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An Alternative Treatment Approach to Piriformis Syndrome. Korey Pieper, DPT, OCS Marie Potter, DPT, OCS, ATC Rick J Rafael, DPT, OCS, CSCS Jason Tonley, DPT, OCS Kaiser Permanente West Los Angeles Orthopaedic Residency Program September 2008 . Piriformis Syndrome Defined.

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an alternative treatment approach to piriformis syndrome

An Alternative Treatment Approach to Piriformis Syndrome

Korey Pieper, DPT, OCS

Marie Potter, DPT, OCS, ATC

Rick J Rafael, DPT, OCS, CSCS

Jason Tonley, DPT, OCS

Kaiser Permanente West Los Angeles Orthopaedic Residency Program

September 2008

piriformis syndrome defined
Piriformis SyndromeDefined

“Neuritis of the branches of the sciatic nerve, caused by pressure of an injured or irritated piriformis muscle1.”

symptoms
Symptoms

Radiating pain from the low back down over the sacrum into the buttocks and hip region, as well as down the posterior portion of the upper leg to the popliteal region1.

Image from bp1.blogger.com

anatomy
Anatomy

image from www.tpmassageball.com

possible causes of piriformis syndrome
Possible Causes of Piriformis Syndrome

Anatomical variation

L/S dysfunction

Muscle tightness and/or spasm

Overuse

Post surgical injury

SIJ dysfunction

Trauma/fall

differential diagnosis
DifferentialDiagnosis

Differential Diagnosis of Hip pain7,8:

Intra-articular & Extra-articular (Often Managed Operatively) :

Labral Tears

Loose Bodies

Femoroacetabular Impingement (FAI)

Hypermobility

Capsular Laxity

Ligamentum Teres Tear

Chondral Damage

Snapping Hip Syndrome

IT Band Syndrome

Greater Trochanteric Bursitis

Gluteal Tendon Injury

differential diagnosis1
DifferentialDiagnosis

Differential Diagnosis of Hip pain7,8:

Extra-articular Causes (Often Managed Non-Operatively):

Femoral Neck Stress Fracture

Adductor Strain

Piriformis Syndrome

Sacroiliac Joint Syndrome

Tendonitis (hip flexors, abductors, adductors)

differential diagnosis2
DifferentialDiagnosis

Other Competing Diagnosis:

  • Lumbar Facet Syndrome
  • Lumbar Disc Herniation
  • Nerve entrapment
  • Ischial Tuberosity Bursitis
  • Lumbar radiculopathy
  • Spinal stenosis
  • Spondylolisthesis
  • Osteoarthritis
common treatment options
Common Treatment Options

Treatment Options:2,3,4,5,6

Injections

L/S stabilization exercises

Mobilization/manipulation L/S

Mobilization/manipulation SI joint

Foot orthotics

Soft tissue mobilization

Strengthening

Stretching

Surgical / arthroscopic release

Ultrasound

common assumption guiding treatment approaches
Common assumption guidingtreatment approaches

The piriformis is shortened or in “spasm” and is compressing the sciatic nerve

purpose of study
Purpose of study

To create a case series using an alternative treatment approach to piriformis syndrome

inclusion criteria objective exam
Inclusion Criteria: Objective Exam

Unilateral pain from lower lumbar/buttock region to the leg

Symptoms not reproduced from lumbar, SI joint, and/or hip joint examinations

inclusion criteria objective exam1
Inclusion Criteria: Objective Exam
  • Lumbar Exam
    • Negative AROM with OP
    • Negative PA exam
    • Neurological testing negative for nerve root lesion
  • SIJ Exam
    • Negative cluster
  • Hip Exam
    • Negative ROM, excluding quadrant
inclusion criteria objective exam2
Inclusion Criteria: Objective Exam
  • Reproduction of symptoms with:
    • Palpation of piriformis muscle
    • Piriformis stretch test
    • FAIR Test
  • Demonstrates movement dysfunction of ADD and/or IR and reproduction of symptoms with step down test
  • Decreased reproduction of symptoms with corrected movement during step down test
objective exam
Objective Exam
  • Patient to fill out disability questionnaires:
    • Oswestry Disability Index
    • Lower Extremity Functional Scale
treatment approach
Treatment Approach
  • Isolated strengthening for hip extensors, abductors, and external rotators
  • Functional movement re-education for decreasing hip adduction and internal rotation
  • NO!!!!!
    • Stretching
    • Soft tissue massage
    • Modalities
treatment approach examples
Treatment ApproachExamples
  • Hip strengthening:
    • Clams
    • Bridging
    • Prone hip extension
    • Quadruped hip extension
    • Hip abduction
treatment approach examples1
Treatment Approach Examples
  • Movement Re-education:
    • Postural correction
    • Sit to stand transitions
    • Single leg sit to stands
    • Lunges
    • Plyometrics if indicated
patient data
Patient Data
  • 7 Patients
  • Age: mean 56 (range 31 - 69)
  • Duration of symptoms: 197 days (range 45 – 730)
  • # of visits: 5 (range 2-8)
  • Duration of visits: 9 weeks (range 3-16)
average le functional scale
Average LE Functional Scale

Range: initial (37-70) discharge (54-80)

average vas pain scale
Average VAS (Pain Scale)

Range: initial (6-10/10) discharge (0-4/10)

analysis
Analysis
  • Movement assessment allowed proper physical therapy diagnosis and treatment
  • Patient’s can have multiple positive tests, but movement reproduces primary pain complaint
  • Ceiling effect of questionnaires affects data analysis
future research
Future Research
  • Prevalence of movement dysfunction in patient’s diagnosed with piriformis syndrome
  • Most effective treatment modality for movement dysfunction: strength training vs. movement re-education
conclusion
Conclusion
  • Movement re-education and strengthening can be a successful way to treat piriformis syndrome when a patient presents with a coordination deficit.
references
References

Edwards, F.O.: Piriformis syndrome. Academy of Applied Osteopathy. Yearbook, 1962, pp 39-41.

Parizale JR, Hudgins TH, Fishman LM: The Piriformis Syndrome. Am J. Orthrop, 1996:25:819-823.

Parizale JR, Hudgins TH, Fishman LM: The Piriformis Syndrome A Review. Paper.” The. Am J of Orthop. 2002:25:1-11

Bird JW: Piriformis Syndrome. Oper Tech Sports Med 2005 13 71-79

Mayrand N, Fortin J, Descarreaux M, Normand MC. Diagnosis and management of posttraumatic piriformis syndrome: a case study. J. Manipulative Physiol Ther. 2006 Jul-Aug;29(6):486-91

Keskula DR, Tamburello M: Conservative Management of Piriformis. Syndrome. J Athl Train. 1992; 27(2):102, 104, 106-107, 110

Lisa M Tibor, Jon Sekiya. Differential Diagnosis of Pain Around the Hip Joint. The Journal of Arthroscopic and Related Surgery. 2008;19:1-15

Michael K Shindle, Benjamin G Domb, Bryan T Kelly. Hip and Pelvic Problems in Athletes. Oper Tech Sports Med. 2007; 15: 195-203.