Transcript Piriformis Syndrome/ Sciatica: A Case Presentation

Piriformis Syndrome

Presented by Dr. Emily Kliethermes

August 8, 2005
Tips for Successful Credit
 Case
History
 Chief Complaint Worksheet
 Physical & spinal Exam
 Problem Management Treatment
Plan
 Differential Diagnosis Worksheet

PIRIFORMIS SYNDROME
– Sciatica like pain caused by compression of the
sciatic nerve by the piriformis muscle, which
extends from the pelvic surface of the sacrum to
the upper border of the greater trochanter of the
femur and, during running or sitting, can
squeeze the sciatic nerve at the site where the
nerve emerges from under the piriformis to
over the gemellus and obturator internus
muscles. (Merck Manual 17th edition)
Piriformis
Posted by
Origin
[email protected], 6/2/00 at 12:24:02 PM.
Anterior surface of lateral process of sacrum and gluteal
surface of ilium at the margin of the greater sciatic
notch
Insertio
Superior border of greater trochanter
n
Action
Lateral rotator of the hip joint; also helps abduct the hip
if it is flexed
Innervat
Piriformis nerve (L5, S1, S2)
ion
Arterial Superior and inferior gluteal and internal pudendal
Supply arteries
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Patient Information

Twenty-two year old male caucasian
 History
– Family history was not contributory
– Patient had been treated previously by
chiropractic in California for similar symptoms
that improved but did not remit.
– The patient moved from California to Texas
following a change in relationship status
Patient Information

History (cont.)
– Patient experienced an acute exacerbation of
symptoms following the move.
– Patient attributes exacerbation to caring two
150 lbs bags, one over each shoulder, through
the airport.
Chief Complaint

Low back pain that radiates down the right
leg below the knee to the lateral foot.
 Experiences burning type pain in foot and
“tightness or pressure in the muscles of the
low back and outside aspect of the thigh”.
 Pain is constant, however, worse in
morning.
Chief Complaint

Patient states that moist heat over low back
and hip area decreases the pain.
 Cold (including weather) increases his pain.
 Standing and sitting for prolonged periods
increase the pain.
Physical Exam

Abnormal Thoracolumbar ROM
– Flexion 75 degrees with pain in right low back
(norm 90 deg.).
– Extension 45 degrees with pain (norm 35 deg.).
– Right lateral flexion 35 degrees (norm 40 deg.).
– Right rotation 28 degrees (norm 35 deg.).
Physical Exam

Positive/Clinically Relevant Orthopedic
Tests
– Supported Adam’s Test (dec pain with support)
– SLR on Right at 8 degrees (pain decreases with
external rotation of the hip)
– Braggard’s
– Patrick Fabere (dec sciatic symptoms)
– SOTO decrease pain
Physical Exam

Postural Analysis
– Left head tilt
– Left high shoulder
– Left high hip
– External rotation of right foot
Physical Exam

Palpation
– Restriction throughout spine
– Hypertonicity in lumbar musculature
– Trigger points in belly of Piriformis Muscle
X-ray Findings

Mild left curvature involving the T9-L5
levels
 Lateral lumbar reveals a uniform reduction
of the posterior body height of L5 (probable
congenital variation in anatomical
presentation of L5 body).
DDX:

Sciatica
 Piriformis Syndrome
 Disc Herniation
Diagnosis:

Condition: Piriformis Syndrome
(pseudosciatica)
 Secondary to: Sacroiliac segmental
dysfunction
 With associated: myospasm
Treatment

CMT 3 x / week for 2 weeks
 CMT 2 x / week for 3 weeks
 Then Re-evaluate
 Adjunctive procedures were performed as
listed PRN
– Myofascial release of piriformis, TFL, and QL
muscles
– PIR stretch of piriformis and psoas muscles
Treatment

Adjunctive procedures (cont.)
– Percussor (lower extremities)
– Aqua massage

Treatment Goals:
– Decrease trigger points, spasm and pain
– Increase ROM
Treatment

Nutrition
– Calcium / Magnesium complex
– Increase Water intake
Home stretches were given for piriformis and
psoas muscles to be performed bid