Condition of the Month: Piriformis Syndrome


Overview

Piriformis syndrome is literally a pain in the butt. The piriformis muscle lies deep in the hip and buttock region on top of the sciatic nerve, the single largest nerve in the body. In some individuals, the sciatic nerve may even pass straight through the piriformis muscle. When this muscle becomes tight and dysfunctional, the sciatic nerve can get irritated and cause pain, numbness, and tingling into the leg and foot ("pseudo sciatica"). This condition often gets confused with actual sciatic pain that results from a pinched nerve in the low back.

Causes

There are no exact causes of piriformis syndrome, but it is usually an overuse condition in which the piriformis muscle gets overworked and goes into spasm. The muscle may be overworked due to various reasons:

  • Habitually poor posture (prolonged sitting or standing)

  • Leg length discrepancies or other postural/alignment abnormalities

  • Weakness of the surrounding stabilizing hip muscles

  • Dysfunction of the SI (sacroiliac) joint or hip joint

Signs and symptoms

  • Tenderness or pain in one buttock that may radiate down the leg

  • Numbness and tingling in the leg and foot

  • Pain that is aggravated by hip movements, such as going up or down the stairs, prolonged sitting, getting in and out of the car, bending down and getting up, etc.

  • Sitting lopsided in order to avoid pressure and pain on the affected buttock

  • Walking with the foot turned out

  • Difficulty sleeping on the affected side

Physiotherapy treatment

  • Rest: If pain is aggravated by certain activities such as prolonged sitting, then try to avoid positions that cause discomfort. Resting the area will help to make the muscle relax and become less irritated or inflamed. However, rest will only help to alleviate the symptoms temporarily and not fix the cause of the problem that is making the piriformis muscle tight in the first place.

  • Activity modification: Similar to the above, it's important to change the way that daily activities are performed in order to allow the irritated muscle to heal. This could mean changing the sitting surface, altering the way you get in and out of the car, sleeping in a different position, adding or taking away pillows when you sleep, lowering or raising the height of chairs, etc.

  • Modalities: Heat or ice may be used to relieve muscle tightness and promote circulation and healing. IFC or TENS can help with pain and muscle relaxation, and ultrasound or laser are often used to reduce inflammation.

  • Acupuncture and dry needling: Needling is often quite helpful if the piriformis muscle is really tight or in spasm. These techniques can help the muscle relax, thereby putting less pressure on the sciatic nerve.

  • Manual therapy: Manual therapy or massage is beneficial to release the tightness in the muscles of the hip and buttock. In addition, nerve flossing techniques can be used to free up the sciatic nerve from any adhesions. Hip and SI joint mobilizations are performed to increase flexibility and mobility.

  • Exercise: Exercises and stretches are performed to reduce tension in the piriformis muscle and reduce compression on the sciatic nerve. If the condition is caused by muscle imbalances in the SI joint or hip, it is important to address those issues to prevent future flareups. If the piriformis muscle is compensating for another muscle that is weak, it is critical to find out what muscle that is and strengthen it in order to decrease the workload of the piriformis.

Other treatments

  • NSAIDs

  • Injections

  • Surgery

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