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Piriformis Syndrome

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Brandon Maggen, Jan 19, 2011.

  1. Brandon Maggen

    Brandon Maggen Active Member


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    Hi

    If internal rotation of the femur contributes to the Piriformis stretching and or spasming - in turn compressing the sciatic nerve and causing deep buttock pain, then ante-torsion of the tibia and maintaing talar and sub-talar neutrality seem central in the biomechanical aspect of its aetiology.
    So, what if this has been achieved and on review remains so, and exclusion of 'usual suspects' (or the adequate control/ management of them) shows no extraordinary rotation of the tibia and femur, yet deep buttock pain persists?

    Pt: 36 F, No skeletal /medical hx. Of normal weight. Sedantary. Office bound.
    Pedal Biomechanics: FnHL, Sagittal plane block, med deviated STJ axis, late f/f pronation with abductory twist.

    Besides the help of chiropractics and physiotherapy, any suggestions re better biomechanical control?

    Thanks in advance.

    Brandon
     
  2. Griff

    Griff Moderator

    Maintaining subtalar joint neutrality? We'll leave that one I think.

    So if you believe femoral rotation control is one of the issues contributing to the symptoms here is there any other way of controlling this other than with foot orthoses?
     
  3. Ann PT

    Ann PT Active Member

    A few thoughts...

    How do you know the buttock pain is coming from her piriformis versus lumbar spine, ilium or SIJ? Why would internal rotation of the femur cause spasm of the piriformis? I had a female runner in my office today with an anteverted hip and significant internal rotation of the femur but no symptoms. (She was coming to me for a different problem.) Many people have internally rotated femurs for many reasons (esp. teenage girls!) but don't have buttock pain. Also, even if maintaining subtalar and talar neutrality were desired or possible (I assume you mean with an orthotic), do you think that force applied by the orthotic is really going to have any effect on femoral rotation (assuming the woman doesn't have rigid subtalar and ankle joints)?

    Ann
     
  4. Admin2

    Admin2 Administrator Staff Member

    Piriformis syndrome

    Piriformis syndrome is a controversial condition which is believed to result from compression of the sciatic nerve around the piriformis muscle.[5][2] Symptoms may include pain and numbness in the buttocks and down the leg.[3][2] Often symptoms are worsened with sitting or running.[3]

    Causes may include trauma to the gluteal muscle, spasms of the piriformis muscle, anatomical variation, or an overuse injury.[2] Few cases in athletics, however, have been described.[2] Diagnosis is difficult as there is no definitive test.[5][4] A number of physical exam maneuvers can be supportive.[3] Medical imaging is typically normal.[2] Other conditions that may present similarly include a herniated disc.[3]

    Treatment may include avoiding activities that cause symptoms, stretching, physiotherapy, and medication such as NSAIDs.[3][5] Steroid or botulinum toxin injections may be used in those who do not improve.[2] Surgery is not typically recommended.[3] The frequency of the condition is unknown, with different groups arguing it is more or less common.[4][2]

    1. ^ Martin, HD; Reddy, M; Gómez-Hoyos, J (July 2015). "Deep gluteal syndrome". Journal of hip preservation surgery. 2 (2): 99–107. doi:10.1093/jhps/hnv029. PMC 4718497Freely accessible. PMID 27011826. 
    2. ^ a b c d e f g h i j k Cass, SP (January 2015). "Piriformis syndrome: a cause of nondiscogenic sciatica". Current sports medicine reports. 14 (1): 41–4. doi:10.1249/JSR.0000000000000110. PMID 25574881. 
    3. ^ a b c d e f g h i "Piriformis Syndrome". Merck Manuals Professional Edition. October 2014. Retrieved 30 December 2017. 
    4. ^ a b c d Hopayian, K; Danielyan, A (23 August 2017). "Four symptoms define the piriformis syndrome: an updated systematic review of its clinical features". European journal of orthopaedic surgery & traumatology: orthopedie traumatologie. 28: 155–164. doi:10.1007/s00590-017-2031-8. PMID 28836092. 
    5. ^ a b c d Miller TA, White KP, Ross DC (September 2012). "The diagnosis and management of Piriformis Syndrome: myths and facts". The Canadian Journal of Neurological Sciences. Le Journal Canadien Des Sciences Neurologiques. 39 (5): 577–83. doi:10.1017/s0317167100015298. PMID 22931697. 
     
  5. HansMassage

    HansMassage Active Member

    Atomically the piriformis is listed as an external rotator of the femur but biomechanicly it sways the hips toward the opposite side.It dose this by abduction of the femur against the ground force. This is a typical posture pattern for keeping the majority of the weight on one foot.
    The avoidance cause then is typically on the opposite side. It can be anywhere from the big toe to the neck.
    If it is the left piriformis it could be from reaching for the mouse with the right hand.
    This is my most common puzzle. It usually requires careful observation of the clients walkin, sitting and working posture, to find the answer.

    Hans Albert Quistorff, LMP
    Antalgic Posture Pain Specialist
     
  6. RobinP

    RobinP Well-Known Member

    Having not really had much call to consider piriformis syndrome previously, I started investigating it for a patient I had.

    I came across this article. I don't know how accurate it is as I don't really have the anatomical or physiological knowledge to criticise it. However, it is a nicely written guide to anyone who like me, may not have really come across it much.

    I've attached the PDF as it is freely available at the this link

    http://www.jaoa.org/cgi/reprint/108/11/657

    Robin
     

    Attached Files:

  7. David Wedemeyer

    David Wedemeyer Well-Known Member

    Nice find Robin. I've seen a number of piriformis syndromes that went misdiagnosed and untreated over the years. In those rare patients where it is confirmed via imaging that the sciatic nerve actually passes through the belly of the piriformis muscle, the symptoms are the most severe. In these cases I refer them out for injection and begin treatment after the inflammation has decreased.

    I perform a manual treatment with a combination of PT modalities and segue into active stretches and low load strength training, pilates, yoga etc. There is also always sacral dysfunction in these patients, which responds very favorably to chiropractic manipulation. These patients have very painful SI joints. Overall weak gluteal muscles contribute greatly to piriformis dysfunction.

    I do disagree that there is more pain at rest. I find the more active they are, the greater their symptoms. There is pain at rest but not as dramatic as on activity.
     
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    Last edited by a moderator: Sep 22, 2016
  9. Brandon Maggen

    Brandon Maggen Active Member

    THANK YOU for all the replies. It really helped understanding differing view points from colleagues.

    Pt has since been for Chiropractics and now physiotherapy. We may have to consider Botox inj into the Piriformis (?concerned over the long term possibility of weakening to the muscles) to allow for a more 'aggressive' approach from the physio.

    I will certainly advise on posture - since the pt is office bound, right hand on mouse, possibly slouched, all day "If it is the left piriformis it could be from reaching for the mouse with the right hand." Thanks HansMassage.

    Also, she has recently started a gym program under guidance of a personal trainer - "Overall weak gluteal muscles contribute greatly to piriformis dysfunction", thanks David.

    regards

    Brandon
     
  10. I have had my piriformis spasm before causing major sciatic pain. This is an excellent video of the exercises I did to relieve the pain and spasm.

     
    Last edited by a moderator: Sep 22, 2016
  11. Dananberg

    Dananberg Active Member

    Kevin...terrific video.

    Another way to look at piriformis syndrome from a podiatry perspective is as following. Exam ankle joint dorsiflexion with the knee extended. If it is restricted, it is often related to fixation of the fibula. Since the proximal fibula is the insertion of the biceps femoris, lost fibula translation prevents relaxation of the biceps. At the proximal end of the biceps, it attaches to the sacrotuberous ligament at the ischial tuberosity. Therefore, loss of fibula translation can affect the SIJ's normal nutation and counternutation motion. Since the piriformis causes the SIJ to stabilize, when it is counternutated (rotated posteriorly and open packed), the piriformis must constantly fire to maintain SIJ stability. When the ankle joint is manipulated, this can free the fibula and therefore relieve the posteriorly directed tension on the SIJ, and therefore relax the piriformis.

    Howard
     
  12. davsur08

    davsur08 Active Member

    [I]ankle joint dorsiflexion with the knee extended. If it is restricted, it is often related to fixation of the fibula.[/I]

    Dr.Dananberg, would this be the case in patients with foot drop. I've seen lot of them complain of buttock pain. would ankle mobilization benefit hese patient group? (provided there is not osseous blockage)

    david
     
  13. Dananberg

    Dananberg Active Member

    David,

    Buttock pain in patients with drop foot is another issue entirely. There may be piriformis related symptoms, but the underlying cause is not equinus related.

    If you make or can adjust AFO's, try making the foot plate end behind the met heads, and add a 1st ray c/o (like you would on a standard CFO). Exam carefully for LLD, and correct as necessary. Once the patient can step over the foot plate, gait is very positively altered and this type of symptom can improve.

    Howard
     
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    The piriformis muscle syndrome: An exploration of anatomical context, pathophysiological hypotheses and diagnostic criteria.
    Michel F, Decavel P, Toussirot E, Tatu L, Aleton E, Monnier G, Garbuio P, Parratte B.
    Ann Phys Rehabil Med. 2013 Apr 30
     
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    The diagnosis and management of Piriformis Syndrome: myths and facts.
    Miller TA, White KP, Ross DC.
    Can J Neurol Sci. 2012 Sep;39(5):577-83.
     
  17. JaY

    JaY Active Member

    Definitely sounds like the SIJ and lumbar spine needs a look at - physio or chiro.
     
  18. toughspiders

    toughspiders Active Member

    Suffer from this horrendous issue myself!
     
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  20. bmjones1234

    bmjones1234 Active Member

    Whats the Tilt of the Pelvis like? Neutral/Anterior or Posterior?

    Curious & Brainstorming.

    Cheers
     
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    Yoga pose to stretch piriformis:

     
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    Gait Analysis of Patients with Unilateral Piriformis Syndrome
    H. P. Huang, C. T Wang, S. W. Hong, T. W. Lu
    1st Global Conference on Biomedical Engineering & 9th Asian-Pacific Conference on Medical and Biological Engineering; IFMBE Proceedings Volume 47, 2015, pp 104-106
     
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    A pain in the butt
     
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    The piriformis muscle syndrome: An exploration of anatomical context, pathophysiological hypotheses and diagnostic criteria
    F. Michel et al
    Annals of Physical and Rehabilitation Medicine Volume 56, Issue 4, May 2013, Pages 300–311
     
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