I.
A. Definition of Piriformis Syndrome: Piriformis syndrome causes pain and numbness in the gluteal, hip and upper leg region. It is caused when the muscle negatively interacts and irritates the sciatic nerve causing impingement and pain. (Piriformis Syndrome: Symptoms, Causes and Treatment, 2022)
B. Prevalence and common misconceptions: piriformis syndrome (PS) is a highly controversial syndrome due to their being “no consensus regarding diagnostic criteria or pathophysiology” (Halpin & Ganju, 2009, 197-202) This means that identifying whether the piriformis muscle itself is actually the problem can be very difficult and elusive.
C. Lumbar radiculopathy from nerve root compression is the most common cause of sciatic symptoms. (Piriformis Syndrome and Sciatica Nerve, n.d.) We will explore the different possibilities of nerve entrapment sites and diagnosis for PS and nerve root compression. Another term that clinicians use is Deep Gluteal Syndrome (DGS). This label is more broad and may be more appropriate for a greater number of individuals experiencing pain symptoms.
D. Understanding the other structures in the deep gluteal space that can interact with the sciatic nerve such as both sacrospinous and Sacro tuberous ligaments will be explored. The purpose of the article is to clarify misconceptions and provide accurate information on PS.
II. Understanding Piriformis Syndrome
A. Anatomy of the piriformis muscle: The Piriformis is a dense flat muscle deep to the gluteals of the hip. It originates from the anterior aspect of the sacrum, Sacro tuberous ligaments and the sciatic notch. It attaches to the superomedial aspect of the greater trochanter. Innervated by the anterior rami of S1 and S2.
B. Function of the piriformis muscle: Its two primary actions are lateral rotation of the hip in neutral/standing and Abduction of the hip in the flexed position.
This allows a soccer player to turn their leg outwards to kick a ball with the inside of their foot or hold their legs in a crisscross position when sitting on the floor.
C. Causes and contributing factors of piriformis syndrome: Spasm, strain and inflammation will irritate the underlying sciatic nerve. Oftentimes sedentariness will lead to PS or DGS due to a lack of tissue tolerance in the gluteal space.
III. Debunking Myths
A. Myth #1: Strengthening the piriformis is bad
Lack of physical activity perpetuates the “tight” sensation in the deep gluteal space. Our body's response to weakness and strain is guarding, compensation and adaptation. The deep gluteal muscles of the hip may be in reactive spasm or straining with regular activities due to its lack of tolerance. Training and loading the hip is an excellent approach to treatment and rehab. The misconception comes from the idea that the “tight” sensation in the tissue is caused by muscles being actively flexed. Rather, strained, weakened and irritated tissues often produce the same sensations via our nervous system.
B. Myth #2: Piriformis syndrome is always the cause of sciatic pain
The most common cause of sciatic pain is lumbar radiculopathy from nerve root compression. Conditions such as herniated/bulging disk, degenerative disk disease (DDD) and lumbar stenosis are all common causes of nerve root compression. Without imaging and proper screening, identifying the nerve compression site can be discerning because of the variety of signs and symptoms displayed.
Special tests are frequently used by clinicians to help identify symptoms associated with a particular diagnosis. (Brookbush, 2023) Special tests vary in reliability however, often producing false positives. Though great insight, special tests and a consultation may not be reliable in identifying a case of piriformis syndrome in some cases.
C. Myth #3: Does unique anatomy and sciatic nerve morphology have a correlation to nerve pain syndromes?
A large study was conducted to investigate the possible relationship between variety in sciatic nerve anatomy and its relationship to piriformis syndrome, buttock pain, and sciatica.
Figure 1 identifies approximately 6 varieties of the sciatic nerve. (Bartret et al., 2018) Despite a wide variety of hip variations, Even some sciatic nerves running straight through the piriformis, the results did not have a statistically significant difference between normal and varied hip anatomy.
IV. Signs and Symptoms
A. Common symptoms associated with piriformis syndrome: Numbness and tingling through buttocks down the back of the leg, Pain and irritation of the greater trochanter ( side of the hip), pain centered in the deep gluteals.
B. Treatment options
1. Conservative approaches: The most effective conservative and preventative approach to PS is strength and conditioning. A comprehensive exercise program developed by your clinician or trainer is the primary treatment and first line of defense. Exercises such as; glute bridges, hip abduction and other glute and hip activation exercises are indicated.
2. Manual Therapy treatments can relieve perceived tension and pain symptoms and help build awareness of hip and the sensations that you may experience. Treating the deep gluteal structures via soft tissue manipulation and stretching may yield therapeutic results. Nerve Gliding/flossing/mobilizations is another great technique for treating nerve pain under the scope of manual therapy.
VI. Prevention and Management Strategies
A. Preventive measures for reducing the risk of piriformis syndrome: Increasing physical activity is the most effective way to prevent PS and DGS.
B. Lifestyle modifications and ergonomic practices: Try adding a walking, stretching or movement routine to your day if you work a sedentary job. The issue with desk/sitting jobs is not the act of sitting itself. Rather it's the lack of movement and variety of movement. Switching sitting positions multiple times throughout the day and including movement activities over breaks is a great way to reduce the aches and pains of sedentary lifestyles.
Email me for more information at gavin.massage.crump@gmail.com or click here make an appointment.
VII. Real-Life Experiences
Patient testimonials and experiences with piriformis syndrome: Client aged 52, female presenting with mild gluteal pain and paresthesia localized in the hip and does not travel into the leg. Symptoms for about 2 weeks. Sitting makes it worse. She has a generally active lifestyle outside of work but once the onset of symptoms came on she became afraid to continue certain exercises because she feared it would make her symptoms worse.
Upon assessment and examination, I have ruled out the likelihood of lumbar radicular pain and could infer based on my assessments I was likely dealing with a case of DGS. Approximately 40 min of manual therapy her sensitivity and symptoms had significantly been reduced. Instructing and encouraging the client to return to their normal hip and lower body exercises in smaller doses and loads as to avoid flare ups. This allows their sensitive tissues to heal and strengthen back up to the normal levels of activity they desire and remain pain free.
Though rehabilitation of DGS and PS may take weeks to months to recover, flare ups often occur and it's important the client/patient understand flare ups are a normal part of the healing process and it's your body's signal that those tissues have reached a threshold they have not overcome quite yet. After a few manual therapy sessions and gradually returning to their regular exercises. They have been pain free ever since.
VIII. Conclusion
A. Recap of key points: Piriformis Syndrome in and of itself is a rare diagnosis due to the likelihood that identifying the specificity of nerve impingement is extremely difficult. Strengthening muscle tissue is never a hindrance to rehabilitation progress. Rather it is the best preventative measure and treatment for it.
B. Sciatic pain comes in many forms and may be unlikely that the piriformis is causing the impingement syndrome. Every person and body is unique and understanding there are many influencing factors to your pain is paramount to understanding a path to healing. Variety in anatomy does not influence the chances that an individual will or not have piriformis syndrome. No one individual is more prone than another; it is a culmination of factors that lead to painful syndromes such as DGS.
C. A large variety of treatment options such as rehab exercise, physical therapy interventions and manual therapy are great for treating pain and beginning the road to recovery from this elusive syndrome. PS and DGS have excellent prognosis and keeping a positive mindset about recovering is key.
D. Our outlooks, treatments and understanding all evolve with research over time. Without it we never grow and learn more about how to help ourselves and others. We must stay on top of evidence based research and base our understanding off of such quality research when available. The ability to treat piriformis syndrome with methodologies mentioned in this article are no exception!
Email me for more information about treating Piriformis and sciatic pain at gavin.massage.crump@gmail.com or click here make an appointment.
References
Bartret, A. L., Beaulieu, C. F., & Lutz, A. M. (2018, Nov 28). Is it painful to be different? Sciatic nerve anatomical variants on MRI and their relationship to piriformis syndrome. Eur Radiol, (11), 4681-4686. Pubmed. Retrieved 03 27, 2023, from https://pubmed.ncbi.nlm.nih.gov/29713768/
Brookbush, B. (2023, June 6). Special Tests: Introduction. Brookbush Institute. Retrieved March 27, 2024, from https://brookbushinstitute.com/articles/special-tests-introduction#
Halpin, R. J., & Ganju, A. (2009). Piriformis syndrome: a real pain in the buttock? Neurosurgery, 65(4), A197–A202. Pubmed. https://pubmed.ncbi.nlm.nih.gov/19927068/
Piriformis Syndrome and Sciatica Nerve. (n.d.). Complete Orthopedics. Retrieved March 27, 2024, from https://www.cortho.org/spine/sciatica/piriformis-syndrome-and-sciatica/
Piriformis Syndrome: Symptoms, Causes and Treatment. (2022, July 13). Cleveland Clinic. Retrieved March 27, 2024, from https://my.clevelandclinic.org/health/diseases/23495-piriformis-syndrome
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