Piriformis Syndrome Piriformis Syndrome is quite a controversial clinical phenomenon because the diagnostic criteria are not entirely

agreed on and reliability of clinical tests is not fully proven. However, some key issues with this condition are: what are the biomechanical relationships between the sciatic nerve and piriformis muscle? how can the nerve component be detected and treated? PIRIFORMIS SYNDROME AS A CAUSE OF SCIATICA

BIOMECHANICS Based on the work of Dr Alf Breig, it can be seen that significant interactions between the sciatic nerve and the piriformis muscle occur with the straight leg raise (SLR). During the SLR, the muscle and nerve perform an action similar to two blades of a pair of scissors, sliding diagonally and compressing one another as they attempt to pass the shortest distance between the spine and distal edges of the pelvis (Figure 1). Hence, it becomes clear that it may at times be important to use physical techniques in diagnosis that help ascertain if the patient problem contains an emphasis of one or other components or if the interactions themselves are the key aspect. Therefore differentiation tests can be performed to establish clinical evidence of these components. Biomechanical interactions between the neural tissues in the pelvis and piriformis muscle during the SLR.

Fig. 1A (left) Neutral SLR Position - Fig. 1B (right) Straight Leg Raise From Breig 1978, Neurodynamic Solutions (NDS)

Fig. 1C (left) Anatomical Relations Fig. 1D (right) Top Part: Lumbar Spine - To the Left: Caudad From Breig 1978, Neurodynamic Solutions (NDS) A. Fig. 1A: Neutral SLR position - spinal nerves (L4-S1) joining the lumbosacral trunk and sacral plexus on their course toward the greater sciatic foramen. The curved rim at the bottom of the picture is the bony outline of the foramen. Note that the neural tissue is loose. B. Fig. 1B: Straight leg raise produces increased tension and distal sliding in the nerves toward the greater sciatic foramen, indicated by the black marker placed on the nerve immediately proximal to the foramen. C. Fig. 1C: Anatomical relationsbetween the piriformis muscle and sciatic nerve, neutral SLR. D. Fig. 1D: The top part of the picture is the lumbar spine, caudad is to the left. o o o o o o o Abbreviations: PMM - psoas major muscle; ARLN5 - anterior ramus of the fifth lumbar nerve root; LST - lumbosacral trunk; ON - obturator nerve; SGA - superior gluteal artery; PM - piriformis muscle;

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SP - sacral plexus; IGA - inferior gluteal artery. During the SLR the muscle and nerve approximate and are aligned more parallel, producing a scissor action between the two.

The dynamic interactions between the muscle and nerve during the SLR have important clinical implications in relation to both diagnosis and treatment (for detailed more information, see Shacklock 2005, Clinical Neurodynamics). CLINICAL TESTING A key aspect of assessment of the piriformis syndrome is neurodynamic testing. A technique that evaluates the neural and musculoskeletal component is the neurodynamic test for the peroneal or tibial nerve components because each of these may be involved. An early technique of choice is the neurodynamic test in Figures 2 and 3.

Figure 2. Internal RotationFigure 2. The straight leg raise test with plantarflexion/inversion and internal rotation below 70 of hip flexion. The leg raise component applies distal force to the sciatic nerve (Goddard and Reid 1965), the internal rotation stretches piriformis onto the nerve and simultaneously applied distal tension to the nerve (Breig 1978; Breig and Troup 1979). The plantarflexion/inversion component applies tension to the peroneal component of the nerve. The reason this last movement may be used is that sciatica due to piriformis problems sometimes involves the peroneal component. Naturally, the problem may also involve the tibial part of the sciatic nerve and this is where dorsiflexion is used to test this component.

Figure 3. External RotationFigure 3. The SLR test with plantarflexion/inversion and external rotation at or above 70 of hip flexion. External rotation is performed because this accommodates the tendency of the muscle to internally rotate at 70 or more of hip flexion. This helps to stretch the muscle onto the nerve and test the dynamics between the two. The aim of changing the rotation from external to internal from below to above 70 is to use the natural biomechanics of the muscle to maintain pressure on the nerve. Resisted static muscle contraction can also be performed to apply further pressure. The piriformis syndrome can definitely involve the sciatic nerve in some cases (see references) and therefore neurodynamic testing is an essential ingredient of all examinations for the syndrome. Higher level progressions for assessment can be achieved by use of the 3b neurodynamic sequences and the slump test, applying similar principles. The proximal components of slump test are performed. Since the hip joints are flexed to approximately 90, passive external rotation and active internal rotation of the hip are used to integrate muscle with neural functions (Figure 4). As mentioned, dorsiflexion or plantarflexion/inversion can be used to emphasize the peroneal or tibial components.

Figure 4. Piriformis Slump TestFigure 4. Piriformis slump test. The proximal components of slump test consist of thoracic, lumbar and cervical flexion. The hip is externally rotated and plantarflexion/inversion or dorsiflexion can be performed. The neural component is differentiated with neck movements. Active internal

rotation of the hip is performed actively against the therapists resistance, if so desired for a higher degree of sensitization (Shacklock 2005). In searching for a link between a symptomatic piriformis muscle and nerve involvement, it can be necessary to produce muscle contraction at the same time as the neurodynamic test (eg. SLR). Because of its increased sensitivity, it is often suited to patients whose symptoms are small the problem is difficult to detect, athletes, occupational overuse and sporting situations. Lower levels of testing can be performed at levels 1 and 2. The subject of progressing neurodynamic diagnosis and treatment is elaborated on in Clinical Neurodynamics. The techniques presented above are classified as a level/type 3c (multistructural) technique (see chapter 6 and pages 218-233). Since the nerve may be involved in some cases, it is essential that a neurological evaluation be performed, including vibration sense which is a particularly sensitive indicator of neuropathy. Muscle anomalies and intrapelvic pathologies can cause sciatica at the piriformis and obturator regions, such that several variations in anatomy have been identified some of which are described in Figure 5. However, another surgically proven pathology is that of pressure of obturator internus being applied to the nerve and endometriosis also.

Figure 5. Anatomical variations in the passage of the sciatic nerve past piriformis. The peroneal component sometimes passes through the muscle.Figure 5. Patterns in which the peroneal component of the sciatic nerve anomalously passes through the piriformis muscle. The tibial nerve has also been described to be compressed between piriformis and gamelli, along with the smaller gluteal nerves. Treatment of Piriformis Syndrome - Neural Component The treatment for piriformis syndrome when it involves the sciatic nerve is derived from the clinical presentation, in particular what level the patient is at. For instance, if the patient is at level 1, the treatment will be quite different from if they are at level 3c. Here are some basic progressions which form a part of what the therapist can do for the problem.

Figure 6. Static Off-LoaderFigure 6. Static off-loader for releasing the sciatic nerve adjacent piriformis; hip flexion/abduction/external rotation. This position is likely to place the sciatic nerve in an off-loaded position and at the same time take tension off the nerve, as long as the amount of hip flexion is not too great. 1. The patient is positioned so as to reduce tension from the sciatic nerve and also eliminate as best possible any compression between the nerve and piriformis. The patient can use this as a rest position and, from here, neural mobilisations can be performed and they can be performed as a home exercise (Figure 6). Knee extension can be performed as a one-ended distal slider and as the patient improves. Dorsiflexion can be added. This will naturally produce more distally directed tension in the nerve and must be performed with more care than the earlier progression. Add neck flexion and spinal flexion and repeat 2. More tension can be added to the nerve by positioning the patient in hip internal rotation. This may also apply more pressure of the muscle on the nerve. Then the piriformis slump can be performed (Figure 4.) as a neural technique in which the patients hip is positioned external rotation to apply pressure of the muscle on the nerve. Resisted static contraction piriformis can then be performed then, as the muscle is relaxed, the hip is moved into more external rotation and the piriformis is stretched once the technique is finished.

2. 3. 4. 5. 6. 7.

These are a few of the techniques that can be used to treat sciatica when the piriformis muscle is involved. For more information on openers, closers, more progressions and exercises, refer to Clinical Neurodynamics (pp. 218-223). REFERENCES
Breig A 1978 Adverse mechanical tension in the central nervous system. Almqvist and Wiksell, Stockholm. Breig A, Troup J 1979 Biomechanical considerations in the straight leg raising test. Cadaveric and clinical studies of medial hip rotation. Spine 4 (3): 242-250 Goddard M, Reid J 1965 Movements induced by straight leg raising in the lumbo-sacral roots, nerves and plexus, and in the intrapelvic section of the sciatic nerve. Journal of Neurology, Neurosurgery and Psychiatry. 28: 12: 12-18 Shacklock 2005 Clinical Neurodynamics: a new system of musculoskeletal treatment.