Piriformis Syndrome

THE CLINICAL SYNDROME

Piriformis syndrome is an entrapment neuropathy that presents as pain, numbness, paresthesias, and associated weakness in the distribution of the sciatic nerve. Piriformis syndrome is caused by compression of the sciatic nerve by the piriformis muscle as it passes through the sciatic notch. The piriformis muscle as it passes through the sciatic notch. The piriformis muscle is innervated by the sacral plexus. With internal rotation of the femur, the tendinous insertion and belly of the muscle can compress the sciatic nerve and, if this persists, cause entrapment of the sciatic nerve. These symptoms often begin as severe pain in the buttocks that may radiate into the lower extremity and foot. Patients suffering from piriformis syndrome may develop altered gait, which may result in the development of coexistent sacroiliac, back, and hip pain, which may confuse the clinical picture. If the condition remains untreated, progressive motor deficit of the gluteal muscles and lower extremity can result. The onset of symptoms of piriformis syndrome usually occurs after direct trauma to the sacroiliac and gluteal region and occasionally as a result of repetitive hip and lower extremity motions or repeated pressure on the piriformis muscle and underlying sciatic nerve.

SIGNS AND SYMPTOMS

Physical findings include tenderness over the sciatic notch. A positive Tinel’s sign over the sciatic nerve as it passes beneath the piriformis muscle is often present. A positive straight leg raising test is suggestive of sciatic nerve entrapment, which may be due to piriformis syndrome. Palpation of the piriformis muscle will reveal tenderness and a swollen, indurated muscle belly. Lifting or bending at the waist and hips will increase the pain symptomatology in most patients suffering from piriformis syndrome. Weakness of affected gluteal muscles and lower extremity, and ultimately muscle wasting, are often seen in advance untreated piriformis syndrome.

Piriformis syndrome is an entrapment of the sciatic nerve.

Piriformis syndrome is often misdiagnosed as lumbar radiculopathy or attributed to primary hip pathology. Radiographs of the hip and electromyography will help distinguish piriformis syndrome from radiculopathy of pain emanating from the hip. Most patients suffering from a lumbar radiculopathy will have back pain associated with reflex, motor and sensory changes, whereas patients with piriformis syndrome will have only secondary back pain and no reflex changes. The motor and sensory changes of piriformis syndrome will be limited to the distribution of the sciatic nerve below the sciatic notch. It should be remembered that lumbar radiculopathy and sciatic nerve entrapment may coexist as the “double crush” syndrome. As mentioned, piriformis syndrome causes alteration of gait that may result in secondary back and radicular symptomatology, which may coexist with this entrapment neuropathy.

TREATMENT

Initial treatment of the pain and functional disability associated with piriformis syndrome should include a combination of the nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 inhibitors and physical therapy. The local application of heat and cold may also be beneficial. Any repetitive activity that may exacerbate the patient’s symptomatology should be avoided. Nighttime splinting of the affected extremity by placing a pillow between the legs if the patient sleeps on his or her side may be beneficial. If the patient is suffering form significant paresthesias, gabapentin may be added. For patients who do not respond to these treatment modalities, injection of local anesthetics in combination with methylprednisolone acetate in the region of the sciatic nerve at the level of the piriformis muscle may be a reasonable next step. Rarely, surgical release of the entrapment is required to provide relief.

Low intensity laser therapy as well as a coordinated wellness program is also effective in treating this disorder.

Low Intensity Laser Therapy (LILT)

The low intensity Laser (LILT) sends photons (light) into the injured tissues and can penetrate two to three inches to treat affected areas. It uses a natural enhancement of the cellular machinery that can and has been dynamically measured in published studies to promote healing without burning affected tissue. Once the photons find the injured tissues, they stimulate and energize the cells to repair and strengthen at a remarkable rate. The treatment does not hurt, takes about 30 minutes and is very cost advantageous.

Wellness Program

A wellness program whichindividualizes treatment for age, performance and function has been shown in pilot studies to improve the overall health and well being of the individuals evaluated. A well conceived dietary and supplementary regimen based on scientific age–related decline in certain necessary compounds can improve quality of life, correct the ravages of hormone imbalance, balance critical neurotransmitter function without resorting to powerful drugs for depression that often have unfavorable side-effect profiles and restore vitality and youth in daily exercise routines. Furthermore, when wellness products are utilized with success, individuals often seek less costly interventions including unnecessary surgeries and narcotic options to treat pain. For more information go to www.drpwellness.com.