Piriformis syndrome is a condition that causes piriformis muscle spasms and hip pain.Also, the piriformis muscle can irritate the sciatic nerve nearby, causing pain, numbness, and tingling from the posterior leg to the feet.There are more women than men with piriformis syndrome and the ratio is 6:1.The reason can be explained with wider quadriceps femoris muscle angle in the ossa coxae of women.
It starts at the spine and connect to the each femur.The functions are abduction and external rotation.In general , the sciatic nerve exists from foramen infrapiriforme but there are may be a various congenital deformities.
According to Boyajian-O ‘Neill LA et al. , there are 2 types of piriformis sydrome ; primary and secondary.
PRIMARY PIRIFORMIS SYNDROME
Primary piriformis syndrome has an anatomical reason like divided piriformis muscle,divided sciatic nerve and abnormal sciatic nerve pathway.Less than 15% has primary reasons of the cases.
SECONDARY PIRIFORMIS SYNDROME
Secondary piriformis syndrome is a result of a reason like macrotrauma,microtrauma and local ischemia.
Generally, secondary piriformis syndrome causes a nerve compression that gives rise to soft tissue,muscle spasms or inflammation of both because of the macrotrauma to the hips.
Most often, the reasons of piriformis spasms are direct trauma, post-op injury,lumbar and sacroiliac joint pathologies.
Additionally, the syndrome may be caused by shortened muscles due to changing biomechanics of the lower extremity,low back and pelvic regions.
Also, using piriformis muscle excessive like microtrauma , long distance walking and running or direct compression causes this syndrome.
Piriformis Syndrome Symptoms
Patients with piriformis syndrome typically have many symptoms consisting of persistent and radiating low back pain, (chronic) hip pain, numbness, paresthesia, difficulty walking and other functional activities such as sitting, squatting, standing.
They may also have pressure pain in the hip on the same side as the piriformis lesion and in almost all cases show tenderness over the sciatic notch. Hip pain may radiate to the hip, back of the thigh, and proximal part of the lower leg. (3)
Pain may be exacerbated by activity, prolonged sitting or walking, squatting, hip adduction and internal rotation, and maneuvers that increase piriformis muscle tension.
Treatment in Piriformis Syndrome
Conservative treatment for piriformis syndrome includes non-steroidal anti-inflammatory agents (NSAIDs), muscle relaxants and physical therapy, lifestyle changes.
Surgical interventions should only be considered when conservative treatment has failed and symptoms have become difficult and disabling.
Physiotherapy in Piriformis Syndrome
Non-invasive treatments include physical therapy, manipulative therapy, and lifestyle modification. Ozone Therapy can be considered in the treatment of PS due to the absence of side effects, practicality of use and the extent of clinical improvement. (5)
According to Tonley et al., the most commonly reported physical therapy interventions include ultrasound, soft tissue mobilization, piriformis stretching, hot packs or cold spray, and various lumbar spine treatments.(2)
Additionally, Tonley et al. describes an alternative treatment approach for piriformis syndrome:
1) Begin with ultrasound therapy: 2.0-2.5 W/cm2 for 10-14 minutes. Apply the ultrasound gel in broad strokes longitudinally along the piriformis muscle from the common tendon to the lateral edge of the greater sciatic foramen.
2) Before stretching the piriformis muscle, treat the same area with hot packs or cold spray for 10 minutes. The use of heat and cold before stretching is very helpful for reducing pain.
3) Continue with the piriformis stretch. Lie on your back with both feet flat on the floor and both knees bent. Put the ankle of the right leg on the knee of the left leg. Pull the left thigh towards the chest and hold the stretch. Repeat for both sides.
4) In piriformis syndrome, especially in the case of weak gluteal musculature, using a strengthening program for hip muscles may lead to an alternative treatment approach for piriformis syndrome.
Recommendations to alleviate the Symptoms of the Syndrome:
1) Avoid sitting for a long time; stop and walk every 20 minutes
2) Avoid trauma to the gluteal area and avoid further irritating activities.
3) Daily stretching is recommended to prevent recurrence of piriformis syndrome.
1)Boyajian-O’Neill LA, McClain RL, Coleman MK, Thomas PP. Diagnosis and management of piriformis syndrome:an osteopathic approach. The Journal of the American Osteopathic Association. 2008 Nov 1;108(11):657-64
2)Tonley JC, Yun SM, et al. Treatment of an individual with piriformis syndrome focusing on hip muscle strengthening and movement reeducation: a case report. J Orthop Sports Phys Ther 2010;40(2):103-111.
3)Kunbong Choi, The etiology, diagnosis and treatment of piriformis syndrome (2004)(5)
4)Shah S, Wang TW. Piriformis syndrome. eMedicine specialities: Sports medicine: hip 2009
5)Valdenassi L, Bellardi D. Treatment of piriformis syndrome with oxygen-ozone therapy. Ozone Therapy. 2017 Dec 31;2(3)