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Piriformis Syndrome: The Manual Therapy and Exercise Road to Relief

Updated: Apr 1


Abstract Image of Hips

Piriformis Syndrome (PS) is a form of non-discogenic sciatica where the piriformis muscle in the buttock region irritates or compresses the sciatic nerve, leading to pain and discomfort along its pathway. Distinct from spinal causes such as disc herniation, PS is an elusive condition that intertwines with the broader concept of Deep Gluteal Syndrome (DGS)—a spectrum of disorders causing sciatic-like symptoms due to nerve entrapment in the deep gluteal space.


This article will dissect the complexities of PS, clarifying its pathology, clinical presentation, and management strategies. We will explore the intricate anatomy of the piriformis muscle and its relationship with the sciatic nerve, illuminate the various factors contributing to this syndrome, and discuss the nuances of diagnosis and treatment. Our focus is to equip practitioners and patients with a clear understanding of PS, enabling precise identification and effective intervention.


Article Index:

 


Piriformis Anatomy Image

Causes and Considerations


Definition and Clinical Presentation:

  • Piriformis Syndrome is characterized by buttock pain and sciatic nerve irritation due to compression by the piriformis muscle.

  • Symptoms include pain, numbness, and tingling radiating from the buttock down the leg, often worsening with sitting or activity.


Anatomical Considerations and Variations:

  • The piriformis muscle stabilizes and rotates the hip; its relation to the sciatic nerve varies among individuals.

  • Anatomical variations in this relationship may predispose to nerve compression, with muscle spasms or hypertrophy exacerbating the condition.


Epidemiology and Gender Disparity:

  • PS is more common in women, possibly due to wider pelvises and hormonal effects on muscles and ligaments.

  • It often affects athletes and those in sedentary occupations, highlighting the need for targeted interventions based on patient demographics and activity levels.


 


Fibrous Band Image

Mechanisms Underlying Piriformis Syndrome


Sciatic Nerve Compression Dynamics:

  • Compression of the sciatic nerve by the piriformis muscle can result from intramuscular changes such as hypertrophy, myospasm, or inflammation, often incited by mechanical stressors or acute trauma.


Causal Factors:

  • Extrinsic factors like occupational ergonomic risks and athletic overuse contrast with intrinsic anatomical variations, such as the bifid piriformis or anomalous sciatic nerve piercing, which elevate the risk for PS development.


Contributions of Fibrous Bands:

  • Collagenous fibrous bands can form perineurally, leading to adhesions that restrict neural mobility and potentiate entrapment neuropathy along the course of the sciatic nerve.


Fascial Tension Interplay:

  • Increased tension within the piriformis fascial sheath may impair the nerve's ability to glide, causing symptomatology that mirrors direct nerve entrapment and necessitates differential diagnosis for appropriate management.


 

Clinical Manifestations


Specific Symptomatology:

  • Piriformis Syndrome primarily presents as a deep, aching pain in the buttock, often radiating down the leg along the sciatic nerve's path. This pain can intensify with activities like sitting for long periods, climbing stairs, or running. Other symptoms include tenderness in the buttock region, and sometimes, pain during bowel movements or sexual activity.


Differentiation from Other Sciatic-like Symptoms:

  • Distinguishing Piriformis Syndrome from other causes of sciatica, such as lumbar disc herniation or spinal stenosis, is crucial. Unlike discogenic sciatica, Piriformis Syndrome does not typically cause pain in the lower back, and symptoms are more localized to the buttock and leg. Also, neurological deficits such as reduced reflexes or muscle weakness are less common in PS compared to lumbar radiculopathy.


Implications of Misdiagnosis and Over-diagnosis:

  • Misdiagnosing or over diagnosing Piriformis Syndrome can lead to inappropriate treatments, prolonged discomfort, and potentially the worsening of underlying conditions. It's important to conduct a thorough clinical assessment and consider imaging studies to rule out other causes of sciatica, ensuring that patients receive the most effective and targeted treatment.


 

Physical Examination

Manual Therapy Image

A comprehensive evaluation is crucial for patients presenting with sciatica-like symptoms to discern if Piriformis Syndrome (PS) is the underlying cause. This process involves a detailed medical history, thorough physical examination, and a combination of orthopedic and neurological assessments.


Initial Assessment:

  • The examination begins with a visual inspection and range-of-motion tests focusing on the lumbar spine. Observation for asymmetry, muscle spasms, or posture deviations that might suggest underlying mechanical issues is essential.


Palpation and Specific Tests:

  • Palpation of the lower back, particularly around the piriformis muscle, helps identify areas of tenderness or muscle tightness. Specialized tests, such as the Piriformis Stretch Test or the Freiberg Test, can be more indicative of PS than general tests like the Straight Leg Raise, which is more commonly used to diagnose disc herniation.


Differentiating PS from Other Conditions:

  • Additional assessments may include hip joint mechanics and vascular screening (like the Homans Test for deep vein thrombosis). These tests are integral to differentiating PS from other conditions presenting with similar sciatica symptoms.


This thorough and specific approach to physical examination is key to accurately diagnosing Piriformis Syndrome and distinguishing it from other lumbar spine disorders.


Orthopedic Assessment Video

Low Back Examination


To observe a demonstration of the standard orthopedic tests conducted during a clinical examination of the low back, click on the video located to the right. The video showcases various tests that are commonly used to diagnose musculoskeletal conditions that affect the lower back.


 

Neurological/Vascular Testing

Practitioner With Reflex Hammer Examining Patient

A comprehensive neurological exam is vital for diagnosing musculoskeletal issues. It should assess sensation changes via dermatomal patterns—though these may vary between individuals and lack unanimous chart agreement—and deep tendon reflexes, which signal peripheral or central nervous system integrity, graded on a 0 to 4 scale at key reflex points.


Motor function is gauged through myotomes, with muscle strength rated from 0 (no contraction) to 5 (full motion against resistance) at specific muscle sites. Plain radiographs are advised for older patients or those with significant risk factors or symptoms. The Babinski sign, if present, points to an upper motor neuron issue. This in-depth neurological assessment aids in pinpointing and managing musculoskeletal disorders.


Lower Limb Neuro Examination video

The Lower Limb Neurological Examination is an essential component of the overall neurological examination process and is performed to evaluate the sensory and motor neurons that supply the lower limbs. This examination aids in identifying any dysfunction in the nervous system and serves as a valuable screening and investigative tool.


Peripheral Vascular Examination - Video

Conducting a peripheral vascular examination is a vital means of identifying any signs of vascular-related pathology and can help prevent cardiovascular and cerebrovascular complications. This examination is a valuable tool for ruling out any possible issues. The video presented here demonstrates some of the most commonly used procedures in daily clinical practice.


RECOMMENDED ORTHOPAEDIC REFERENCE BOOKS

Orthopaedic Physical Assessment – David J. Magee https://amzn.to/3zgu0za

Dutton's Orthopaedic: Examination, Evaluation and Intervention, Fifth Edition https://amzn.to/3st1AOv


 

Imaging

MRI Image of Lumbar Spine

Imaging is an integral part of diagnosing Piriformis Syndrome (PS), differentiating it from other causes of sciatica and pinpointing the specific source of nerve irritation or compression. Various imaging techniques are employed, each with its strengths in visualizing different anatomical structures.


X-ray:

While X-rays are limited in their ability to view soft tissues and nerves, they are valuable in excluding other potential causes of sciatic pain such as fractures or tumors. This makes them a useful initial screening tool in the diagnostic process.


MRI:

Magnetic Resonance Imaging (MRI) is the most informative imaging modality for PS, providing detailed images of the piriformis muscle, sciatic nerve, and surrounding structures. It excels in identifying muscular abnormalities, inflammation, and any anomalous anatomical relationships between the sciatic nerve and piriformis muscle.


Ultrasound:

Ultrasound imaging offers real-time visualization of the sciatic nerve's path in relation to the piriformis muscle. Its dynamic nature allows for assessment of nerve movement and potential entrapment during different positions or activities, making it particularly useful for diagnosing PS.


 

Conservative Management


Effective treatment of Piriformis Syndrome (PS) typically involves a combination of non-surgical approaches tailored to alleviate pain, reduce muscle tension, and improve mobility:


Manual Therapy:

Techniques like myofascial release and massage are essential for loosening the piriformis muscle. Targeted stretching exercises help alleviate nerve compression, and applications of heat or cold therapy can reduce muscle spasm and pain.


Motion Specific Release (MSR):

MSR is particularly effective in treating PS. This comprehensive approach involves specific techniques to release muscle tension and improve mobility, focusing on the interconnectedness of body structures to address the root cause of the syndrome.


Mobilization Techniques:

Mobilizing the sacroiliac and hip joints can reduce muscle tension and improve alignment, subsequently reducing nerve irritation.


Acupuncture and Acupressure:

These traditional methods can be beneficial for pain and inflammation management in PS, stimulating specific body points to release muscle tension and enhance nerve function.


Epidural Steroid Injections:

For severe pain, an epidural steroid injection may be suggested to decrease inflammation and facilitate more effective participation in physical therapy and MSR.


Pain Medication:

Over-the-counter pain relievers like acetaminophen or NSAIDs can provide symptomatic relief by managing pain and inflammation.


Lifestyle Modifications:

Adjustments in daily activities, including ergonomic seating, regular stretching, weight management, and minimizing prolonged sitting, play a crucial role in managing symptoms and preventing PS recurrence.


Combining these approaches, especially the integration of MSR, can significantly improve outcomes in PS, focusing on restoring function and alleviating discomfort.


 

Motion Specific Release


In treating Piriformis Syndrome, Motion Specific Release (MSR) adopts a holistic approach that extends beyond the piriformis muscle to the entire myofascial kinetic chain. This methodology recognizes that dysfunctions causing sciatic nerve compression are often linked to imbalances and restrictions in other parts of the body. By addressing these interconnected structures, MSR aims to tackle the root cause of symptoms and reestablish healthy movement patterns.


Central to MSR's approach is the assessment and treatment of fascial restrictions and joint dysfunctions that contribute to Piriformis Syndrome. Techniques such as joint mobilization and targeted soft tissue therapies are used to enhance fascial health and improve joint function. This not only helps in alleviating the immediate discomfort associated with Piriformis Syndrome but also aids in promoting long-term musculoskeletal health and functional balance.

Demonstration Video

You can eliminate your sciatic nerve pain! In this video, Dr. Abelson demonstrates some of the Motion Specific Release (MSR) procedures we use to release the Sciatic Nerve. Symptoms of sciatica can be caused by disc herniation, foraminal stenosis, spinal stenosis, piriformis syndrome or entrapment of the sciatic nerve. Fortunately, most cases of Sciatica do NOT require Surgery, as long as no red flags are present.


 

Exercise is Critical


Exercise plays a crucial role in the management of Piriformis Syndrome by facilitating the elongation and strengthening of the piriformis muscle. This targeted approach helps in alleviating nerve compression and mitigating pain. Regular, specific exercises enhance muscular flexibility and contribute to hip joint stabilization. Improved blood circulation from these activities aids in reducing inflammation and expediting the healing process. Consequently, a structured exercise regimen is essential for symptomatic relief and preventing future episodes of Piriformis Syndrome.


Piriformis Syndrome Exercise Video
Click Image to Watch Video

Piriformis Syndrome: Exercises for Pain Relief

In this video, MIki Burton RMT demonstrates some very effective exercises in resolving Piriformis Syndrome (PS). PS, a neuromuscular disorder, arises due to the piriformis muscle's entrapment or compression of the sciatic nerve. It's characterized by low back and buttock pain and is sometimes interchangeably used with Deep Gluteal Syndrome (DGS). The piriformis muscle, while small, plays a significant role in lower body mechanics, especially in hip joint stability and rotation.


 

Conclusion


Piriformis Syndrome (PS) demands a nuanced understanding and a multifaceted treatment approach. This article has detailed the complex interplay between the piriformis muscle and the sciatic nerve, highlighting the importance of precise diagnosis and targeted treatment strategies. The emphasis on conservative management, including Motion Specific Release (MSR) and exercise, underscores the effectiveness of non-surgical methods in alleviating symptoms and enhancing function in PS patients. Ultimately, this comprehensive approach, integrating manual therapy, structured exercise, and lifestyle modifications, is crucial for effective symptom relief and long-term musculoskeletal health in Piriformis Syndrome management.


 

Dr. Brian Abelson, DC. - The Author


Photo of Dr. Brian Abelson

Dr. Abelson is committed to running an evidence-based practice (EBP) incorporating the most up-to-date research evidence. He combines his clinical expertise with each patient's specific values and needs to deliver effective, patient-centred personalized care.


As the Motion Specific Release (MSR) Treatment Systems developer, Dr. Abelson operates a clinical practice in Calgary, Alberta, under Kinetic Health. He has authored ten publications and continues offering online courses and his live programs to healthcare professionals seeking to expand their knowledge and skills in treating musculoskeletal conditions. By staying current with the latest research and offering innovative treatment options, Dr. Abelson is dedicated to helping his patients achieve optimal health and wellness.


Despite being in the field for over three decades, Dr. Abelson remains open to welcoming new patients at Kinetic Health, save for the periods he dedicates to teaching or enjoying travels with his cherished wife, Kamali. However, be forewarned, he will anticipate your commitment to carry out the prescribed exercises and punctuality for your appointments (smile). His dedication towards your health is absolute, particularly in ensuring that you can revel in life unimpeded. He genuinely delights in greeting both new faces and familiar ones at the clinic (403-241-3772).


 


Manual Therapy Image

Revolutionize Your Practice with Motion Specific Release (MSR)!


MSR, a cutting-edge treatment system, uniquely fuses varied therapeutic perspectives to resolve musculoskeletal conditions effectively.


Attend our courses to equip yourself with innovative soft-tissue and osseous techniques that seamlessly integrate into your clinical practice and empower your patients by relieving their pain and restoring function. Our curriculum marries medical science with creative therapeutic approaches and provides a comprehensive understanding of musculoskeletal diagnosis and treatment methods.


Our system offers a blend of orthopedic and neurological assessments, myofascial interventions, osseous manipulations, acupressure techniques, kinetic chain explorations, and functional exercise plans.


With MSR, your practice will flourish, achieve remarkable clinical outcomes, and see patient referrals skyrocket. Step into the future of treatment with MSR courses and membership!


 

References

  1. Boyajian-O'Neill L., McClain R.L., Coleman M.K., Thomas P.P. (2019). Piriformis Syndrome: A Narrative Review of the Anatomy, Diagnosis, and Treatment. PM R, 11(Suppl 1), S54–S63. doi:10.1002/pmrj.12189.

  2. Cassidy L., Walters A., Bubb K., Shoja M.M., Tubbs R.S., Loukas M. (2015). Piriformis Syndrome: Implications of Anatomical Variations, Diagnostic Techniques, and Treatment Options. Surg Radiol Anat, 37(8), 875–881. doi:10.1007/s00276-015-1457-9.

  3. Filler A.G. (2016). Piriformis Syndrome: A Cause of Nondiscogenic Sciatica. Curr Pain Headache Rep, 20(1), 5. doi:10.1007/s11916-015-0529-4.

  4. Fishman L.M., Dombi G.W., Michaelsen C., Ringel S., Rozbruch J., Rosner B., Weber C. (2002). Piriformis Syndrome: Diagnosis, Treatment, and Outcome—a 10-Year Study. Arch Phys Med Rehabil, 83(3), 295–301. doi:10.1053/apmr.2002.30622.

  5. Hopayian K., Song F., Riera R., Sambandan S. (2010). The clinical features of the piriformis syndrome: a systematic review. Eur Spine J, 19(12), 2095–2109. doi:10.1007/s00586-010-1504-9.

  6. Jankovic D., Peng P., van Zundert A. (2013). Brief review: piriformis syndrome: etiology, diagnosis, and management. Can J Anaesth, 60(10), 1003–1012. doi:10.1007/s12630-013-0009-5.

  7. Jankovic D., Peng P., van Zundert A. (2013). Brief review: Piriformis syndrome: etiology, diagnosis, and management. Anaesthesia, 68(8), 819–831. doi:10.1111/anae.12271.

  8. Keskula D.R., Tamburello M. (2018). Diagnosis and Management of Piriformis Syndrome: A Rare Anatomic Variation. Phys Ther, 98(3), 214–222. doi:10.1093/ptj/pzx120.

  9. Wind H., Geraets J.J.X.R., Becker E.S., Cremers S.M.J., van Kroonenburgh M.J.P.G., Jansen J.J., van Santbrink H., Rijkers K., Willems P.C. (2017). A minimally invasive surgical approach for the treatment of piriformis syndrome. Chin Neurosurg J, 3(13). doi:10.1186/s41016-017-0086-4.

  10. Wind H., Geraets J.J.X.R., Becker E.S., Cremers S.M.J., van Kroonenburgh M.J.P.G., Jansen J.J., van Santbrink H., Rijkers K., Willems P.C. (2017). Four symptoms define the piriformis syndrome: an updated understanding. BMC Musculoskelet Disord, 18(1), 188. doi:10.1186/s12891-017-1481-6.


 

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