Piriformis Syndrome Treatment by Physiotherapists

By: Jonathan Blood-Smyth

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.
There are no clear causative factors for piriformis syndrome which seems to accompany other lumbar or pelvic pains. Direct trauma to the area can cause bleeding and scarring around the nerve and the muscles, with consistent pressure to the buttock perhaps affecting the nerve's function. The syndrome can also be associated with an increased lordotic posture, hip replacement or vigorous activity and mimics back pain syndromes such as sciatica. Physiotherapists diagnose and treat piriformis syndrome on purely clinical grounds as there are no agreed diagnostic criteria, imaging or other tests.
Piriformis syndrome is often not considered as a cause of low back and leg pain but can mimic sciatic nerve compression, giving symptoms similar to back pain with L5 or S1 nerve compression from disc or joint changes. Cases of trochanteric bursitis may be connected to this syndrome as the muscle inserts onto the trochanter. Physio clinical examination will find intense pain over the piriformis trigger point in the buttock, reduced lateral rotation of the hip, pain and weakness on resisted hip abduction and lateral rotation and a difficulty sitting on the affected buttock.
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.
The physiotherapist may find tightness in the piriformis and hip muscles and institute a treatment regime of stretches after loosening up the hip muscles. To stretch the piriformis the patient lies on their back, bends up the hip to 90 degrees and moves the hip across the body with the opposite hand, holding at the end of the stretch. A home exercise programme of stretches is set for regular performance, with the stretches being done every few hours in the more acute episodes. The Physio may find the piriformis muscle is stretched rather than tight, leading them to work on strengthening it up and stretching the opposing tight structures.
Local manipulation is a common treatment directly over the most painful point in the buttock, which can be very tender indeed. Transverse or longitudinal mobilisations over the muscle is the technique used, maintaining the pressure steadily for up to 10 minutes initially. Treatment of the back and sacro-iliac joints is important to address any dysfunction which might contribute. Modifying posture and activity, muscle injections, mobilisations and stretching are commonly successful in reducing symptoms. In resistant cases surgery to the muscle or the tendon at the greater trochanter may be contemplated.

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Jonathan Blood-Smyth is a Principal Physiotherapist at a large NHS teaching hospital in South-West England. He publishes articles on injuries and mishaps in journals and on his website for physiotherapists. If you are looking for local physiotherapy after an mishap or trauma, visit his website for physiotherapy practitioners around the United Kingdom.

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