Journal of Back and Musculoskeletal Rehabilitation 33 (2020) 983–988 983

DOI 10.3233/BMR-181290
IOS Press

Effects of ELDOA and post-facilitation

stretching technique on pain and functional
performance in patients with piriformis
syndrome: A randomized controlled trial
Momena Shahzad, Nazish Rafique∗ , Syed Shakil-ur-Rehman and Syed Ali Hussain
Riphah College of Rehabilitation Sciences, Riphah International University, Islamabad, Pakistan

Received 30 May 2018

Accepted 31 January 2020

Abstract.
BACKGROUND: Piriformis syndrome (PS) is a neuro-muscular condition, which is often underdiagnosed in clinical settings.
This study will determine the effects of myofascial stretching Elongation Longitudinaux Avec Decoaption Osteo Articulaire
(ELDOA) and post-facilitation stretching of the piriformis muscle in patients with PS.
OBJECTIVE: We aimed to compare the effects of ELDOA and post-facilitation stretching of the piriformis muscle on pain,
muscle length and functional performance in patients with PS.
METHODS: A randomized clinical trial was conducted with 40 PS patients including both males and females, between the ages
of 30–70. Patients were randomly assigned to the ELDOA or post-facilitation group after assessments with the Numeric Pain
Rating Scale (NPRS), Lower Extremity Functional Scale (LEFS), Piriformis Length Test and Straight Leg Raise (SLR). The
assessments were done at baseline and at the end of the sixth week of treatment.
RESULTS: The patients treated with ELDOA demonstrated significant improvement in pain (pre = 7.00 ± 2.75, post = 3.00 ±
1.75), piriformis length (pre = 27.6 ± 5.54, post = 36.8 ± 3.13), SLR (pre = 36.40 ± 7.24, post = 67.5 ± 8.36) and LEFS (pre
= 26.90 ± 12.24, post = 58.10 ± 8.62), as compared with the group treated with post-facilitation stretching: pain: pre = 6.00 ±
1.00, post = 2.00 ± 1.50; piriformis length: pre = 28.55 ± 4.03, post = 38.8 ± 2.70; SLR: pre = 40.60 ± 7.48, post = 74.25 ±
5.19, and LEFS: pre = 25.20 ± 7.66, post = 66.30 ± 7.27).
CONCLUSION: It can be concluded that the post-facilitation stretching technique shows more improvement in pain, muscle
length, SLR, and LEFS in patients with PS as compared to ELDOA.

Keywords: Muscle energy technique, myofascial stretching, piriformis syndrome, functional performance, post-facilitation
stretching, Lower Extremity Functional Scale (LEFS)

1. Introduction foramen [1]. It results in gluteal region pain, numbness

Piriformis syndrome (PS) is a neuromuscular dis-
order that causes sciatic nerve entrapment by the piri-
formis muscle, while exiting through the greater sciatic
∗ Corresponding
author: Nazish Rafique, Riphah College of Reha-
bilitation Sciences, Riphah International University, Islamabad, Pak-
istan. Tel.: +92 3002132436; E-mail: nazish.rafique@riphah.edu.pk.
and tenderness, which may radiate down to the ipsilat-
eral lower limb [2]. It is regarded as one of the most
common causes of non-discogenic or extra spinal sciat-
ica [3] and should be considered as a possible diagnosis
if sciatica occurs without any clear spinal pathology [4].
Since keeping a wallet in the back pocket of jeans is
considered to be a predisposing factor, it is also known
as wallet sciatica or back pocket sciatica [5].

ISSN 1053-8127/20/$35.00

c 2020 – IOS Press and the authors. All rights reserved
984 M. Shahzad et al. / Effects of ELDOA and post-facilitation stretching technique
PS has a prevalence of 6% in the general popula-
tion [6] and mostly affects women, with a female to
male ratio of 6:1, possibly due to the wider Q angle in
females [7]. PS commonly occurs during the fourth and
fifth decades of the life span [5]. PS accounts for 6–8%
cases of sciatic pain [7] and is responsible for 5–6%
cases of chronic low back [8].
Boyajian-O’Neill et al. reported two types of PS:
primary and secondary PS. In primary PS, PS occurs
as a result of an intrinsic defect (anatomic cause) of
the muscle itself (e.g. split piriformis muscle) or sciatic
nerve anatomical variations. Primary PS accounts for
less than 15% of cases among PS patients. In secondary
PS, the piriformis muscle abnormality (e.g. inflamma-
tion or hypertrophy) results from predisposing factors,
which involve the local ischemia effect, ischemic mass
effect, micro or macro trauma, excessive exercise and
altered biomechanics (e.g. leg length discrepancy) [9].
In this study, we focused on treating piriformis muscle
tightness or hypertrophy due to which the sciatic nerve
is compressed. We have therefore selected patients with
secondary PS.
PS is characterized by the following symptoms: pain
during walking (e.g. antalgic gait, foot drop); pain that
lasts more than 15–20 minutes when lying, sitting and
standing; pain that arises when standing up from a
seated or squatting position; pain that is not relieved
by change of position; pain in the abdomen, pelvis and
inguinal region; and dyspareunia in females [10].
Three tests (when positive) are indicative of PS,
namely: the Beatty test, Freiberg test [11] and Pace
test [12]. The positive FAIR test (flexion, adduction and
internal rotation) is also an indicator of PS. It has a
sensitivity of 0.88 and specificity of 0.83 [13].
Conservative treatment of PS includes medication,
physiotherapy, acupuncture and local anesthetic injec-
tions [3]. Elongation Longitudinaux Avec Decoaption
Osteo Articulaire (ELDOA) or Longitudinal Osteo-
Articular Decoaptation Stretching (LOADS) in English,
is a manual physical therapy tool and myofascial stretch
technique designed to produce active decompression
by creating a space in the targeted area and causes re-
alignment of the structure by correcting fascial tension.
Locally, ELDOA improves muscle tone for posture cor-
rection and generally, improves the kinetic sense of the
myofascial chain and causes normalization of tension
in the myofascial system [14].
The muscle energy technique (MET) is an active soft
tissue technique in physical therapy, in which a mus-
cle lengthens itself by using its energy to relax. Post-
facilitation stretching is one of the two MET techniques
and is used to treat chronically shortened muscles [14].
In 2016, Marques et al. conducted a randomized con-
trolled trial (RCT) that showed that MET results gained
greater flexibility in comparison to self-stretching [15].
In a quasi-experimental study conducted by Clement
(2016), ELDOA showed improvement in range of mo-
tion and flexibility, and also decreased physical ten-
sion and anxiety [16], whereas in 2014 Talapalli and
Sandeep concluded that MET (PFS) is more effective
than PIR in reducing hamstring muscle tightness and
improving popliteal angle range [17]. According to a
systemic review by Joseph and Arthur, the muscle en-
ergy technique seems to be more beneficial in decreas-
ing pain that lasts more than 24 hours and minimizing
disability that lasts more than four weeks in low back
pain patients [18].
All previous studies in which the post-facilitation
stretching technique has been performed on different
muscles, have shown greater improvement in compari-
son to other techniques. However, the post-facilitation
stretching technique and ELDOA have never been com-
pared and performed to the piriformis muscle. There-
fore, the current study was designed to compare the
effects of myofascial stretching ELDOA and post-
facilitation stretching on pain, muscle length and func-
tional performance in patients with PS.
2. Methodology
This RCT study was conducted at Riphah Rehabili-
tation and Research Center of Pakistan Railway Gen-
eral Hospital, Rawalpindi, from 1 August 2017 to 31
January 2018. In total 46 PS patients were enrolled in
the study. The sample size was calculated by the online
OpenEpi tool. Out of 46 participants, 23 were included
in each group. Participants were randomly assigned to
Group A (myofascial stretching ELDOA) or Group B
(post-facilitation stretching) by the toss and trial method
in which an unbiased coin was tossed with one side as
A (Group A) and the other as B (Group B).
Males and females, aged between 30–70, diagnosed
with PS with short piriformis length (< 40◦ ), a positive
FAIR (flexion, adduction and internal rotation) test and
pain for more than one month were included in the
study. Individuals with leg pain that was not related
to the piriformis (e.g. disc herniation, sacroiliac joint
dysfunction, degenerative joint disease) were excluded
from the study. Three participants dropped out of both
groups, so the study was completed with a total of 40
patients: 20 in Group A and 20 in Group B.
Treatment was given three days/week for six weeks.
The Numeric Pain Rating Scale (NPRS), Lower Ex-
 M. Shahzad et al. / Effects of ELDOA and post-facilitation stretching technique 985

Fig. 1. CONSORT diagram for the data collection.

tremity Functional Scale (LEFS), Piriformis Length

Test and Straight Leg Raise ranges were used as assess-
ment tools. Assessments were done at baseline and at
the end of the sixth week of treatment. Informed con-
sent was collected from all participants in both Urdu
and English. The data collection procedure is outlined
in Fig. 1.

3. Procedure

Prior to the treatment, both groups were treated with

ultrasound (1 MHz frequency, constant mode, and 1.0
intensity) for three minutes at the piriformis muscle
tender or the trigger point.

3.1. Group A

Group A was treated with myofascial stretching (EL-

DOA) of the piriformis muscle. Each patient was seated
with the sound leg in a knee extended position with
supinated foot, while the affected leg was internally
rotated with knee flexion and the foot was in prona-
tion. Arms were straight, externally rotated and reach-
ing forward. The spine was erect moving towards the
ceiling. The pelvis was slightly posteriorly rotated and
the head was kept straight and in a neutral position.
While this position was maintained, internal rotation
of the affected leg was increased or decreased until the
patient felt a stretch in the piriformis muscle. This posi-
tion was held for one minute with 15 seconds rest. Five
reps/sessions were done, as shown in Fig. 2.
Fig. 2. ELDOA of the piriformis muscle.
3.2. Group B
Group B was treated with post-facilitation stretching
(PFS) of the piriformis muscle. Each patient was in the
supine position with hip flexion greater than 60◦ , and
a slight adduction and external rotation of the affected
leg. The practitioner then wrapped the leg with the su-
perior arm and placed the inferior hand on the table
and moved the piriformis muscle in the midrange posi-
tion. The patient was asked to externally rotate the leg
986 M. Shahzad et al. / Effects of ELDOA and post-facilitation stretching technique
Fig. 3. PFS technique for the piriformis muscle.
Table 1
Age, gender and trigger points of the participants
Variables Mean ± S.D
Age 50.42 ± 10.03
Gender Male 9 (22.5%)
Female 31 (77.5%)
Trigger point Positive 13 (32.5%)
against the resistance. This isometric contraction was
held for 10 seconds and the stretch was applied for 15
seconds with a 30 seconds rest period. The leg was then
gently adducted and internally rotated, and moved to
the new barrier. Five reps/sessions were done, as shown
in Fig. 3.
After the treatment, both groups were given a hydro
collateral pack for 10 minutes. A home plan, consisting
of piriformis stretching, hamstring muscle stretching,
hip abductors strengthening and prone hip extension ex-
ercises, was provided. These exercises were performed
in three phases: phase I (first and second week), one set
of 10 reps/day; phase II (third and fourth week), two
sets of 10 reps/day; and phase III (fifth and sixth week),
two sets of 10 reps/twice a day).
Statistical analysis was done on SPSS software ver-
sion 21 (IBM, USA). The Wilcoxon test was used for
within-group analysis and the Mann-Whitney U test
was used for between-group analysis.
4. Results
In the study, the mean age of the participants was
50.42 ± 10.03 years, nine (22.5%) patients were male
and 31 (77.5%) were females. Thirteen (32.5%) patients
reported piriformis trigger points, as shown in Table 1.
Significant improvements were found in both groups
after treatment. In Group A, pre-treatment values were:
sitting duration 20.00 ± 17.50, standing duration 12.50
± 5.00, NPRS 7.00 ± 2.75, piriformis length 27.6
± 5.54, SLR ranges 36.40 ± 7.24 and LEFS 26.90
± 12.24. Post-treatment values were: sitting duration
90.00 ± 30.00, standing duration 45.00 ± 27.50, NPRS
3.00 ± 1.75, piriformis length 36.8 ± 3.13, SLR ranges
67.5 ± 8.36 and LEFS 58.10 ± 8.62.
In Group B, pre-treatment values were: sitting du-
ration 25.00 ± 17.50, standing duration 15.00 ± 8.75,
NPRS 6.00 ± 1.00, piriformis length 28.55 ± 4.03,
SLR ranges 40.60 ± 7.48 and LEFS 25.20 ± 7.66.
Post-treatment values were: sitting duration 80.00 ±
52.50, standing duration 52.50 ± 26.25, NPRS 2.00 ±
1.50, piriformis length 38.8 ± 2.70, SLR ranges 74.25
± 5.19 and LEFS 66.30 ± 7.27, as shown in Table 2.
There were no significant differences between the
groups in post-sitting (p-value 0.978) and post-standing
(p-value 0.406) duration. After treatment, Group B
showed significant improvements in the Numeric Pain
Rating Scale (p-value 0.003), Straight Leg Raise ranges
(p-value 0.004), Piriformis Length Test (p-value 0.037)
and Lower Extremity Functional Scale (p-value 0.002)
in comparison to Group A, as can be seen in Table 2.
5. Discussion
Significant improvements were found in both groups.
Participants in Group B, who were treated with post-
facilitation stretching, showed more improvements in
pain, SLR range, piriformis length and lower extremity
function, in comparison to Group A, who were treated
with myofascial stretching ELDOA.
Redij et al. concluded in one of their RCTs that
MET results in greater improvement in hip extension
range and iliopsoas muscle flexibility than the PIR tech-
nique [19]. Another RCT conducted by Marques et
al. showed the MET (PFS) and self-stretching effect
on the posterior chain flexibility of different muscles.
They concluded that MET results in greater flexibil-
ity than self-stretching [15]. Jadav and Patel concluded
that post-facilitation stretching results in greater im-
provement in range and flexibility [20]. Talapalli and
Sandeep reported that MET is more effective than PIR
in reducing hamstring muscle tightness and improving
popliteal angle range [17]. Joseph and Arthur reported
in a systemic review that the muscle energy technique
was more beneficial in decreasing pain and minimizing
disability in low back pain patients [21].
In all previous studies, the PFS technique was applied
to different muscles rather than the piriformis muscle,
but the PFS technique nevertheless showed greater re-
duction in pain, improvement in flexibility, range and
 M. Shahzad et al. / Effects of ELDOA and post-facilitation stretching technique 987

Table 2
Comparison of median, IQ and p-value
Pre-median Pre-median Post-median Post-median
Variables p-value p-value
± IQ (Group A) ± IQ (Group B) ± IQ (Group A) ± IQ (Group B)
Sitting duration 20.00 ± 17.50 25.00 ± 17.50 0.074 90.00 ± 30.00 80.00 ± 52.50 0.978
Standing duration 12.50 ± 5.00 15.00 ± 8.75 0.590 45.00 ± 27.50 52.50 ± 26.25 0.406
NPRS 7.00 ± 2.75 6.00 ± 1.00 0.491 3.00 ± 1.75 2.00 ± 1.50 0.003
SLR ranges 36.40 ± 7.24 40.60 ± 7.48 0.790 67.40 ± 8.36 74.25 ± 5.19 0.004
Piriformis length 27.65 ± 5.54 28.55 ± 4.03 0.561 36.80 ± 3.13 38.80 ± 2.70 0.037
LEFS 26.90 ± 12.24 25.20 ± 7.66 0.602 58.10 ± 8.62 66.30 ± 7.27 0.002

disability as compared to other techniques. These out- References

comes are comparable to the results of this study, which
also concludes that PFS results in greater reduction in
pain and improvement in piriformis muscle length, SLR
ranges and functional ranges, in comparison to ELDOA.
Clement reported in a quasi-experimental study that
ELDOA resulted in improvement of range of motion
and flexibility, and also decreased physical tension and
anxiety [16]. The results of the study are quite contra-
dictory to the findings of the current study. One of the
possible reasons is that in Clement’s study, ELDOA was
the only treatment given to patients and was not com-
pared to other techniques, whereas in the current study,
ELDOA also showed improvement. The difference is
that there is a greater improvement in the range of mo-
tion and flexibility with the post-facilitation stretching
technique in comparison to ELDOA.
6. Conclusion
We can conclude that the post-facilitation stretching
technique shows more improvements in pain, muscle
length, SLR, and LEFS in patients with PS, as compared
to ELDOA.
Limitations and recommendation
In this study, only short term effects of the treatment
techniques were measured. Hence, a study with a longer
duration is recommended to evaluate the long term ef-
fectiveness of these treatments as a true representative
of the study population.
Conflict of interest
None to report.
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