An Alternative Treatment Approach to Piriformis Syndrome

1. 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

2. Piriformis SyndromeDefined “Neuritis of the branches of the sciatic nerve, caused by pressure of an injured or irritated piriformis muscle1.”

3. 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

4. Anatomy image from www.tpmassageball.com

5. Possible Causes of Piriformis Syndrome Anatomical variation L/S dysfunction Muscle tightness and/or spasm Overuse Post surgical injury SIJ dysfunction Trauma/fall

6. DifferentialDiagnosis 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

7. DifferentialDiagnosis Differential Diagnosis of Hip pain7,8: Extra-articular Causes (Often Managed Non-Operatively): Femoral Neck Stress Fracture Adductor Strain Piriformis Syndrome Sacroiliac Joint Syndrome Tendonitis (hip flexors, abductors, adductors)

8. DifferentialDiagnosis Other Competing Diagnosis: • Lumbar Facet Syndrome • Lumbar Disc Herniation • Nerve entrapment • Ischial Tuberosity Bursitis • Lumbar radiculopathy • Spinal stenosis • Spondylolisthesis • Osteoarthritis

9. 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

10. Common assumption guidingtreatment approaches The piriformis is shortened or in “spasm” and is compressing the sciatic nerve

11. Purpose of study To create a case series using an alternative treatment approach to piriformis syndrome

12. 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

13. 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

14. 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

15. Objective Exam • Patient to fill out disability questionnaires: • Oswestry Disability Index • Lower Extremity Functional Scale

16. 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

17. Treatment ApproachExamples • Hip strengthening: • Clams • Bridging • Prone hip extension • Quadruped hip extension • Hip abduction

18. Treatment Approach Examples • Movement Re-education: • Postural correction • Sit to stand transitions • Single leg sit to stands • Lunges • Plyometrics if indicated

19. 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)

20. Average LE Functional Scale Range: initial (37-70) discharge (54-80)

21. Average VAS (Pain Scale) Range: initial (6-10/10) discharge (0-4/10)

22. 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

23. 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

24. Conclusion • Movement re-education and strengthening can be a successful way to treat piriformis syndrome when a patient presents with a coordination deficit.

25. References 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.