PIRIFORMIS SYNDROME

WHAT IS IT?

(Keywords: piriformis syndrome, help for sciatica pain, chiropractic help, tingling in feet and legs )


The name piriformis syndrome arises from the piriformis muscle, a small muscle that passes from the sacrum, [or tailbone, the large wedge-shaped bone that forms the base of the spine], deep in the buttock to its attachment on the side of the hipbone. It is a small muscle compared to other muscles around the hip and thigh, aiding in external rotation (turning out) of the thigh bone (femur).

The sciatic nerve passes close by the piriformis, and sometimes through the fibres of the muscle.



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AN ENTRAPMENT SYNDROME

This is what is called an entrapment neuropathy. It is postulated that when the muscle becomes tight, it may press on the sciatic nerve which lies close by. Pain along the course of the sciatic nerve is called sciatica. The piriformis muscle and its tendon have an intimate relationship to the sciatic nerve - the largest nerve in the body - which supplies the legs with motor and sensory function. It drives many of the leg muscles, and brings sensation and other information back to the Central Nervous System. (For example hot and cold, position sense, vibration sense.)

Misdiagnosis

Medically, it is acknowledged that about a quarter of surgeries for sciatica fail and lead to FBS, Failed Back Syndrome.

In the United States alone, each year 1.5 million people have lumbar MRI scans to look for the cause of the buttock and leg pain called 'sciatica'.

More than 1.2 million (over 80%) of those scans fail to find the cause in the spine.

But three hundred thousand of the scans are sufficiently positive that the patient has lumbar spine surgery. Of the 300,000 surgeries, as many as 25% fail to relieve the pain - in many cases this is because the diagnosis of a spinal cause for the sciatica was incorrect. Was it an irritation of the sciatic nerve by the piriformis muscle?


Diagnosis 


Physical findings include tenderness of the buttock region, increased pain with adduction, internal rotation and flexion of the affected thigh, weakened abduction of the flexed thigh and frequently sacroiliac joint derangement and/or an associated iliotibial band syndrome. Sacro-iliac joint tests are often positive. Electrodiagnostic tests may be positive if the thigh is placed in a position which places the piriformis under extreme stretch (flexed, adducted and internally rotated).

Sometimes referred to as "deep buttock pain," other causes of this type of pain include spine problems (including herniated discs, spinal stenosis, etc.), pinched and irritated nerves, and tendonitis. The diagnosis of this syndrome is often given when all of these diagnoses are eliminated as possible causes of pain. Other signs of of this syndrome include examination maneuvers that attempt to isolate the function of this muscle, and the finding of pain directly over the tendon of the piriformis muscle, which then radiates down the leg.


Maigne's syndrome

A high lumbar facet syndrome can irritate the superior cluneal nerves which supply part of the buttock, and the groin, and can easily lead one to suspect a piriformis syndrome.


Exclusion diagnosis

In medicine it is freely acknowledged that no one really knows exactly what causes piriformis syndrome, or if it really exists. Some physicians believe that it is the name given to hip/buttock pain that cannot be otherwise diagnosed. However, others believe that piriformis syndrome is a very real cause of pain and disability.


Medical Treatment

Unfortunately, the treatment of piriformis syndrome is quite general, and it is acknowledged by orthopedists that it is often a difficult problem to recover from. Some treatment medical suggestions are:

* Physical Therapy - Emphasis on stretching and strengthening the hip rotator muscles

* Rest - Avoid the activities that cause symptoms for at least a few weeks

* Anti-Inflammatory Medication - To decrease inflammation around the tendon

* Deep Massage - Advocated by some physicians

On some occasions, when these treatment fail, patients have surgery to release, or loosen, the piriformis muscle tendon. This surgery is not a small procedure, and generally considered the last resort if a lengthy period of conservative treatment does not solve the problem.


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CHIROPRACTIC HELP

Chiropractors treat the piriformis syndrome with confidence. Treatment is based on findings of a fixated sacrum (based on motion palpation and the Derefield test) and active trigger points in the piriformis muscle.

A true short leg may be a part of the problem, in which case a heel lift may be employed.

Some chiropractors consider that carrying of a wallet in the back pocket may be part of the problem.

Manipulation of the sacral portion of the sacroiliac joint anatomy and  stretching of the piriformis muscles, cross-friction of the muscle and possibly needling, and rehabilitative exercises.


Note the proximity of the sacro-iliac joint to the piriformis muscle which has its origin on the anterior surface of the sacrum and passing to the hip bone. They have a profound effect on each other.

Motion palpation inevitably reveals a FIXATION of the Sacro-iliac joint. Releasing this fixation is what gives chiropractic the edge in treating the piriformis syndrome.

Because the piriformis muscle forms part of the pelvic floor, it is often associated with groin and pubic bone pain, especially in pregnancy. Read more about pubic bone pain …

See the piriformis? It's striped...


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Interesting challenges of the day

1. Mr D has very severe midback back. He bent and twisted, feeding his son, and then laughed. Every breath is a nightmare. A sprung rib is every chiropractor's delight. He or she has golden hands. 30 percent better after one treatment.

2. Mrs C has a long history of severe, disabling migraine headaches since having her wisdom teeth removed. She clenches her teeth at night. After six treatments she has no migraines but some jaw joint discomfort remains; a bite plate is in the offing.

3. Mrs U has the trophy for the worst back this year. After major surgery with plates and screws two years later she still had paresis in the lower leg and severe disabling back pain. She's doing far better than expected, in no little part due to a lift in her shoe for a very short leg.

4. Mr V is 86 years old and hurt his back helping his wife into the car. Just one treatment of the sacroiliac joint and he's eighty percent better. It's not always like that.

5. Mr W lay on his back knocking down a pillar. Turning his head causes severe vertigo. He needs the Epley exercises, not pills, research shows. Update, he's fine.

6. I myself had an acute exacerbation of a femoral nerve lesion last year. One immediate treatment by my colleague has fixed the pain in the lower back, but there's some residual numbness in the lower leg; no soaring tomorrow alas.

7. This lady is a 86 year old woman with a 63 scoliosis. Chronic lower back has been her lot in life but she's well pleased with chiropractic and comes for chiropractic help once a month; some conditions you can never cure.

8. She is an 78 year old woman, is doing remarkably well with a bad sciatica. But over 200 pounds she is not losing weight; in fact, gaining despite my suggestions. She's high risk for a stroke. I have referred her to a dietician to crack the whip.

9. A 61 year old man with upper cervical pain yesterday; it's not severe but also not getting better of its own accord. He's afraid it may turn very acute as when I treated him three years ago. Since then it's been fine. 

10. A 64 year old woman has had scheuermanns disease; it's left her with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment provides she come every six weeks or so for maintenance treatment.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mrs D, a middle aged woman with hip pain of one year duration, despite other treatment. Xrays reveal an impingement syndrome and early hip arthritis. There's much to be done.

13. Mrs B has had one of the nastiest of conditions; vertigo caused by a disturbance in the inner ear. Falling repeatedly and vomiting she consulted her doctor but medication didn't help. After two sessions of the Epley manoeuvres she was 50 percent better. After two weeks 75 percent improved. No longer vomiting all falling. She's not enjoying the Brandt Daroff home exercises.

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.



Have a problem that's not getting better? Looking for a different slant on your pain? Want to pose a question?


Interesting questions from visitors

CLS writes:

Greetings, Dr B.
You helped me quite some time back with a soothing and professional response which turned out to be exactly correct. I now consult a local chiropractor. You write a superb newsletter, too.

Your own unresolved problem. Pose a question

Knowing that up to 70% of the time the correct diagnosis is made with no examination, no special tests, no xrays, but just from the history, there's a fair chance I can add some insight to your unresolved problem. But at least 30% of the time, I may be quite wrong! Give plenty of detail if you want a sensible reply.


You visited this chiropractic help site no doubt because you have a problem that is not resolving and want to know more about what chiropractors do.

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