Piriformis Syndrome: A Pain in the Butt!
Piriformis syndrome has been recognised as a source of buttock and leg pain for years, but it is still a controversial diagnosis. The pain is thought to be related to the proximity of the muscle to the sciatic nerve in the buttock and irritation or compression of the nerve have been suggested as causes. Physiotherapists diagnose and treat piriformis syndrome regularly, as it can often be mistaken for sciatica.
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 hip 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.
There are several causes of piriformis syndrome: a direct injury can cause a haematoma and scarring between the nerve and the small buttock muscles, or prolonged pressure on the area could cause changes in the nerve. Other predisposing factors may be excessive lumbar lordosis, total hip replacement and strong physical activity. It may also be mimicked by lumbar nerve or joint syndromes. Piriformis syndrome is a clinical diagnosis as there is no imaging, diagnostic or other tests apart from physical examination.
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.
There may be tightness in the hip and piriformis muscles and in these cases the physiotherapist will start a programme of muscle stretches after warming up the hip muscles. Piriformis stretches are taught in lying, the hip positioned in 90 degrees, stretching the thigh over the other leg and pulling it with the other hand. The patient will need to follow a home exercise programme of muscle stretches, up to every few hours in cases of an acute nature. Stretching the piriformis may not be appropriate if the muscle is loose or stretched, in which case muscle strengthening and stretching of the opposing stiff areas is used.
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. Active Release Technique (ART), acupuncture and Intra Muscular Stimulation (IMS) are also very effective techniques in reducing pain & symptoms. The Physio will treat any contributory dysfunction of the lumbar spine or sacro-iliac joint. Each individual’s presentation is unique & must be treated based on the findings of the assessment & the symptoms. If you are suffering from a pain in the butt, maybe you have piriformis syndrome and would benefit from treatment.
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