An Alternative Treatment An Alternative Treatment Approach to Piriformis Approach to Piriformis

SyndromeSyndromeKorey Pieper, DPT, OCSKorey Pieper, DPT, OCS

Marie Potter, DPT, OCS, ATCMarie Potter, DPT, OCS, ATC

Rick J Rafael, DPT, OCS, CSCSRick J Rafael, DPT, OCS, CSCS

Jason Tonley, DPT, OCSJason Tonley, DPT, OCS

Kaiser Permanente West Los Angeles Orthopaedic Kaiser Permanente West Los Angeles Orthopaedic Residency ProgramResidency Program

September 2008 September 2008

Piriformis SyndromePiriformis SyndromeDefinedDefined

““Neuritis of the branches of the sciatic Neuritis of the branches of the sciatic nerve, caused by pressure of an injured nerve, caused by pressure of an injured or irritated piriformis muscleor irritated piriformis muscle11.”.”

SymptomsSymptoms

Radiating pain from the low back down Radiating pain from the low back down over the sacrum into the buttocks and over the sacrum into the buttocks and hip region, as well as down the hip region, as well as down the posterior portion of the upper leg to the posterior portion of the upper leg to the popliteal regionpopliteal region11..

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AnatomyAnatomy

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Possible Causes of Piriformis Possible Causes of Piriformis SyndromeSyndrome

Anatomical variationAnatomical variation

L/S dysfunctionL/S dysfunction

Muscle tightness and/or spasmMuscle tightness and/or spasm

OveruseOveruse

Post surgical injuryPost surgical injury

SIJ dysfunctionSIJ dysfunction

Trauma/fallTrauma/fall

DifferentialDifferential DiagnosisDiagnosis

Differential Diagnosis of Hip painDifferential Diagnosis of Hip pain7,87,8::Intra-articular & Extra-articular (Often Managed Operatively) :Intra-articular & Extra-articular (Often Managed Operatively) :– Labral TearsLabral Tears– Loose BodiesLoose Bodies– Femoroacetabular Impingement (FAI)Femoroacetabular Impingement (FAI)– HypermobilityHypermobility– Capsular LaxityCapsular Laxity– Ligamentum Teres TearLigamentum Teres Tear– Chondral DamageChondral Damage– Snapping Hip SyndromeSnapping Hip Syndrome– IT Band SyndromeIT Band Syndrome– Greater Trochanteric BursitisGreater Trochanteric Bursitis– Gluteal Tendon InjuryGluteal Tendon Injury

DifferentialDifferential DiagnosisDiagnosis

Differential Diagnosis of Hip painDifferential Diagnosis of Hip pain7,87,8::Extra-articular Causes (Often Managed Non-Extra-articular Causes (Often Managed Non-Operatively):Operatively):– Femoral Neck Stress FractureFemoral Neck Stress Fracture– Adductor StrainAdductor Strain– Piriformis SyndromePiriformis Syndrome– Sacroiliac Joint SyndromeSacroiliac Joint Syndrome– Tendonitis (hip flexors, abductors, adductors)Tendonitis (hip flexors, abductors, adductors)

DifferentialDifferential DiagnosisDiagnosis

Other Competing Diagnosis: Other Competing Diagnosis: Lumbar Facet SyndromeLumbar Facet SyndromeLumbar Disc HerniationLumbar Disc HerniationNerve entrapmentNerve entrapmentIschial Tuberosity BursitisIschial Tuberosity BursitisLumbar radiculopathyLumbar radiculopathySpinal stenosisSpinal stenosisSpondylolisthesisSpondylolisthesisOsteoarthritisOsteoarthritis

Common Treatment OptionsCommon Treatment Options

Treatment Options:Treatment Options:2,3,4,5,62,3,4,5,6

InjectionsInjectionsL/S stabilization exercisesL/S stabilization exercisesMobilization/manipulation L/SMobilization/manipulation L/SMobilization/manipulation SI jointMobilization/manipulation SI jointFoot orthoticsFoot orthoticsSoft tissue mobilizationSoft tissue mobilizationStrengtheningStrengtheningStretchingStretchingSurgical / arthroscopic releaseSurgical / arthroscopic releaseUltrasoundUltrasound

Common assumption guidingCommon assumption guidingtreatment approachestreatment approaches

The piriformis is shortened or in The piriformis is shortened or in “spasm” and is compressing the “spasm” and is compressing the sciatic nervesciatic nerve

Purpose of studyPurpose of study

To create a case series using an To create a case series using an alternative treatment approach to alternative treatment approach to piriformis syndromepiriformis syndrome

Inclusion Criteria: Inclusion Criteria: Objective ExamObjective Exam

Unilateral pain from lower lumbar/buttock Unilateral pain from lower lumbar/buttock region to the legregion to the leg

Symptoms not reproduced from lumbar, SI Symptoms not reproduced from lumbar, SI joint, and/or hip joint examinationsjoint, and/or hip joint examinations

Inclusion Criteria: Inclusion Criteria: Objective ExamObjective Exam

Lumbar ExamLumbar Exam– Negative AROM with OPNegative AROM with OP– Negative PA examNegative PA exam– Neurological testing negative for nerve root lesionNeurological testing negative for nerve root lesion

SIJ ExamSIJ Exam– Negative clusterNegative cluster

Hip ExamHip Exam– Negative ROM, excluding quadrantNegative ROM, excluding quadrant

Inclusion Criteria: Inclusion Criteria: Objective ExamObjective Exam

Reproduction of symptoms with:Reproduction of symptoms with:– Palpation of piriformis musclePalpation of piriformis muscle– Piriformis stretch testPiriformis stretch test– FAIR TestFAIR Test

Demonstrates movement dysfunction of Demonstrates movement dysfunction of ADD and/or IR and reproduction of ADD and/or IR and reproduction of symptoms with step down testsymptoms with step down test

Decreased reproduction of symptoms with Decreased reproduction of symptoms with corrected movement during step down testcorrected movement during step down test

Objective ExamObjective Exam

Patient to fill out disability questionnaires:Patient to fill out disability questionnaires:

– Oswestry Disability IndexOswestry Disability Index

– Lower Extremity Functional ScaleLower Extremity Functional Scale

Treatment ApproachTreatment Approach

Isolated strengthening for hip extensors, Isolated strengthening for hip extensors, abductors, and external rotatorsabductors, and external rotators

Functional movement re-education for Functional movement re-education for decreasing hip adduction and internal decreasing hip adduction and internal rotationrotation

NO!!!!!NO!!!!!– StretchingStretching– Soft tissue massageSoft tissue massage– ModalitiesModalities

Treatment ApproachTreatment Approach ExamplesExamples

Hip strengthening:Hip strengthening:– ClamsClams– BridgingBridging– Prone hip extensionProne hip extension– Quadruped hip extensionQuadruped hip extension– Hip abductionHip abduction

Treatment Approach ExamplesTreatment Approach Examples

Movement Re-education:Movement Re-education:– Postural correctionPostural correction– Sit to stand transitionsSit to stand transitions– Single leg sit to standsSingle leg sit to stands– LungesLunges– Plyometrics if indicatedPlyometrics if indicated

Patient DataPatient Data

7 Patients7 Patients

Age: mean 56 (range 31 - 69)Age: mean 56 (range 31 - 69)

Duration of symptoms: 197 days Duration of symptoms: 197 days (range 45 – 730)(range 45 – 730)

# of visits: 5 (range 2-8)# of visits: 5 (range 2-8)

Duration of visits: 9 weeks (range 3-16)Duration of visits: 9 weeks (range 3-16)

Average LE Functional ScaleAverage LE Functional Scale

Range: initial (37-70) discharge (54-80)

Average VAS (Pain Scale)Average VAS (Pain Scale)

Range: initial (6-10/10) discharge (0-4/10)

AnalysisAnalysis

Movement assessment allowed proper Movement assessment allowed proper physical therapy diagnosis and treatmentphysical therapy diagnosis and treatment

Patient’s can have multiple positive tests, Patient’s can have multiple positive tests, but movement reproduces primary pain but movement reproduces primary pain complaintcomplaint

Ceiling effect of questionnaires affects Ceiling effect of questionnaires affects data analysisdata analysis

Future ResearchFuture Research

Prevalence of movement dysfunction in Prevalence of movement dysfunction in patient’s diagnosed with piriformis patient’s diagnosed with piriformis syndromesyndrome

Most effective treatment modality for Most effective treatment modality for movement dysfunction: strength training movement dysfunction: strength training vs. movement re-educationvs. movement re-education

ConclusionConclusion

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

ReferencesReferences1.1. Edwards, F.O.: Piriformis syndrome. Academy of Applied Osteopathy. Yearbook, 1962, pp 39-41.Edwards, F.O.: Piriformis syndrome. Academy of Applied Osteopathy. Yearbook, 1962, pp 39-41.

2.2. 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. Am J. Orthrop, 1996:25:819-823.

3.3. Parizale JR, Hudgins TH, Fishman LM: The Piriformis Syndrome A Review. Paper.” The. Am J of Orthop. Parizale JR, Hudgins TH, Fishman LM: The Piriformis Syndrome A Review. Paper.” The. Am J of Orthop. 2002:25:1-112002:25:1-11

4.4. Bird JW: Piriformis Syndrome. Oper Tech Sports Med 2005 13 71-79Bird JW: Piriformis Syndrome. Oper Tech Sports Med 2005 13 71-79

5.5. Mayrand N, Fortin J, Descarreaux M, Normand MC. Diagnosis and management of posttraumatic piriformis 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):486-91syndrome: a case study. J. Manipulative Physiol Ther. 2006 Jul-Aug;29(6):486-91

6.6. Keskula DR, Tamburello M: Conservative Management of Piriformis. Keskula DR, Tamburello M: Conservative Management of Piriformis. Syndrome. J Athl Train. 1992; 27(2):102, Syndrome. J Athl Train. 1992; 27(2):102, 104, 106-107, 110104, 106-107, 110

7.7. Lisa M Tibor, Jon Sekiya. Differential Diagnosis of Pain Around the Hip Joint. The Journal of Arthroscopic and Lisa M Tibor, Jon Sekiya. Differential Diagnosis of Pain Around the Hip Joint. The Journal of Arthroscopic and Related Surgery. 2008;19:1-15Related Surgery. 2008;19:1-15

8.8. Michael K Shindle, Benjamin G Domb, Bryan T Kelly. Hip and Pelvic Problems in Athletes. Oper Tech Sports Michael K Shindle, Benjamin G Domb, Bryan T Kelly. Hip and Pelvic Problems in Athletes. Oper Tech Sports Med. 2007; 15: 195-203.Med. 2007; 15: 195-203.