Physiotherapy Treatment of Piriformis Syndrome

Published: 21st October 2008
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Physiotherapists and other manual therapists recognise piriformis syndrome as a cause of buttock and leg pain which sometimes simulates sciatic symptoms. The piriformis muscle is very close to the sciatic nerve as it traverses the buttock and nerve compression or irritation have been put forward as reasons for the pain. Piriformis syndrome is not recognised universally outside physiotherapy and other therapy professions but the diagnosis is gaining credence.

The piriformis ("pear shaped") is a small, flat muscle in the buttock, running centrally from the sacral areas across the buttock to the upper part of the greater trochanter of the femur, the large bony lump on the side of the hip. With the leg straight it turns the leg outwards, when the hip is bent it moves the leg away from the centre of the body. There is some anatomical variation in the relationship between the piriformis muscle and the sciatic nerve in the buttock. In most people the nerve lies in front of the muscle but in some the muscle belly is divided into two with parts of the nerve passing through the division.

There are no clear causative factors for piriformis syndrome which seems to accompany other lumbar or pelvic pains. Direct trauma to the area can cause bleeding and scarring around the nerve and the muscles, with consistent pressure to the buttock perhaps affecting the nerve's function. The syndrome can also be associated with an increased lordotic posture, hip replacement or vigorous activity and mimics back pain syndromes such as sciatica. Physiotherapists diagnose and treat piriformis syndrome on purely clinical grounds as there are no agreed diagnostic criteria, imaging or other tests.

Low back pain and leg pain can be lumbar or sacro-iliac in origin, but piriformis syndrome is a poorly recognised cause of these symptoms, simulating the picture of a disc protrusion or joint arthritic change. Trochanteric bursitis occurs over the area of the trochanter which also carries the insertion of the piriformis tendon, linking the two syndromes clinically. Physiotherapy examination clinically will note acute trigger point tenderness in the buttock, a reduction in hip lateral rotation, reduced power and pain on testing of hip abductor and lateral rotator strength and difficulty sitting on the affected buttock.

Physiotherapists use many treatment modalities to improve piriformis symptoms but partly due to the lack of a clear diagnosis there is no agreed scientific treatment approach. Physios check the findings such as tightness in the piriformis, hip external rotator and adductor muscles, hip abductor weakness, sacro-iliac and lumbar dysfunction, externally rotated hip in walking, apparent leg shortening and a shorter stride length.

If the physiotherapist finds that the piriformis and other muscles are tight then treatment consists of loosening up the hip joint followed by stretches of the muscle. Stretching the muscle is performed in lying with the hip flexed, pulling the hip into adduction and internal rotation. A home stretching programme is important, with regular stretching every two or three hours in the acute phase. If the piriformis is looser than expected the Physio may exercise the muscle to tighten it up and stretch out the tight structures which oppose this tendency.

Local manipulation is a common treatment directly over the most painful point in the buttock, which can be very tender indeed. Transverse or longitudinal mobilisations over the muscle is the technique used, maintaining the pressure steadily for up to 10 minutes initially. Treatment of the back and sacro-iliac joints is important to address any dysfunction which might contribute. Modifying posture and activity, muscle injections, mobilisations and stretching are commonly successful in reducing symptoms. In resistant cases surgery to the muscle or the tendon at the greater trochanter may be contemplated.

Jonathan Blood-Smyth is a Superintendent Physiotherapist at a prominent NHS teaching hospital in Devon. He publishes articles on injuries and mishaps in periodicals and on his website for physiotherapists. If you are looking for local physiotherapy after an mishap or injury, visit his website for physiotherapy professionals around the United Kingdom.

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