rich Plasma injection Dry Needling / Acupuncture In patients with severe pain, corticosteroid or anesthetic[jonhymanmd.com]
  • Get immediate medical care if: You have sudden, severe pain in your low back or leg and numbness or muscle weakness in your leg The pain follows a violent injury, such as a traffic accident You have trouble controlling your bowels or bladder Causes Sciatica[mayoclinic.org]
Difficulty Walking
  • See your physician if you have severe pain, numbness, tingling or difficulty walking. Because this syndrome involves nerves, you can suffer permanent damage and may need physical therapy before starting exercise again.[livestrong.com]
  • While the specific symptom depends on the underlying cause, some common complaints associated with piriformis syndrome include: Numbness in feet Difficulty walking Weakness in lower extremities Headache Muscle spasms Radiating pain Neck pain Abdominal[nevadapain.com]
  • walking (eg, antalgic gait, foot drop) Numbness in foot Weakness in ipsilateral lower extremity Headache Neck pain Abdominal, pelvic, and inguinal pain Dyspareunia in women Pain with bowel movements Signs: 2 Tenderness in region of sacroiliac joint,[morphopedics.wikidot.com]
  • Pain at the sacroiliac joint, greater sciatic notch, and piriformis muscle that radiates down the limb and causes difficulty walking. Acute exacerbation of pain by stooping or lifting and moderate relief of pain by traction in a supine position.[radsource.us]
  • Difficulty walking It takes us at least 12 months as a baby to learn the fundamentals of walking. It takes even longer to learn how to walk properly and eventually run.[avenuestherapyclinic.com]
Surgical Procedure
  • This material is intended to give the patient an overview of surgical procedures and treatments and is not intended to replace the advice and guidance of a physician.[neurosurgicalassociatespc.com]
  • Thus, the sciatic nerve block is a non-surgical procedure to anaesthetize the sciatic nerve bundle and thereby prevent the transmission of pain information.[nevadapain.com]
  • About Post-surgery Rehab There are many surgical procedures for the low back including discectomies, laminectomies and even spinal fusion surgeries.[avenuestherapyclinic.com]
  • Key words: Chronic pain; Failed back surgery syndrome; Psycho-social impact; Quality of life INTRODUCTION Failed back surgery syndrome (FBSS) is characterized by residual or persistent pain after lumbar spine surgical procedures being increasingly a common[scielo.br]
  • Although controversial, the proper diagnosis of piriformis syndrome may have prevented some of these patients from undergoing unnecessary surgical procedures. 2010 – NEW! Assoum, H.A., Jawish, R.M., & Khamis, C.F. (2010).[naric.com]
Leg Swelling
  • Some patients may present with leg swelling and sexual dysfunction. Motor deficits, in the form of muscle weakness and decreased/ absent reflexes, are usually not seen in piriformis syndrome. This is in contrast to the other causes of low back pain.[symptoma.com]
Fecal Incontinence
  • Symptoms of pudendal nerve entrapment include tingling and numbness in the groin and saddle areas, and can lead to urinary and fecal incontinence. [ citation needed ] Piriformis syndrome may also be associated with direct trauma to the piriformis muscle[en.wikipedia.org]
Muscle Spasm
  • Piriformis syndrome has many causes, but muscle spasm plays an important role in the origin of sensitization due to local injury, trauma, or strain.[necksolutions.com]
  • Suspected causes include: Muscle spasm in the piriformis muscle, either because of irritation in the muscle itself or irritation of a nearby structure such as the sacroiliac joint or hip Tightening of the muscle, in response to injury or spasm Swelling[cedars-sinai.edu]
  • Video Transcript Piriformis syndrome occurs when the piriformis muscle spasms and irritates or compresses the sciatic nerve. It often causes symptoms similar to sciatica, though it is not caused by a spinal problem like sciatica is.[spine-health.com]
  • Reducing pain If the injury is acutely painful or inflamed then applying ice may help reduce muscle spasm.[sportsinjuryclinic.net]
  • Suspected causes include: Muscle spasm in the piriformis muscle, either because of irritation in the piriformis muscle itself, or irritation of a nearby structure such as the sacroiliac joint or hip Tightening of the muscle, in response to injury or spasm[spine-health.com]
Low Back Pain
  • This is in contrast to the other causes of low back pain. The diagnosis of piriformis syndrome is one of exclusion and is primarily made on clinical grounds.[symptoma.com]
  • See Lumbar Epidural Steroid Injections for Low Back Pain and Sciatica[spine-health.com]
  • Overview Piriformis syndrome is a cause of low back pain (LBP) characterized by pain and instability. It occurs when the piriformis muscle which externally rotates and moves the thigh out to the side, impinges (puts pressure on) the sciatic nerve.[michigansportsandspine.com]
  • […] of sciatica and low-back pain. Spine. 1991; 16: 608-14. 35. HOLLINSHEAD W.H., ROSSE C. Textbook of Anatomy. 4th ed. Philadelphia: Harper and Row Publishers, 1985: 365-86. 36. HUBER H.M. The piriform syndrome – a possible cause of sci- atica.[passeidireto.com]
  • Low Back Pain • Buttock Soreness • Radiating Leg & Thigh Pain • Pain When Sitting • Tightness, Burning, Feeling of a Knot • Sciatica • Gluteal Pain If you have low back, buttock tingling, burning, or numbness extending down to your feet, most will tell[miraclestretch.com]
Low Back Pain
  • This is in contrast to the other causes of low back pain. The diagnosis of piriformis syndrome is one of exclusion and is primarily made on clinical grounds.[symptoma.com]
  • See Lumbar Epidural Steroid Injections for Low Back Pain and Sciatica[spine-health.com]
  • Overview Piriformis syndrome is a cause of low back pain (LBP) characterized by pain and instability. It occurs when the piriformis muscle which externally rotates and moves the thigh out to the side, impinges (puts pressure on) the sciatic nerve.[michigansportsandspine.com]
  • […] of sciatica and low-back pain. Spine. 1991; 16: 608-14. 35. HOLLINSHEAD W.H., ROSSE C. Textbook of Anatomy. 4th ed. Philadelphia: Harper and Row Publishers, 1985: 365-86. 36. HUBER H.M. The piriform syndrome – a possible cause of sci- atica.[passeidireto.com]
  • Low Back Pain • Buttock Soreness • Radiating Leg & Thigh Pain • Pain When Sitting • Tightness, Burning, Feeling of a Knot • Sciatica • Gluteal Pain If you have low back, buttock tingling, burning, or numbness extending down to your feet, most will tell[miraclestretch.com]
Muscle Strain
  • The differential diagnosis of piriformis syndrome includes spinal canal stenosis, lumbar muscle strain, herniated nucleus pulposus (HNP) and facet arthropathy.[symptoma.com]
  • Other, more common causes of buttock pain and leg pain, such as muscle strain, sacroiliac joint irritation, and hip pathology, as well as other causes of sciatica, such as disk pathology and spinal stenosis, must be ruled out.[britannica.com]
  • In order to ascertain a diagnosis of PS the clinician must rule out herniated nucleus propulpsus, facet arthropathy, spinal stenosis, and lumbar muscle strain. 1 Diagnostic machines such as CT, MRI, ultrasound and EMG are beneficial for ruling out other[morphopedics.wikidot.com]
Muscle Weakness
  • Motor deficits, in the form of muscle weakness and decreased/ absent reflexes, are usually not seen in piriformis syndrome. This is in contrast to the other causes of low back pain.[symptoma.com]
  • Some people also have numbness, tingling or muscle weakness in the affected leg or foot. You might have pain in one part of your leg and numbness in another part. When to see a doctor Mild sciatica usually goes away over time.[mayoclinic.org]
  • You have sudden, severe pain in your low back or your leg, and you have muscle weakness or numbness in your leg. Your pain starts after you have been injured in a traumatic event. You have problems controlling your bowels or bladder.[familydoctor.org]
  • Call your provider if you have: Pain that lasts longer than a few weeks Pain that starts after you have been injured in an accident Get medical help immediately if: You have sudden severe pain in your lower back or legs, along with muscle weakness or[medlineplus.gov]
  • Using compensatory body mechanics, triggered by the pain and muscle weakness, may also lead to muscle and ligament damage to other areas of your lower extremities or lower back. 7 Advertisement Body Mechanics That Can Trigger Pain The exact cause of piriformis[fitness.mercola.com]
Sexual Dysfunction
  • Some patients may present with leg swelling and sexual dysfunction. Motor deficits, in the form of muscle weakness and decreased/ absent reflexes, are usually not seen in piriformis syndrome. This is in contrast to the other causes of low back pain.[symptoma.com]
Sciatica
  • It is an important cause of buttock pain that may often be accompanied by sciatica. The pain is usually increased by muscular contraction, palpation or prolonged sitting.[ncbi.nlm.nih.gov]
  • @article{Mizuguchi1976DivisionOT, title {Division of the pyriformis muscle for the treatment of sciatica.[semanticscholar.org]
  • Complications Although most people recover fully from sciatica, often without treatment, sciatica can potentially cause permanent nerve damage.[mayoclinic.org]
  • When faced with a diagnosis of Piriformis Syndrome or Sciatica what helps? Sciatica treatments often depend on how severe the physical damage is, whether that damage has resulted from disc herniation or something else.[nydnrehab.com]
  • See Lumbar Epidural Steroid Injections for Low Back Pain and Sciatica[spine-health.com]
Sciatica
  • It is an important cause of buttock pain that may often be accompanied by sciatica. The pain is usually increased by muscular contraction, palpation or prolonged sitting.[ncbi.nlm.nih.gov]
  • @article{Mizuguchi1976DivisionOT, title {Division of the pyriformis muscle for the treatment of sciatica.[semanticscholar.org]
  • Complications Although most people recover fully from sciatica, often without treatment, sciatica can potentially cause permanent nerve damage.[mayoclinic.org]
  • When faced with a diagnosis of Piriformis Syndrome or Sciatica what helps? Sciatica treatments often depend on how severe the physical damage is, whether that damage has resulted from disc herniation or something else.[nydnrehab.com]
  • See Lumbar Epidural Steroid Injections for Low Back Pain and Sciatica[spine-health.com]
Irritability
  • This yet-investigational test can demonstrate the sciatic nerve irritation caused by the stretched piriformis muscle.[symptoma.com]
  • Suspected causes include: Muscle spasm in the piriformis muscle, either because of irritation in the piriformis muscle itself, or irritation of a nearby structure such as the sacroiliac joint or hip Tightening of the muscle, in response to injury or spasm[spine-health.com]
  • "If you have weakness of the piriformis and glute muscles, that increased internal rotation of the hip can lead to issues and irritate the piriformis."[active.com]
  • Your Sciatic nerve becomes irritated When your piriformis gets overused or irritated, it affects the sciatic nerve and causes the pain that you feel.[lowbackpainprogram.com]
  • Spasm and hypertrophy can physically irritate the nerve. 4 Second, when irritated, the piriformis can release inflammation byproducts that have been shown to be chemical irritants. 5 With the patient prone, efforts to place the thigh into internal rotation[footlevelers.com]
Radiculopathy
  • Due to this innervation, a lower lumbar radiculopathy may cause secondary irritation of the piriformis muscle, which may complicate diagnosis and hinder patient progress.[emedicine.medscape.com]
  • Clinical utility of reflex studies in assessing radiculopathy. Muscle Nerve. 1999 ; 22 ( 8 ): 1075 – 9. 50. Giesebrecht, S, Martin, PG, Gandevia, SC, Taylor, JL.[cambridge.org]
  • Sacroiliac and Iliosacral Influences Although there are 14 different dysfunctions possible within the pelvic girdle (some say more), iliosacral upslips and backward sacral torsions are at the top of my list as pain generators that mimic lumbar radiculopathies[erikdalton.com]
  • Patients with lumbosacral radiculopathy - pain that radiates into the buttock and leg due to problems at the spine - often have pain with a straight leg raise test; for those with piriformis syndrome, this test is typically negative.[britannica.com]
  • Sciatica, or lumbar radiculopathy, originates from the lumbar spine, whereas piriformis syndrome originates in the buttocks. In most people, the sciatic nerve passes underneath the piriformis muscle.[livestrong.com]
Paresthesia
  • This may be associated with prolonged low back pain and sensory deficits in the form of numbness and paresthesia over the affected regions. Pain may also be present in the coccyx, groin or the distal parts of the leg.[symptoma.com]
  • Attempts to establish an operational definition of the disorder have been made, but none are definitive. 3 Signs and Symptoms: as stated by Boyajian-O'Neill L et al Symptoms: 2 Pain with sitting, standing, or lying longer than 15 to 20 minutes Pain and/or paresthesia[morphopedics.wikidot.com]
  • Patients with sciatic nerve entrapment often have previous history of trauma and symptoms of sit pain, radicular pain of the lower back or hip and paresthesias of the affected leg [ 4 , 16 ].[ncbi.nlm.nih.gov]
  • The patient described his symptoms as a shooting pain from the buttock to the lateral part of the foot, along the back of his thigh and calf, sometimes accompanied by paresthesia.[naric.com]

Workup

The diagnosis of piriformis syndrome is one of exclusion and is primarily made on clinical grounds. Imaging techniques, such as computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography (USG) and electromyography (EMG), are used to rule out other conditions presenting in a similar manner [10]. The differential diagnosis of piriformis syndrome includes spinal canal stenosis, lumbar muscle strain, herniated nucleus pulposus (HNP) and facet arthropathy [6].

A potentially useful modality for diagnosing piriformis syndrome is magnetic resonance neurography (MRN). This yet-investigational test can demonstrate the sciatic nerve irritation caused by the stretched piriformis muscle. Via its efficacy to show a split nerve/ muscle, this test may serve as a guide to effective therapy in the form of surgery or injections.

Image-guided injections may also be useful to make a diagnosis. These can be accomplished by MRI or 3D imaging techniques. Other modalities such as ultrasound, EMG, fluoroscopic guided or blind injections are usually not preferred owing to their lack of reliability and potential side-effects.

Treatment

  • The prognosis is for complete recovery after symptomatic treatment with nonsteroidal antiinflammatory medication and physical therapy.[ncbi.nlm.nih.gov]
  • @article{Mizuguchi1976DivisionOT, title {Division of the pyriformis muscle for the treatment of sciatica.[semanticscholar.org]
  • Treatment: Treatment for piriformis syndrome starts with relaxing the piriformis muscle as much as possible. All the activities that cause or aggravate this disorder should be avoided.[neurosurgicalassociatespc.com]
  • […] use of botulinum toxin type A for the treatment of piriformis syndrome but the results were inconclusive and further research is needed to validate this treatment.[m.webmd.boots.com]

Prognosis

  • The prognosis is for complete recovery after symptomatic treatment with nonsteroidal antiinflammatory medication and physical therapy.[ncbi.nlm.nih.gov]
  • Treatment of acute piriformis syndrome usually has a good prognosis; the prognosis declines as the disease becomes chronic.[medicinenet.com]
  • What Is the Prognosis for Piriformis Syndrome? The prognosis for piriformis syndrome varies, often depending on when it is diagnosed. Since it is a condition that is often overlooked and misdiagnosed, delayed diagnosis is common.[emedicinehealth.com]
  • What is the prognosis? The prognosis for piriformis syndrome is normally good. Once the underlying problems and symptoms have been addressed, you can usually resume your normal activities.[adjustinchiropractic.com]

Etiology

  • Secondary piriformis syndrome (pelvic outlet syndrome) - This classification would encompass all other etiologies of piriformis syndrome, with the exclusion of lumbar spinal pathology.[emedicine.medscape.com]
  • Imaging Given the multiple etiologies of piriformis syndrome, the findings on imaging studies are variable.[radsource.us]
  • The success of BTX in treating PS supports the prevailing pathoanatomic etiology of the condition and suggests a promising future for BTX in the treatment of other myofascial pain syndromes.[ncbi.nlm.nih.gov]
  • Etiology early sciatic nerve division and passage through the muscle belly or above it narrowed sciatic foramen accessory piriformis muscle muscle hypertrophy lumbar lordosis ganglion or cyst any mass lesion spasm athletes cerebral palsy bursitis and[radiopaedia.org]
  • Lesion of sciatic nerve, unspecified lower limb G57.01 - Lesion of sciatic nerve, right lower limb G57.02 - Lesion of sciatic nerve, left lower limb M62.838 Other muscle spasm Piriformis Syndrome ICD-9 355.0 (lesion of sciatic nerve) Piriformis Syndrome Etiology[eorif.com]

Epidemiology

  • […] sciatic nerve, unspecified lower limb G57.01 - Lesion of sciatic nerve, right lower limb G57.02 - Lesion of sciatic nerve, left lower limb M62.838 Other muscle spasm Piriformis Syndrome ICD-9 355.0 (lesion of sciatic nerve) Piriformis Syndrome Etiology / Epidemiology[eorif.com]
  • Of these, epidemiological studies suggest that between 5-36% have lower back pain that is attributable to piriformis syndrome.[nevadapain.com]
  • Failure of piriformis syndrome treatment may be secondary to an underlying internal obturator muscle injury. [21] Epidemiology [ edit ] Comparison of the average cost of treatment between males and females in 2010 and 2011.[en.wikipedia.org]
  • Epidemiology Frequency United States The female-to-male incidence ratio of piriformis syndrome is 6:1. In one study at a regional hospital, 45 of 750 patients with LBP were found to have piriformis syndrome.[emedicine.medscape.com]
Sex distribution
Age distribution

Pathophysiology

  • It is interesting to note that a description of the syndrome is found in most medical texts, yet the criteria for diagnosing piriformis syndrome and pathophysiology still remains a controversial issue (3,4).[blog.nasm.org]
  • The weakness, atrophy and relief of the sciatic nerve compression are all result of the botox, which essentially reverses the underlying pathophysiology of PS. 1 In a 10 year cohort study it was reported reported that patients who received the botox injection[morphopedics.wikidot.com]
  • Although no general consensus about the etiology and pathophysiology of piriformis syndrome exists, many physicians and physical therapists attribute this syndrome to a specific mechanism involving the sciatic nerve.[emedicine.medscape.com]
  • […] prevalence of the anomaly and little evidence to support whether or not the anomaly of the sciatic nerve causes piriformis syndrome or other types of sciatica. [10] These findings suggest that piriformis and sciatic anomalies may not be as important to the pathophysiology[physio-pedia.com]

Prevention

  • PREVENTION Most causes of piriformis syndrome are preventable and frequently are related to activities of daily living.[journals.lww.com]
  • Learn how to treat and prevent this lower-back and buttock pain that is common among runners and triathletes. Photo: Shutterstock.com Learn how to treat and prevent this lower-back and buttock pain that is common among runners and triathletes.[triathlete.com]
  • Developing good technique can prevent these repetitive motions from damaging the piriformis. Investing in comfortable, well-fitting running shoes is important.[medicalnewstoday.com]
  • After meticulously reconstructing the pelvis of our ancient ancestor Lucy, Lovejoy confirmed the piriformis muscle reinforces the femoral neck and prevents it from bending while we walk and run (Fig. 1).[running.competitor.com]
  • Is it possible to prevent piriformis syndrome? It is possible to prevent some individuals from getting piriformis syndrome by avoiding overuse of and trauma to the low back/gluteal muscles.[medicinenet.com]

References

Article

  1. Tonley JC, Yun SM, et al. Treatment of an individual with piriformis syndrome focusing on hip muscle strengthening and movement reeducation: a case report. J Orthop Sports Phys Ther 2010;40(2):103-111.
  2. Foster MR. Piriformis syndrome. Orthopedics. 2002;25:821-825.
  3. Retzlaff EW, Berry AH, Haight AS, Parente PA, Lichty HA, Turner DM, et al. The piriformis muscle syndrome. J Am Osteopath Assoc. 1974;73:799-807.
  4. Cramp F, Bottrell O, et al. Non–surgical management of piriformis syndrome: A systematic review. Phys Ther Rev 2007; 12:66-72.
  5. Hughes SS, Goldstein MN, Hicks DG, Pellegrini VD. Extrapelvic compression of the sciatic nerve. An unusual cause of pain about the hip: report of five cases. J Bone Joint Surg Am. 1992;74:1553-1559.
  6. Kirschner JS, Foye PM, Cole JL. Piriformis syndrome, diagnosis and treatment. Muscle Nerve Jul 2009; 40(1):10-18.
  7. Lori A, Boyajian-O’ Neill, et al. Diagnosis and management of piriformis syndrome:an osteopathic approach. J Am Osteopath Assoc Nov 2008; 108(11):657-664.
  8. Chaitow L. Soft Tissue Manipulation: A Practitioner's Guide to the Diagnosis and Treatment of Soft-Tissue Dysfunction and Reflex Activity. 3rd ed. Rochester, Vt: Healing Arts Press;1988.
  9. Magee DJ. Orthopedic Physical Assessment. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1997.
  10. DiGiovanna EL, Schiowitz S, Dowling DJ, eds. An Osteopathic Approach to Diagnosis and Treatment. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins;2005 .

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Last updated: 2019-07-11 21:19