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Piriformis Syndrome Symptoms Causes Treatment Preventions & More All you need to know

December 28, 2021

Piriformis syndrome (PS) is a musculoskeletal condition marked by pain. The pain involves the buttock or hip. The situation is often confused with sciatic pain, but the two are different entities.

Piriformis syndrome arises as a result of peripheral neuritis of the branches of the sciatic nerve. This happens due to an injured or irritated piriformis muscle.

PS is also known as the deep gluteal syndrome, extra-spinal sciatica, wallet neuritis. It affects more women than men.

Piriformis Syndrome Symptoms Causes Treatment Preventions

Anatomy of the piriformis muscle

The piriformis muscle (PM) originates from the pelvic surface of the sacral segments S2-S4 of the spine. It passes through the greater sciatic arch of the hip bone and gets inserted onto the greater trochanter of the femur, the thigh bone.

The piriformis muscle controls external rotation, abduction (inward movement), and partial extension of the hip joint.

The sciatic nerve passes below the muscle belly to exit the pelvis. The sciatic nerve and the piriformis muscle are related in this way.

Causes of piriformis syndrome

There are two types of piriformis syndrome;

  • Primary; accounts for 15% of the cases of piriformis syndrome. It results from anatomical defects.
  • Secondary; accounts for the rest of the cases of the syndrome. It results from a triggering factor like significant injury, micro-trauma, and disturbance of the local blood supply of the muscle.

Following are the causative factors of the PS due to secondary reasons;

  • Macro-trauma to the buttocks results in 50% of the cases of PS. The overall effect is inflammation of soft tissue surrounding the muscle, muscle spasms, or both. Usually, nerve compression accompanies the condition.
  • Muscle spasms of the piriformis muscle result from direct trauma in sports or accidents, post-surgical injury, or the lumbar and sacroiliac joint overuse.
  • Shortening of the lower limb muscles may occur due to disturbance in structure and function of the lower back, and pelvic regions may also result in piriformis syndrome. The sciatic nerve gets compressed in such conditions. The malfunction of the piriformis muscle results in many signs and symptoms in the area supplied by the sciatic nerve, including the glutes, back of thigh or leg, and outside of the foot.
  • Micro-trauma to the piriformis muscle may occur in sports like long-distance walking or running.
  • Repeated direct compression may be the underlying cause, a condition called "wallet neuritis," which happens when sitting on hard surfaces for an extended time.
  • Other causes include anatomic variations of the sciatic nerve branches or the piriformis muscle, hypertrophy of the piriformis muscle, and hip arthritis.
  • A Morton's Toe is also a predisposing factor to piriformis syndrome. Skiers, truck drivers, tennis players, and long-distance bikers are more prone to this kind of injury.

Signs and symptoms of piriformis syndrome

Following are the signs and symptoms of PS;

  • Persistent and radiating low back pain
  • Buttock pain which becomes chronic
  • Numbness and paresthesia in the lower limb
  • Difficulty with walking
  • Pain with activities like sitting, squatting, standing, bowel movements
  • Dyspareunia (painful intercourse) in women

On examination, such patient reveal;

  • Pressure pain in the buttock on the side of the PS
  • Point tenderness over the sciatic notch
  • The buttock pain often radiates into the hip, the back of the thigh, and the lower leg's proximal portion.
  • Swelling in the legs
  • Disturbed sexual functions
  • Aggravation of pain with activity, prolonged sitting or walking, squatting, hip adduction and internal rotation and movements that increase the tension of the piriformis muscle

In some patients, the pain resolves on lying down, knee bending, or while walking.

Piriformis syndrome presents patients who walk with a limp or have their leg in a shortened and externally rotated supine position. This is a positive piriformis sign called a splayfoot. Contracted piriformis muscle results in splayfoot.

X-rays, CT, and MRI scans confirm the diagnosis. In addition, Electromyography (EMG) helps to differentiate piriformis syndrome from other possible disorders.

Injection of a local anesthetic drug, steroids, and botulinum toxin into the piriformis muscle serves to diagnose and treat the PS.

Treatment of piriformis syndrome

  1. Immediately after an injury to few days
  1. RICER
    1. Medication

Non-steroidal anti-inflammatory agents (NSAIDs), muscle relaxants, and neuropathic pain medication help manage the syndrome.

Ozone therapy is a newer treatment module that is said to help the symptoms.

  • TENS

TENS helps to improve the pain of the PS. Injections of anesthetic drugs, botox, and steroids may help severe symptoms.

  • Surgical Management

Surgical interventions are advised when conservative therapy fails.

Surgical intervention releases the muscle with tenotomy of the piriformis tendon. The nerve pressure is relieved immediately.

Partial weight-bearing by use of crutches and unrestrictive ROM exercises are a must after surgery.

  • After few weeks
  • Massage

Massage for piriformis syndrome often involves soft tissue mobilization, piriformis stretching, and myofascial release of the muscle. Different techniques used include effleurage, kneading, frictions, and wringing.

  • Therapeutic ultrasound

Ultrasound treatment is applied for at least 10-14 minutes per session. The ultrasound is employed in broad strokes longitudinally along with the piriformis muscle.

  • Active rehabilitation

Physical therapy involving hot packs or cold spray and osteopathic manipulative treatment is applied in piriformis syndrome. Application of hot and cold therapy is beneficial before stretching to decrease the pain.

Treatment is usually followed for a couple of months to achieve relief. Some stretching exercises include;

Pretzel stretch

  • Lie down on your back. Make sure the surface is soft as a yoga mat.
  • Bend your knees and cross the affected thigh onto the other healthier side.
  • Place the ankle of the affected side over your healthy thigh.
  • Now gently pull your knee to your chest.
  • A gentle stretch in your hip should be felt.
  • Hold the stretch for few seconds before releasing slowly.
  • Repeat on the other side.

Knee to chest stretch

  • Lie down on a yoga mat or a soft surface.
  • Bring your right knee to your chest.
  • Keep the other knee straight extended on the ground.
  • Bend your foot of the bent knee toward the opposite hip.
  • Hold for few seconds.
  • Repeat on the other side as well.

Performing self-massage by using a softball or soft roller foam also helps to manage the pain.

Prevention of Piriformis syndrome

Some tips to avoid PS include;

  • Avoid sitting for extended periods. Instead, walk every 20 minutes or so during a sedentary session.
  • Stand and stretch whenever you can
  • Prevent trauma and other muscle offending activities.
  • Daily stretching is a must.
Abdur Rashid
Medically Reviewed By Abdur Rashid
MSC Public Health, MCSP, MHCPC
BSC (Hon) Physiotherapy
Consultant Neuro-spinal & Musculoskeletal Physiotherapist

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