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Conservative Management of

Piriformis Syndrome
Douglas R. Keskula, MS, PT, ATC
Michael Tamburello, MS, PT

ABSTRA CT: Piriformis syndrome is aques- indicate (1). Whether or not one embraces ever, variations in this arrangement have
tionable clinical entity that has been cited this as a clinical entity, our purpose is to beenreportedwith thenervecrossing above
as a cause of buttock pain and sciatica. provide the reader with an understanding or through the muscle belly itself (3,4).
The intimate relationship between the of piriformis syndrome by reviewing the The typical relationship of the sciatic nerve
piriformis and the sciatic nerve has been relevant anatomy and the proposed and the piriformis is presented in Fig 1.
suspected as being the source of the signs pathomechanics of this syndrome. More-
and symptoms that often appearfollowing over, practical and systematic strategies
minor trauma to the pelvic or buttock re- for evaluating and managing the athlete
gion. Muscle function is an important with suspected piriformis syndrome will
consideration in the evaluation and treat- be offered.
mentoftheathletewithsuspectedpiriformis
syndrome. The action of the piriformis Incidence/Etiology
muscle on the hip varies as the hip moves The incidence of piriformis syndrome
from a neutral to aflexed position. While in has been reported to be six times more
aflexed position, the piriformis internalty prevalent infemalesthanmales (11). While
rotates and abducts the hip; however, in a no dominant etiological factors have been
neutral position, the piriformis acts as an reported, piriformis syndrome often oc-
external rotator of the hip. A comprehen- curs following a minor trauma to the but-
sive evaluation provides the information tocks or pelvis (1,2,12). The trauma is
necessary to design a treatment plan spe- thought to precipitate a spasm of the
cific to the involved structures, while meet- piriformis muscle, which subsequently in-
ing the functional needs of the individual flames the adjoining sciatic nerve (2).
athlete. This paper describes the anatomy, Piriformis syndrome has typically been
pathomechanics,physicalexamination, and characterized by symptoms consistentwith Fig 1.-Posterior view of the pelvis and right
treatment options relevant to the piriformis irritation of the sciatic nerve. Isolating the proximal lower extremity, illustrating the ana-
syndrome. Treatment protocols stressing dysfunction to this region usually follows tomical relationship between the piriformis
exercises that promote strength, flexibil- exclusion of the more common causes of muscle and the sciatc nerve
ity, andfunctional activities are believed to buttock pain and sciatica. More specifi-
be essential in restoring the athlete's abil- cally, complaints of buttock pain with dis- Some tiink tfiat the piriformis can
ity to return to pain-free competition. tal referral of symptoms are not unique to become hypertrophied or can spasm, re-
piriformis syndrome. Similar symptoms sulting in compression of the nerve against
are prevalent with the more clinically evi- the ischium, or, more specifically, against
r he piriformis syndrome has been im- dentlowerbackpain syndromes and pelvic the bony edge of the sciatic notch (3). It
plicated as a potential source of pain dysfunctions. Thus, a thorough evaluation also has been suggested that an accentu-
and dysfunction, not only in the general of these regions must be performed to ated lumbar lordosis and hip flexor tight-
population, but in athletes as well (2,8,11). exclude underlying pathology. ness predisposes one to increased com-
While there is disparity in the literature as pression of the sciatic nerve against the
to whether this syndrome actually exists Anatomy sciatic notch by a shortened piriformis (7).
(1,8,12), some suggestthatitismore preva- The key elements of the piriformis Although differences in the anatomical re-
lent than citations in the literature would syndrome are the anatomical relationships lationships are helpful to facilitate under-
ofthepiriformismuscletothesciaticnerve. standing the mechanism of dysfunction,
Douglas Keskula is a doctoral candi- The piriformis muscle arises from the pel- these differences do not affect conserva-
date at the University of Virginia in vic surface of the sacrum, the greater sci- tive treatmnent strategies.
Charlottesville, VA. atic notch, and the sacrotuberous ligament. The pirifonmis muscle primarily is in-
Michael Tamburello is a commander The lower attachment is the superior bor- nervated by the S1 and S2 spinal nerve
in the United States Navy and a doctoral der of the greater trochanter of the femur. segments viathe sacral plexus. The sciatic
candidate at the University of Virginia. The pirifonnis muscle passes over the sci- nerve is derived from the same spinal seg-
atic nerve in the majority of cases. How- ments with contributions from theL4, L5,

102 Volume 27 * Number 2 * 1992 * Joumal ofAthletic Training


and S3 segments (4). Thus, one can appre- insight for the clinician to use to better tional and sport specific abilities to allow
ciate the constellation ofneurological signs focus on the relevant signs and symptoms. the clinician to clearly defime the athlete's
and symptoms that could emanate locally The subjective evaluation should be di- functional limitations.
or be referred distally to the lower extrem- rected toward determining causative fac-
ity as a result of this syndrome. tors, such as ahistory of arecent trauma, or Range of Motion
The piriformis is an external rotator of changes in training regimen or lifestyle. Qualitative and quantitative assess-
the hip and functions in conjunction with Information regarding the location, inten- ment ofthemobility ofthepiriformismuscle
the quadratus femoris, obturator externus, sity, behavior, and frequency of pain will is an important component of the evalua-
obturator internus, and the gemellus supe- assist in directing the clinician during the tion. Passive intemal rotation of the hip
rior and inferior. The rotary component of evaluation. Generally, individuals with while in 00 flexion may be painful, with
this muscle group has been reported to piriformis syndrome will report deep pain limitation of motion secondary to pain and
decrease with flexion of the hip (9). At 900 that is localized to the posterior aspect of spasm. Passive extemal rotation and ad-
hip flexion, this group of muscles has a the hip and is accentuated with standing or duction while the hip is flexed to 900 would
significant abductor component. Some activity. This discomfort often lessens also be expected to be limited and painful.
report that the piriformis functions as an when the patient is lying down. Also, flex- Saunders (14) suggests a clarifying testfor
internal rotator in hip flexion (5,15). The ion of the knees may further moderate the assessing sciatic nerve entrapment by the
function of the piriformis at varying joint symptoms. Pain, numbness, and piriformis. He advocates that when a
angles is an important considerationfor the paresthesiaradiating distally into the lower straight leg raising test is positive for but-
clinician who is evaluating and treating extremity may be encountered; however, tock pain, you should then extemally rotate
piriformis syndrome. these symptoms frequently arepresent with the extremity to see if the symptoms dimin-
lumbo-pelvic dysfunctions as well. There- ish. A lessening of symptoms is purported
Evaluation fore, it is crucial that you extend the exam tobeconfimationthatthepirifoimismuscle
The diagnosis ofpiriformis syndrome to these regions to rule out associated lum- is impinging on the sciatic nerve.
is primarily a clinical determination; there- bar or sacroiliac dysfunction.
fore, a thorough history must be taken, and Strength
a careful, comprehensive physical exam Objective Evaluation The conventional manual muscle test
mustbe performed. Establishing a system- The objective evaluation mustencom- for the external rotators, including the
atic routine of evaluation not only facili- pass an assessment of active and passive pirifonnis, is carried out while the patient
tates gathering objective information from range of motion of the spine and lower is sitting (6). The test position is repre-
the examination, but it ensures that signifi- extremities, as well as muscle strength and sented in Fig 2. However, testing hip
cantfactors arenot overlooked. The evalu- posture. Palpation of the area is necessary
ation of the spinal neuromusculoskeletal to delineate the specific tissues involved.
system is summarized in the Table. Several provocation tests have been sug-
gested to differentiate piriformis syndrome
Subjective Evaluation from other types of dysfunction and will be
Obtaining a thorough medical history discussed later. In addition, aneurovascular
from the athlete is an integral component assessment is necessary to rule out more
of the evaluation. It serves to enhance the severe spinal pathology. The evaluation
physical assessment process by providing also should include assessment of func-

Evaluaton of the Spinal Neuromusculoskeletal System


1. Observe the athlete's gait, stance, and sitting posture/position. Fig 2.-Conventional manual muscle test posi-
2. Take a thorough history of the sequence and nature of the problem. tion t assess the external rotators of the hip
3. Examine the structure and posture. including the piriformis muscle (Adapted from
4. Assess the range of motion and muscle length, qualitatively and Kendall (6))
quantitatively.
5. Assess strength, qualitatively and quantitatively.
6. Palpate to determine the tension, texture, and temperature of the tissue. rotation in this position may provide mis-
7. Perform neurogical assessment: deep tendon reflexes, myotome leading information about the status of the
screening, sensation, and special tests. piriformis and other intemal rotators (9),
8. Assess fuctonal ability and sport-specific activity. because, in hip flexion, the piriformis acts
9. Examine X-rays, CT scans, and reports. as an internal rotator. The correct manual
10. Define problem areas. muscle test for the piriformis with the hip
11. Establish short- and long-term goals. flexed to 900 would be resisted intenal
12. Develop treatment strategies to meet goals. rotation. Also, test the piriformis as an
13. Reassess to determine effectiveness of the treatment program. external rotator with the hip inO0 flexion as
the patient lies on his or her side or is prone

104 Volume 27 * Number 2 * 1992 * Joumal of Athletic Training


(Fig 3). Testing hiprotation inboth neutral difficult to palpate because of the depth of pain in this area. This region is normally
and flexed positions provides you with a the muscle and the often large mass of tender to palpation, and you must compare
more comprehensive clinical picture of overlying muscle and soft tissues. How- it with the uninvolved side to verify find-
muscle performance. ever, you can locate the piriformis muscle ings of painful areas. Furthermore, this
region is the site of referred pain for lower
back disorders and may develop trigger
areas thatcouldbeconfused withpirifornmis
syndrome.
Functional Abilities
The athlete with piriformis syndrome
may exhibit functional limitations; how-
ever, it is the pain that restricts activity or
limits normal function. Difficulty may be
encountered when moving the leg outside
a car to stand up, moving laterally while in
A B a sitting position, and maintaining balance
on a movable surface. Sport-specific limi-
Fig 3.-Alternative manual musde testing positions to assess the piriformis musde while the hip is tations may be present and must be evalu-
in a neutral position. Theathletemaybe evaluated in A, the prone position, or B, the sidelying position. ated to further enhance the clinical deci-
sion-making process.
Manual muscle testing applied to hip in the prone athleteusing deeppalpation. If Treatment
rotation may elicit contractions that are a line were drawn from the posterior supe- Treatment options for piriformis syn-
strong, but painful. Because many func- rior iliac spine (PSIS) to the greater tro- drome focus around the subjective and
tional activities are performed while stand- chanter, and an intersecting line were drawn objective findings of the assessment. In
ing, testing in a neutral hip position may from the anterior superior iliac spine (ASIS) mostcircumstancesofpiriformissyndrome,
provide you with a more functionally ap- to the ischial tuberosity, the piriformis an inflammatory response is suspected in
plicable strength test. muscle would lie where the lines cross (Fig the muscle and/or sciatic nerve. Therefore,
The pirifonrnis is an abductor of the 5) (10). the treatment goals are directed initially
hip in a flexed position. Carter (2) de- toward decreasing inflammation, associ-
scribed an abduction provocation test where ated pain, and spasm, if present. Treatment
the athlete is seated over the edge of the options may include rest, cryotherapy,
table and asked to push his or her legs apart gentle pain-free stretching exercises, and
against maximal manual resistance (Fig 4). electrical modalities. Heating modalities
The test is positive for a piriformis syn- often are useful later in the rehabilitation
drome if pain is localized directly over the process, when more vigorous stretching
piriformis muscle. exercises are necessary. These modalities
are beneficial because soft tissue elonga-
tion seems to be facilitated by the applica-
tion of heat (18).
Exercise is perhaps the optimal means
of managing this disorder. Active exer-
Fig 5.-Anatomical references used to locate cise, passive stretching, soft tissue mobili-
the piriformis musde zation, and proprioceptive neuromuscular
facilitation (PNF) techniques are particu-
Others (2,12) advocate placing the larly effective in moderating the symptoms
athlete on his or her side with the involved and restoring range of motion. Fig 6 illus-
hip flexed, and palpating at the midpoint trates specific exercise techniques thatpro-
between the ischial tuberosity and greater mote lengthening and relaxation of the
Fig 4.- Manual musde test for hip abduction trochanter. This position seems to displace piriformis muscle, facilitating the restora-
with the athlete sitting the gluteus maximus superiorly to partially tion of pain-free range of motion. The
uncover the sciatic notch for palpation of exercises are easily adapted for use in the
Palpation the piriformis and sciatic nerve. In addi- clinic or as a component of the home exer-
Careful palpation about the lumbo- tion to assessing tenderness with palpa- cise program. When incorporating these
pelvic region not only provides you with tion, you should note evidence of muscular techniques into a plan, the clinician must
information about tissue turgor, but will spasm. When using deep palpation to remember the internal rotation and abduc-
adequately locate hyperirritable regions in locate suspected trigger areas, be careful tion function of the piriformis in the flexed
the soft tissues. The piriformis can be when interpreting the athlete's report of hip. Therefore, the direction to stretch the

106 Volume 27 * Number 2 * 1992 * Joumal of Athletic Training


hip in a flexed position, emphasizing ab-
duction and internal rotation, as well as in
aneutral position addressing external rota-
tion. Resistance may be provided manu-
ally with cuff weights, or using rubber
tubing. Entry-level exercises designed to
strengthen the piriformis are presented in
Fig 7.
Tofacilitatestrengthgainswhilemini-
mizing adverse symptoms, the strength
program should begin with few repetitions
A B and little resistance. The athlete should
progress based on his or hertolerance to the
exercise. Strength training also might in-
clude the use of PNF diagonal patterns,
specifically D2 flexion and D2 extension
patterns (13,17).
Functional activities are an integral
component of the rehabilitation program.
Proprioceptive, balance, and coordination
activities are introduced when the neces-
sary mobility and strength elements be-
comeevident. Progressing fromcontrolled
mobility activities (distal componentfixed)
C D to skill activities (distal component free)
provides the clinician with a myriad of
Fig 6.-Suggestions for exercises directed at lengthening the piriformis muscle. When the hip is treatment options to meetthe specific goals
flexed, the athlete applies pressure into adduction, as in A and B, or external rotation, as in C and oftheathlete. Consultthework of Sullivan,
D, to stretch the piriformis. et al (16) to expand your knowledge of the
stages of motor control and its application
to therehabilitation ofpiriformis syndrome.
muscle should be opposite to thatused with tate relief from exercise-induced soreness As basic activities are tolerated, sport-spe-
the hip in a neutral position. and may begin additional exercises to cific skills may be introduced.
The intensity, frequency, andduration stretch othershortenedmuscle groups (such A home exercise program is an inte-
ofthe exercise regimens aredetennined by as the hip flexors) at this point. Strength gral component of the overall rehabilita-
the tolerance of the athlete. Initially, a deficits in the piriformis and surrounding tion program. Consider independence and
practical guideline for active exercise in- pelvic musculature also must be addressed compliance with the program in planning
cludes few repetitions (ie, five to ten) per- in the rehabilitation program. Usually a short-term objectives. Providing the ath-
formed in three sets, two to three times progressive strengthening program for the lete with clear and concise illustrated in-
daily. Once a base level of exercise toler- piriformis may be initiated early in the structions should promote independence
ance is established, the exercise program is rehabilitation plan. Strengthening of the and compliance with the exercise regimen.
progressed as tolerated. More aggressive piriformis should be carried out with the Additional treatment options may
stretching methods, including contract-re-
lax PNF techniques, can be employed in
the sub-acute phase.
Soft tissue mobilization may be inte-
grated into the treatment plan to further
enhance soft tissue extensibility. The ath-
lete is positioned in a prone position with a
pillow under the abdomen. Apply gentle
pressure to the piriformis muscle with the
heel of your hand in a medial, superior
direction. You may flex the athlete's knee
to 900 and passively internally and exter-
nally rotate the hip at a slow speed. This A B
technique may be contraindicated in ath-
letes with knee pathology because it places Fig 7.-Suggestions for exercises directed at strengthening the piriformis muscle. When the hip is
increased stress on the knee joint during flexed, the athlete abducts the lower extremity, as in A. When the hip is in a neutral position, theathlete
rotation of the hip. externally rotates the thigh, as in B. External resistance may be applied with rubber tubing to either
You also may use modalities to facili- exercise as illustrated in B.

Volume 27 * Number 2 * 1992 * Journal of Athletic Training 107


include education with respect to body References 11. Pce J, Nagle D. Pirifoimis syndrome. WestJMed.
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110 Volume 27 * Number 2 * 1992 * Joumal of Athletic Training