Transcript 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
“Neuritis of the branches of the sciatic
nerve, caused by pressure of an injured
or irritated piriformis muscle1.”
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
image from www.tpmassageball.com
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
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 Diagnosis
Differential Diagnosis of Hip pain7,8:
Extra-articular Causes (Often Managed NonOperatively):
– Femoral Neck Stress Fracture
– Adductor Strain
– Piriformis Syndrome
– Sacroiliac Joint Syndrome
– Tendonitis (hip flexors, abductors, adductors)
Differential Diagnosis
Other Competing Diagnosis:
Lumbar Facet Syndrome
Lumbar Disc Herniation
Nerve entrapment
Ischial Tuberosity Bursitis
Lumbar radiculopathy
Spinal stenosis
Spondylolisthesis
Osteoarthritis
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
The piriformis is shortened or in
“spasm” and is compressing the
sciatic nerve
Purpose of study
To create a case series using an
alternative treatment approach to
piriformis syndrome
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 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 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
Patient to fill out disability questionnaires:
– Oswestry Disability Index
– Lower Extremity Functional Scale
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
Hip strengthening:
– Clams
– Bridging
– Prone hip extension
– Quadruped hip extension
– Hip abduction
Treatment Approach Examples
Movement Re-education:
– Postural correction
– Sit to stand transitions
– Single leg sit to stands
– Lunges
– Plyometrics if indicated
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
Range: initial (37-70) discharge (54-80)
Average VAS (Pain Scale)
Range: initial (6-10/10)
discharge (0-4/10)
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
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
Movement re-education and strengthening
can be a successful way to treat piriformis
syndrome when a patient presents with a
coordination deficit.
References
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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.