PIRIFORMIS SYNDROME

Piriformis syndrome is a neuromuscular disorder that occurs when the sciatic nerve is compressed or otherwise irritated by the piriformis muscle causing pain, tingling and numbness in the buttocks and along the path of the sciatic nerve descending down the lower thigh and into the leg.

Presented By Gurpreet Kaur Mahal M.P.T 3rd semester

Causes Piriformis Syndrome
Piriformis syndrome is predominantly caused by a shortening or tightening of the piriformis muscle, and while many things can be attributed to this, they can all be categorized into two main groups: Overload (or training errors); and Biomechanical Inefficiencies.

Overload (or training errors):

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Piriformis syndrome is commonly associated with sports that require a lot of running, change of direction or weight bearing activity. However, piriformis syndrome is not only found in athletes. In fact, a large proportion of reported cases occur in people who lead a sedentary lifestyle. Other overload causes include: Exercising on hard surfaces, like concrete; Exercising on uneven ground; Beginning an exercise program after a long lay-off period; Increasing exercise intensity or duration too quickly; Exercising in worn out or ill fitting shoes; and Sitting for long periods of time.

Biomechanical Inefficiencies:
The major biomechanical inefficiencies contributing to piriformis syndrome are faulty foot and body mechanics, gait disturbances and poor posture or sitting habits. Other causes can include spinal problems like herniated discs and spinal stenosis. Other biomechanical causes include:  Poor running or walking mechanics;  Tight, stiff muscles in the lower back, hips and buttocks;  Running or walking with your toes pointed out. Ref 1

Symptom of Piriformis Syndrome

Pain (or a dull ache) is the most common and obvious symptom associated with piriformis syndrome. This is most often experienced deep within the hip and buttocks region, but can also be experienced anywhere from the lower back to the lower leg. Weakness, stiffness and a general restriction of movement are also quite common in sufferers of piriformis syndrome. Even tingling and numbness in the legs can be experienced.

Diagnosis

Freiberg's maneuver of forceful internal rotation of the extended thigh elicits buttock pain by stretching the piriformis muscle, and Pace's maneuver elicits pain by having the patient abduct the legs in the seated position, which causes a contraction of the piriformis muscle. This report describes a maneuver performed by the patient lying with the painful side up, the painful leg flexed, and the knee resting on the table. Buttock pain is produced when the patient lifts and holds the knee several inches off the table. The maneuver produced deep buttock pain in three patients with piriformis syndrome. In 100 consecutive patients with surgically documented herniated lumbar discs, the maneuver often produced lumbar and leg pain but not deep buttock pain. In 27 patients with primary hip abnormalities, pain was often produced in the trochanteric area but not in the buttock. The maneuver described in this report was helpful in diagnosing the piriformis syndrome. It relies on contraction of the muscle, rather than stretching, which the author believes better reproduces the actual syndrome. Ref2 : The Piriformis Muscle Syndrome: A Simple Diagnostic Maneuver, Beatty, Robert A. M.D, Neurosurgery, March 1994 - Volume 34 - Issue 3 - p 512-514, Surgical Neurology

Piriformis Syndrome Treatment

Piriformis syndrome is a soft tissue injury of the piriformis muscle and therefore should be treated like any other soft tissue injury. Immediately following an injury, or at the onset of pain, the R.I.C.E.R. regime should be employed. This involves Rest, Ice, Compression, Elevation, and Referral to an appropriate professional for an accurate diagnosis. It is critical that the R.I.C.E.R. regime be implemented for at least the first 48 to 72 hours. Doing this will give the best possible chance of a complete and full recovery. The next phase of treatment (after the first 48 to 72 hours) involves a number of physiotherapy techniques. The application of heat and massage is one of the most effective treatments for removing scar tissue and speeding up the healing process of the muscles and tendons. Once most of the pain has been reduced, it is time to move onto the rehabilitation phase of treatment. The main aim of this phase is to regain the strength, power, endurance and flexibility of the muscles and tendons that have been injured.

Aims of rehabilitation
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Reduce pain. Improve flexibility and condition of the surrounding muscles through deep massage and stretching and strengthening. Return to full fitness. Injury prevention.

Reducing pain

 Ref:7 Surgical management of pain, By Kim Burchiel , 2002, Thieme medical publishers

Heat in the form of a hot bath or hot water bottle applied for approximately 20 minutes three times a day. Rest from activities that produce pain. This is likely to include running. Gentle stretching if pain allows

Soft tissue mobilization,and proprioceptive neuromuscular facilitation (PNF) techniques are particularly effective inmoderating the symptoms and restoring range of motion.

Ref4: Conservative Management of Piriformis Syndrome, Douglas R. Keskula, MS, PT, ATC, Michael Tamburello, MS, PT, Joumal ofAthletic Training, Volume 27 * Number 2 * 1992 * 102-110

Flexibility and conditioning

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As soon as comfortable to do so, a stretching and strengthening programme can begin. It is important to stretch in conjunction with strengthening and massage. Deep sports massage techniques can be used to release the tension in the Piriformis muscle. Massage can be applied on alternate days. At the very least two to three sessions at the start of rehabilitation is a good idea. Muscle energy techniques are an excellent way of improving the stretch of the muscle. On a daily basis perform Piriformis and outer hip strengthening exercises immediately followed by stretching. Hold stretches for 30 seconds and repeat 5 times. In addition to the specific Piriformis stretches it is important to stretch the hamstrings, groin, hip abductors and lower back.

Return to full fitness
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One daily tasks are pain-free, a return to activity program can commence. This should be a gradual process. An example return to running programme is given below. How quickly you progress through the programme will depend on the extent of the injury and original fitness levels. Day 1:walk 4 minutesjog 1 minutesrepeat 3 timesDay 2:rest Day 3:rest Day 4:walk 4 minutesjog 1 minutesrepeat 4 timesDay 5:rest Day 6:rest Day 7:walk 3 minutesjog 2 minutesrepeat 3 timesDay 8 rest Day 9 walk 3 minutesjog 2 minutesrepeat 3 timesDay 10 rest Day11walk 3 minutes jog 2 minutes repeat 4 times Day 12 rest Day 13 walk 2 minutes jog 3 minutes repeat 3 times This programme should be continued until you reach 15 minutes of solid running. You can then continue to gradually increase as normal, provided there are no symptoms. It is essential that stretching and strengthening are continued throughout the rehabilitation process and beyond.

Injury Prevention
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The following steps can be taken to avoid Piriformis syndrome returning: Stretch religiously before and after training. If you have a break from training, keep doing the stretches as you may find things tighten up, especially if you sit for long periods. Get a regular sports massage. A good therapist will spot potential problems before they happen. Get a biomechanical assessment. If you over pronate or have one leg longer than the other then this may make you more susceptible to injury. Maintain regular hip and Piriformis strengthening exercises. Make sure you have the right shoes for your sport and that they are not too old. Finally when recovering from injury, do not do too much too soon.

Initially, progressive piriformis stretching is employed, starting with 5 seconds of sustained stretch and gradually working up to 60 seconds. This is repeated several times throughout the day. It is important that any abnormal biomechanical problems, such as overpronation of the foot or other coexisting conditions, are treated. This stretching can be combined with physical therapy modalities such as ultrasound. If these fail, then injections of a corticosteroid into the piriformis muscle may be tried. Finally, surgical exploration may be undertaken as a last resort.

Piriformis Self-stretching

To keep your muscles and tendons flexible and supple, it is important to undertake a structured stretching routine. Stretching exercises are important in the rehabilitation of piriformis syndrome. The piriformis muscle itself should be stretched on a daily basis, as should the groin and other buttock muscles.

1) Sit with one leg straight out in front. Hold onto the ankle of your other leg and pull it directly towards your chest. 2) Lie face down and bend one leg under your stomach, then lean towards the ground.
Ref3: Piriformis syndrome: a rational approach to management ,Pamela M. BartonPain, Volume 47, Issue 3, December 1991, Pages 345-352

Stretching Exercises
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Outer hip stretch To stretch the muscles that rotate the hip outwards. Lie on your back and bend the knee of the leg to be stretched. Use the opposite hand to pull the knee over to the side as shown opposite. You should feel this in the hip and buttocks. Hold stretch for 30 seconds, repeat 3-5 times and stretch 3 times a day.

Piriformis stretch
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Lay on your back and bend both knees with the feet flat on the floor. Place the outer foot of the leg you wish to stretch on the lower thigh/knee of the other leg. Grip behind the thigh and pull this knee in towards your chest. You should feel a stretch in the buttock. Hold this position for 30 seconds, repeat 3-5 times and stretch 3 times a day.

Groin stretch
Stand with your feet wide apart Bend the leg you don't want to stretch out to the side. Keep the other leg straight. You should feel a streth on the inner thigh. Hold this position for 30 seconds, repeat 3-5 times and stretch 3 times a day.

Short groin muscle stretch
Sit on the floor and put the soles of your feet together. Use your elbows to apply a gentle downward pressure to your knees to increase the stretch You should feel a stretch in your groin. Hold this position for 30 seconds, repeat 3-5 times and stretch 3 times a day.

Muscle energy technique
With a partner lie on your front and get the partner to rotate the bent leg outwards (towards the horizontal) as far as it will comfortably go. Then the athlete applies gentle pressure at about 25% effort to try and return the leg to the vertical. The partner resists this movement. Hold this pressure for about 10 seconds and then relax. The partner then moves the leg further to stretch the muscle and holds this position for 30 seconds. Repeat this process until you get no further improvements in mobility. This is an excellent stretching method and has produced some exceptional and instantaneous results. This should only be done by trained therapists.

Piriformis (muscle energy) Technique
Dysfunction: Restriction of the external rotators of the right hip (hip will not internally rotate fully). Objective: Improve internal rotation of the right hip. Physician Position: Standing at the side of the table facing the patient. Patient Position: Supine. Procedure: Patient’s right hip is flexed to 90 degrees and the knee is flexed to 90 degrees. NOTE: In this position - outward movement of foot is internal rotation of hip. With your left arm, cradle the lower extremity between your arm and side. Place your right hand over the knee. Slowly move the foot outward (internal rotation) until the barrier is engaged. Have the patient contract their muscles and try to move their foot back towards midline (external rotation). Relax and rest for a count of 2-3 seconds. Re-engage the next barrier. Repeat several times. Re-assess the range of motion.  Ref5: Muscle energy technique, Dr Gary Fryer Osteopathic science, Semester 1, 2007

Massages for Piriformis Syndrome

One technique, called Neuromuscular Therapy or Trigger Point Therapy, aids in eliminating myofascial trigger points in the piriformis muscle. The massage therapist may also employ Deep Tissue Massage techniques or Myofascial Release techniques, both of which assist in separating the piriformis muscle from surrounding tissues Custom shoes may also help in preventing the injury from recurring. Correction of posture may also help in reducing the use of the piriformis muscle while allowing the muscle to relax and heal between massage appointments. Ref6: Massages for Piriformis Syndrome, By Amy Butcher, October 26, 2009

Direct manipulation of the most tender spot in the central area of the buttock is a very useful treatment technique commonly used by physiotherapists. Longitudinal or transverse mobilisation techniques are employed on the muscle, with stronger pressure and longer periods being used as the pain reduces. The Physio will treat any contributory dysfunction of the lumbar spine or sacro-iliac joint. Taking this conservative approach is often helpful in reducing symptoms of this syndrome using mobilisation treatment, deep injections, changing typical activities and postures and setting a stretching regime. Where the problem is severe and does not settle then surgery to the tendon insertion or to the muscle may be considered. Ref7: Piriformis Syndrome - A Real Pain in the Butt! By Dr Marybeth Crane

Strengthening exercises
Exercises directed at strengthening the piriformis muscle. When the hip is flexed, theathlete abducts the lower extremity, as in A. When the hipis ina neutral position, the athlete externally rotates the thigh, as in B. External resistance may be applied with rubber tubing to either exercise as illustrated in B. Ref: Conservative Management of Piriformis Syndrome, Douglas R. Keskula, MS, PT, ATC, Michael Tamburello, MS, PT, Journal of Athletic, Volume 27 * Number 2 * 1992 * 102-110

Bibliography
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http://www.thestretchinghandbook.com/archives/piriformis-syndrome.php http://journals.lww.com/neurosurgery/Abstract/1994/03000/The_Piriformis_Muscle_Syndrome__A_Simple. 18.aspx http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T0K-482RGV616&_user=10&_coverDate=12%2F31%2F1991&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort =d&_docanchor=&view=c&_searchStrId=1446975723&_rerunOrigin=scholar.google&_acct=C000050221& _version=1&_urlVersion=0&_userid=10&md5=8fea7360099b09159c58054c4c93d805&searchtype=a http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1317145/pdf/jathtrain00034-0008.pdf http://www.acofp.org/resources/OMT/articles/0104_2_11.html http://www.ehow.com/facts_5572698_piriformis-syndrome-effects-massage.html http://ezinearticles.com/?Piriformis-Syndrome---A-Real-Pain-in-the-Butt!&id=1112388

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