Physiotherapists and other manual therapists recognise piriformis syndrome as a cause of buttock and leg pain which sometimes simulates sciatic symptoms. The piriformis muscle is very close to the sciatic nerve as it traverses the buttock and nerve compression or irritation have been put forward as reasons for the pain. Piriformis syndrome is not recognised universally outside physiotherapy and other therapy professions but the diagnosis is gaining credence.
The piriformis ("pear shaped") is a small, flat muscle in the buttock, running centrally from the sacral areas across the buttock to the upper part of the greater trochanter of the femur, the large bony lump on the side of the hip. With the leg straight it turns the leg outwards, when the hip is bent it moves the leg away from the centre of the body. There is some anatomical variation in the relationship between the piriformis muscle and the sciatic nerve in the buttock. In most people the nerve lies in front of the muscle but in some the muscle belly is divided into two with parts of the nerve passing through the division.
Piriformis syndrome has no clear cause of onset and may occur with sacro-iliac and lumbar spinal syndromes. Direct damage to the buttock could cause scar tissue around the muscles and the nerve, while continual pressure over time could also alter the nerve's function. Other factors could be an increased lumbar curve, strong activity and hip replacement, with some cases imitating back pain problems such as sciatic pain. Diagnosis and treatment of piriformis syndrome is performed by physiotherapists on clinical findings due to the lack of diagnostic and imaging investigations.
Little consideration is given to piriformis syndrome as a reason for back and leg pain but it can imitate sciatic leg pain, presenting as back pain with nerve root compression due to disc prolapse or joint enlargement. Due to the insertion of the piriformis tendon into the greater trochanter this syndrome can have a connection with trochanteric bursitis. Clinical examination by the Physio shows an acutely painful trigger point in the mid buttock, some loss of hip lateral rotation, pain and loss of strength in the hip abductors and lateral rotators and a feeling of sitting on a golf ball.
There are numerous treatments for piriformis syndrome but none are scientifically valid, particularly as accurate diagnosis is not clear. Physiotherapists concentrate on finding physical signs such as a tight piriformis, tight hip external rotators and adductors, weakness of the hip abductors, stiffness of the sacro-iliac joint and lumbar spine problems. The patient may walk with the hip externally rotated, have an apparent leg shortening and a shortened stride.
If the physiotherapist finds that the piriformis and other muscles are tight then treatment consists of loosening up the hip joint followed by stretches of the muscle. Stretching the muscle is performed in lying with the hip flexed, pulling the hip into adduction and internal rotation. A home stretching programme is important, with regular stretching every two or three hours in the acute phase. If the piriformis is looser than expected the Physio may exercise the muscle to tighten it up and stretch out the tight structures which oppose this tendency.
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.
The piriformis ("pear shaped") is a small, flat muscle in the buttock, running centrally from the sacral areas across the buttock to the upper part of the greater trochanter of the femur, the large bony lump on the side of the hip. With the leg straight it turns the leg outwards, when the hip is bent it moves the leg away from the centre of the body. There is some anatomical variation in the relationship between the piriformis muscle and the sciatic nerve in the buttock. In most people the nerve lies in front of the muscle but in some the muscle belly is divided into two with parts of the nerve passing through the division.
Piriformis syndrome has no clear cause of onset and may occur with sacro-iliac and lumbar spinal syndromes. Direct damage to the buttock could cause scar tissue around the muscles and the nerve, while continual pressure over time could also alter the nerve's function. Other factors could be an increased lumbar curve, strong activity and hip replacement, with some cases imitating back pain problems such as sciatic pain. Diagnosis and treatment of piriformis syndrome is performed by physiotherapists on clinical findings due to the lack of diagnostic and imaging investigations.
Little consideration is given to piriformis syndrome as a reason for back and leg pain but it can imitate sciatic leg pain, presenting as back pain with nerve root compression due to disc prolapse or joint enlargement. Due to the insertion of the piriformis tendon into the greater trochanter this syndrome can have a connection with trochanteric bursitis. Clinical examination by the Physio shows an acutely painful trigger point in the mid buttock, some loss of hip lateral rotation, pain and loss of strength in the hip abductors and lateral rotators and a feeling of sitting on a golf ball.
There are numerous treatments for piriformis syndrome but none are scientifically valid, particularly as accurate diagnosis is not clear. Physiotherapists concentrate on finding physical signs such as a tight piriformis, tight hip external rotators and adductors, weakness of the hip abductors, stiffness of the sacro-iliac joint and lumbar spine problems. The patient may walk with the hip externally rotated, have an apparent leg shortening and a shortened stride.
If the physiotherapist finds that the piriformis and other muscles are tight then treatment consists of loosening up the hip joint followed by stretches of the muscle. Stretching the muscle is performed in lying with the hip flexed, pulling the hip into adduction and internal rotation. A home stretching programme is important, with regular stretching every two or three hours in the acute phase. If the piriformis is looser than expected the Physio may exercise the muscle to tighten it up and stretch out the tight structures which oppose this tendency.
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.
About the Author:
Jonathan Blood-Smyth is a Superintendent Physiotherapist at a large NHS teaching hospital in Devon. He publishes articles on injuries and mishaps in periodicals and on his website for physiotherapists. If you are looking for local physiotherapy after an mishap or injury, visit his website for physiotherapy practitioners around the United Kingdom.
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