PIRIFORMIS SYNDROME

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Inflammation or compression of the sciatic nerve adjacent to the piriformis muscle causes the painful condition known as piriformis syndrome (Deep Gluteal Syndrome)

SIGNS AND SYMPTOMS

The typical piriformis syndrome sufferer experiences "sciatica," which is a sudden, intense pain that radiates from the lower back or buttock into the thigh, calf, and foot. The following conditions are also present in people who have piriformis syndrome, which makes it easier for the physician to identify the underlying cause during an examination:
  • Being unable to sit or bear weight on one side's buttock
  • Piriformis muscle spasm
  • Piriformis muscle discomfort during a rectal examination
  • When the hip is moved and rotated outward against resistance, a discomfort similar to sciatica may occur.

CAUSES

  • Injury
  • Abnormal piriformis muscle or sciatic nerve development or placement
  • Improper spinal alignment (such as scoliosis)
  • Difference in leg length (when the legs are of different lengths)
  • Prolonged sitting, especially if the piriformis muscle is immediately beneath a heavy wallet that is kept in a pocket.
  • Prior hip replacement
  • Uncommonly intense workout
  • Foot issues, such as Morton's neuroma
DIAGNOSIS

The diagnosis is "clinical," which means that it is based on physical examination and symptoms. The diagnosis cannot be confirmed by a specific biopsy, imaging test, or blood test.

Observation 

Piriformis syndrome patients may also have gluteal atrophy and a shortening of the affected side's limb. Muscle hypotrophy is seen in the affected extremity in chronic situations.

Palpation

The patient expresses sensitivity when the greater sciatic notch is palpated externally, when the vagina or rectum is palpated internally, or when the sacroiliac joint or the belly of the piriformis muscle is touched. By carefully and deeply palpating the PM, the spasm of the PM can be felt.
Deep digital palpation may reveal soreness and pain with an aggravation of tightness and leg numbness in the gluteal and retro-trochanteric region.

Evaluation

Subjective Evaluation 

  • The subjective assessment should be used to identify causal factors, such as recent trauma in the past or adjustments to training or lifestyle.
  •  Throughout the evaluation, the clinician will be guided by information about the type, severity, behaviour , and frequency of pain.
  • Those with piriformis syndrome typically experience intense pain that is localized to the back of the hip and is made worse by standing or exertion.
  • While the patient is lying down, this soreness frequently becomes better.
  • Furthermore, knee flexion may further reduce the symptoms. 
  • Although similar symptoms are usually present with lumbo-pelvic dysfunctions as well, it is possible to have pain, numbness, and paresthesia spreading distally into the lower extremity.
  •  In order to rule out lumbar or sacroiliac dysfunction, it is essential that you extend the evaluation to these areas.
Objective Evaluation 

  • The objective evaluation must include a measurement of the lower extremities' active and passive range of motion, muscle strength, and posture. 
  • To identify the precise tissues implicated, a palpation of the area is required.
  • To distinguish piriformis syndrome from other types of dysfunction, a number of provocation tests have been proposed . 
  • A neurovascular evaluation is also required to rule out more serious spinal pathology.
  • In order for the clinician to precisely characterize the athlete's functional limitations, the examination should also include an assessment of functional abilities and abilities specific to a particular sport.
The physical examination techniques listed below are all consistent with piriformis syndrome
  • When a patient is relaxed in the supine position, the ipsilateral foot is externally rotated, and active internal rotation hurts, that is a positive piriformis indication.
  • The clinician places the patient in  side-lying with the affected extremity in a hip flexion, adduction, and internal rotation position while holding the patient's knee.The FAIR test is considered positive if it causes discomfort at a location that corresponds to the point where the sciatic nerve and the piriformis join.

  • When the hip is flexed at 90 degrees and the knee is extended, localized pain over the piriformis muscle and its tendon indicates the presence of the Lasegue sign.

  • If localized discomfort is felt during passive internal hip rotation, the Freiberg sign is present.


  • A positive pace sign occurs when sciatic symptoms are recreated with the patient in a lateral recumbent position, the hip flexed to 60 degrees, and the knee flexed between 60 and 90 degrees. The examiner then internally rotates and adducts the hip by pressing downward on the knee while stabilizing the hip.


  • With the Beatty technique, the patient lies on the side that is not affected and raises the affected thigh, activating the ipsilateral piriformis muscle and producing localised pain in the buttocks.

MANAGEMENT

CONSERVATIVE MANAGEMENT

Non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and neuropathic pain medications are among the pharmaceuticals used in the conservative treatment of piriformis syndrome. Other treatments include physical therapy, dietary changes, and psychotherapy.
Local anesthetics, steroids, and botulinum toxin injections can be used for both therapeutic and diagnostic purposes in the PM muscle.

PHYSICAL THERAPY MANAGEMENT

Exercises for Piriformis syndrome are designed to ease muscular tension and reduce pressure on the sciatic nerve, a condition that causes Piriformis syndrome. Implementing the stretching and strengthening techniques necessary for treating Piriformis syndrome.

Piriformis syndrome stretching exercises
  • Piriformis stretching exercises aid in relieving muscular spasms, which relieve strain on the sciatic nerve.
  • Static stretches are more suitable because the piriformis muscle is located in the hip.
  • Stretching that is applied and then held for a while is referred to as static stretching. It's crucial that the stretch is softly applied rather than being forced.
  • Daily stretching of the piriformis muscle is advised; in the beginning, at least three times a day may be necessary.
PIRIFORMIS STRETCH
OUTER HIP STRETCH
LONG ADDUCTOR STRETCH 
SHORT ADDUCTOR STRETCH
 
GLUTEAL STRETCH 

HEMSTRING STRETCH 

FOAM ROLLER EXERCISE
Piriformis muscle strengthening exercise 
  • By strengthening the muscle, you may ensure that it is able to handle the demands placed on it and avoid further injuries.
  • Piriformis syndrome can be avoided by strengthening the piriformis muscle as well as the other hip abductor muscles.
RESISTED HIP ABDUCTION


SIDE-LYING CLAM EXERCISE


HIP EXTENSION PIRIFORMIS EXERCISE

PARTIAL CURL 

QUADRUPED ARM/LEG RAISE
PRONE HIP EXTENSION 

NON CONSERVATIVE MANAGEMENT

The last option for patients with piriformis syndrome is surgery. Only patients who have failed conservative therapy, such as physical therapy, should be given this option. If the nerve is impinged, surgery may assist decompress it. Moreover, the surgeon may dissolve adhesions or remove scar tissue from the nerve. The outcomes of surgery, however, are not always predicted, and some patients continue to have discomfort.





































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