Piriformis Muscle Syndrome

Sr.No. Content Page No.

1. Introduction 3.

2. Anatomy 5.

3. Biomechanics 11.

4. Classification 13.

5. Etiology 15.

6. Pathomechanics 17.

7. Epidemiology 20.

8. Clinical Features 21.

9. Risk Factors 23.

10. Complication 25.

11. Diagnosis 28.

12. Treatment 37.

13. Physiotherapy Intervention & Rehabilitation 42.

14. Prevention 73.

15. Assessment 74..

16. Reference 80.

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INTRODUCTION

Piriformis Syndrome is a clinical condition of Sciatic Nerve Entrapment at the level of Ischial Tuberosity.

Piriformis syndrome comes in the list of frequently missed causes of low back pain and sciatica. As the name

suggests, the condition is secondary to sciatic nerve entrapment in Piriformis muscle at the greater sciatic

notch.

Sciatica refers to musculoskeletal pain felt in the leg along the distribution of the Sciatic Nerve and sometimes

accompanied by low back pain. Abnormal condition of the Piriformis muscle such as hypertrophy,

inflammation, or anatomic variations may lead to this condition.

There are multiple causes for Piriformis Syndrome; however, patients generally describe pain in the

Gluteal/Buttock region that may "Shoot ", "Burn or Ache " down the back of the leg. In addition, Numbness

in the buttocks and Tingling sensation along the distribution of the Sciatic nerve is common. It can happen on

either side of the body or both. Deep gluteal syndrome and wallet neuritis are in common use as synonyms for

Piriformis Syndrome. Piriformis syndrome is diagnosed more in women than men at a ratio of 6:1.

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Low back pain (LBP) is very common. Approximately 30-45% of individuals between the ages of 18 and 55

report an episode of LBP at some time in their life. LBP is most commonly caused by entrapment of the

sciatic nerve, herniated nucleus puplosus, direct trauma, muscle spasm from chronic/overuse injury and

piriformis syndrome.

See image below. Piriformis syndrome is presented as pain and instability. The location of the pain is

typically vague and often is in the hip, coccyx, buttock, groin, or distal part of the leg. History and physical

findings are keys to differentiating the more common forms of LBP from piriformis syndrome. The literature

and general knowledge of piriformis syndrome is also limited compared with that of sciatica or disc

herniation. However, the general findings on piriformis syndrome do appear to have wide agreement.

Nerve irritation in the herniated disk occurs at the root (sciatic radiculitis). In piriformis syndrome, the irritation extends to the full

thickness of the nerve (sciatic neuritis).

Yeoman first described the piriformis syndrome in 1928 when he called it periarthritis of the anterior

sacroiliac joint. The history of this disorder traces back from being one of the many causes of lower back and

leg pain. Most patients who have undergone failed surgery in the lumbosacral region were subsequently

diagnosed with piriformis syndrome.

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ANATOMY

PIRIFORMIS MUSCLE

The piriformis muscle is a flat, pyramidal structure of the gluteal region lying deep to the gluteus maximus.

Piriformis belongs to the group of six short external rotators that compose of the gemellus superior, obturator

internus, gemellus inferior, quadratus femoris, and obturator externus. This muscle has functions to stabilize

the hip joint and move the thigh in various directions.

❖ ORIGIN: The Anterior aspect of the sacrum at the level of about S2 through S4.

• It also has some attachment to the Sacrotuberous ligament and to the periphery of the greater sciatic

notch as it passes through it, exiting the pelvis.

• The sciatic nerve usually exits the pelvis alongside the piriformis and emerges at its inferior border.

❖ INSERTION: Superior and Medial aspect of Greater trochanter of femur.

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 ❖ INNERVATION: Anterior Rami of S1 and S2. The superior gluteal nerve, innervating the gluteus

medius, gluteus minimus, and tensor fascie latae, leaves the pelvis superior to the piriformis. The

inferior gluteal nerve, supplying the gluteus maximus, leaves the pelvis inferior to the piriformis.

❖ BLOOD SUPPLY:

• Superior Gluteal Artery

• Inferior Gluteal Artery

• Internal Pudendal Artery

• All the branches of Internal Iliac Artery

❖ ACTION: HIP External Rotation

• Abduction when HIP is Flexed

• Stabilizes head of femur into acetabulum

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SCIATIC NERVE RELATION

The sciatic nerve is the largest nerve in the human body. It arises from the lumbosacral plexus in the lower

back (L4-S3 spinal levels) and travels through the buttocks, passing through the pelvis and the piriformis

muscle. Being a peripheral nerve, the sciatic nerve arises from the combination of the five spinal nerves—

L4, L5, S1, S2, and S3. This nerve is said to be of mixed type since it possesses both motor and sensory

fibers. These combine deep within the gluteal region to form a single, large long sciatic nerve.

In the buttock, it can travel around the back, underneath, or occasionally even through the belly of the

piriformis muscle—piercing it, then runs down the back of the thigh. Just before reaching the popliteal fossa,

it divides into the

• Common peroneal nerve, which continues through the lateral side of the leg, and

• The tibial nerve, which passes through the posterior part of the leg

When the piriformis muscle spasms, it compresses the sciatic nerve, causing pain, tingling, and numbness

similar to the symptoms of sciatica. This typically happens in piriformis syndrome. The pain comes and goes

and worsens with certain movements like prolonged sitting, standing, walking, jumping, and running.

Piriformis syndrome is also known as sciatica or buttock pain.

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Variations in the relationship of the sciatic nerve to the piriformis muscle: (A) the sciatic nerve exiting the

greater sciatic foramen along the inferior surface of the piriformis muscle; the sciatic nerve splitting as it

passes through the piriformis muscle with the tibial branch passing (B) inferiorly or (C) superiorly; (D) the

entire sciatic nerve passing through the muscle belly; (E) the sciatic nerve exiting the greater sciatic foramen

along the superior surface of the piriformis muscle.

There are two types of classification for peripheral nerve degeneration, which are Sunderland’s

classification and Seddon’s classification

Seddon’s classification: There are three types of nerve injury

1. Neuropraxia: A temporary physiological block produced by ischemia due to compression with no

Wallerian degeneration and recovery in minutes to days.

2. Axonotmesis: The interior architecture of the nerve is well-preserved, but axons are damaged, and

Wallerian degeneration occurs; recovery is in months.

3. Neurotmesis: The nerve structure is disrupted as a result of cutting, severe scarring, or chronic

severe compression; there is complete sensory and motor and sympathetic loss.

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 Type of Injury Pathology Degeneration Prognosis

Neuropraxia Physiological No structural Changes Recovery complete

interruption, within 6 weeks

anatomically normal

Axonotmesis Axons broken nerve Wallerian Recovery takes many

intact Degeneration Occurs months but complete

recovery may not

occur

Neurotmesis Axons as well as Wallerian Recovery is not

nerve broken Degeneration Occurs Possible, Nerve

Repair is Required

Sunderland’s classification: Has five degrees

1ᵒ same as neuropraxia,

2ᵒ and 3ᵒ same as axonotmesis,

3ᵒ, 4ᵒ, and 5ᵒ same as neurotmesis

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RELATIONSHIP TO OTHER STRUCTURES

• Piriformis is deep to the Gluteal Maximus

• The Piriformis is Located inferior or distal to Gluteus Medius

• Laterally in the buttock, the piriformis is located superior/proximal to the superior gemellus

• Medially in the buttock, the piriformis is located superior/proximal to the coccygeus muscle and the

sacrospinous ligament

• Directly inferior/distal to the medial (sacral) attachment of the piriformis is the Sacrotuberous

ligament

• The Piriformis Muscle is involved with the deep front line myofascial meridian

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BIOMECHANICS

Biomechanically, the piriformis muscle is responsible for lateral rotation and abduction of thigh at the hip

joint. When the hip is in an extended position, the piriformis is a lateral rotator of the femur. In the case of

the hip being flexed, the piriformis muscle acts as a helper for the hip abductor. It is crucial in actions such

as stabilizing the hip during walking and running. Meanwhile, it also stands in for the movements that are

complex and involve the balance and agility.

• External Rotation: In the anatomical position I.e., hip extension. The piriformis muscle exerts a pull

on the greater trochanter and is responsible for the femur being rotated outward (external rotation).

This movement is crucial for activities that require turning the foot outward, such as changing

direction during walking or running.

• Abduction: When the hip is flexed, the action of the piriformis muscle changes. It contributes to hip

abduction by pulling the femur away from the midline of the body. This action is important for

movements that involve abducting the legs, like getting in and out of a car.

• Stabilization: The piriformis muscle provides stability to the pelvis and hip joint, particularly during

weight-bearing activities. It helps to maintain the alignment of the hip and pelvis, preventing

excessive internal rotation and ensuring efficient transfer of forces through the lower limb.

Clinical Relevance

• Piriformis Syndrome: This condition occurs when the piriformis muscle irritates or compresses the

sciatic nerve, leading to pain, tingling, and numbness in the buttocks and along the path of the sciatic

nerve. It is often caused by muscle spasms, overuse, or anatomical variations.

• Role in Gait: During walking and running, the piriformis works synergistically with other hip

muscles to control the movement of the femur and stabilize the pelvis, ensuring a smooth and

efficient gait cycle.

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Movement Analysis

• During Walking: In the stance phase of walking, the piriformis muscle helps stabilize the pelvis and

control femoral rotation, preventing excessive internal rotation. During the swing phase, it assists in

preparing the leg for the next step by externally rotating the femur.

• During Running: The demands on the piriformis increase during running due to the greater range of

motion and increased force requirements. The muscle's role in stabilizing the hip and pelvis becomes

even more critical to maintain proper alignment and prevent injuries.

Understanding the biomechanics of the piriformis is essential for diagnosing and treating conditions

associated with it, designing effective rehabilitation programs, and optimizing performance in activities that

involve the lower limbs.

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CLASSIFICATION

Piriformis syndrome is classified on the basis of underlying cause and the anatomical relationship between

the piriformis muscle and the sciatic nerve. Here are the commonly used classifications:

1. Primary Piriformis Syndrome:

• Anatomic Causes: This includes variations in the anatomy of the piriformis muscle, the sciatic nerve,

or the surrounding structures.

Examples include:

• Split Piriformis Muscle: Where the muscle is divided into two parts.

• Split Sciatic Nerve: Where the nerve is divided and passes through or around the muscle.

• Anomalous Course: Where the sciatic nerve has an atypical path in relation to the piriformis muscle.

2. Secondary Piriformis Syndrome:

• Post traumatic Causes: It arises from trauma or injury leading to inflammation, spasm, or

hypertrophy of the piriformis muscle.

• Overuse: Due to repetitive activities or prolonged sitting, which can cause muscle strain and spasm.

• Inflammatory: Associated with inflammatory conditions affecting the piriformis muscle or nearby

structures.

• Iatrogenic: Caused by medical treatment, such as surgery or injections, that affect the piriformis

muscle.

3. Functional Classification:

• Piriformis Spasm: It is caused by muscle spasm without any anatomical anomaly.

• Piriformis Hypertrophy: Due to muscle overuse or compensation for other weak hip muscles, It leads

to an enlargement of piriformis muscle that compresses the sciatic nerve.

4. Etiological Classification:

• Myofascial: Related to trigger points or myofascial pain within the piriformis muscle.

• Neurogenic: Involving nerve entrapment or irritation.

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 • Ischemic: Due to reduced blood flow to the muscle or nerve.

Clinical Presentation:

• Classic Piriformis Syndrome: Characterized by buttock pain that may radiate along the sciatic nerve

distribution, exacerbated by sitting, climbing stairs, or activities involving hip movement.

• Atypical Piriformis Syndrome: Presents with symptoms that may not follow the typical sciatic

distribution and can include more localized buttock pain or atypical patterns of radiating pain.

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ETIOLOGY

The etiology of piriformis syndrome is multifactorial, involving various intrinsic and extrinsic factors that

lead to irritation or compression of the sciatic nerve by the piriformis muscle. Here’s a detailed breakdown

of the common causes and contributing factors:

1. Anatomical Variations:

• Variations in Sciatic Nerve Pathway: The sciatic nerve usually passes underneath the piriformis

muscle, but in some individuals, it may pass through or over the muscle, increasing the risk of nerve

compression.

• Split Piriformis Muscle: A bifid piriformis muscle can create additional potential sites for sciatic

nerve entrapment.

• Split Sciatic Nerve: A bifurcated sciatic nerve can have one branch passing through the piriformis

muscle, making it more susceptible to compression.

2. Trauma:

• Direct Trauma: A fall or blow to the buttock can cause inflammation, spasm, or hypertrophy of the

piriformis muscle, leading to sciatic nerve irritation.

• Microtrauma: Repetitive microtrauma from activities like long-distance running or cycling can result

in cumulative damage and muscle dysfunction.

3. Overuse and Muscle Imbalance:

• Repetitive Activities: Activities that involve repetitive hip movements, such as running, cycling, or

prolonged sitting, can lead to overuse injuries.

• Muscle Imbalance: Weakness in the gluteal muscles or tightness in the hip flexors can place

increased strain on the piriformis muscle, leading to dysfunction and spasm.

4. Inflammatory Conditions:

• Local Inflammation: Conditions such as bursitis or tendinitis in the hip region can cause secondary

inflammation and irritation of the piriformis muscle.

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 • Systemic Inflammatory Diseases: Conditions like rheumatoid arthritis or ankylosing spondylitis can

cause inflammation of the piriformis muscle and surrounding tissues.

5. Postural and Biomechanical Factors:

• Poor Posture: Poor posture, particularly prolonged sitting with improper ergonomics, can lead to

chronic strain on the piriformis muscle.

• Gait Abnormalities: Abnormal walking patterns, leg length discrepancies, or foot abnormalities can

alter the biomechanics of the hip and place undue stress on the piriformis muscle.

6. Iatrogenic Causes:

• Medical Interventions: Surgical procedures, injections, or other medical interventions in the gluteal

or hip region can inadvertently affect the piriformis muscle, leading to irritation or spasm.

7. Other Contributing Factors:

• Previous Surgery: Hip or pelvic surgeries can lead to scar tissue formation and altered biomechanics,

predisposing individuals to piriformis syndrome.

• Lumbar Spine Pathology: Conditions such as herniated discs or lumbar spine arthritis can cause

compensatory changes in posture and movement patterns, increasing the strain on the piriformis

muscle.

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PATHOMECHANICS

Piriformis syndrome affects various movements due to the involvement of the piriformis muscle and its

interaction with the sciatic nerve. A contracted piriformis muscle causes external rotation of the hip on the

same side. When a patient with piriformis syndrome is relaxed and lying on their back, their foot on the

affected side turns outward. Trying to bring the foot toward the middle causes pain. The nerves of the sacral

plexus that supply several muscles, including the tensor fascia lata, gluteus minimus, gluteus maximus,

adductor magnus, quadratus femoris, and obturator externus, can also be irritated by the piriformis muscle.

In some cases, anatomic abnormalities can lead to muscle weakness on the affected side. Evaluation may

show reduced internal rotation of the hip on that side. In most cases of piriformis syndrome, the sacrum tilts

forward toward the affected side on the opposite diagonal axis, causing compensatory rotation of the lower

lumbar vertebrae in the opposite direction. For instance, if piriformis syndrome affects the right side, the

sacrum tilts forward and left with the fifth lumbar vertebra rotating right. This sacral rotation often results in

a leg on the affected side being functionally shorter.

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Here’s a detailed look at the movements typically affected by piriformis syndrome:

Impact of Piriformis Syndrome on Hip Movements Such as Flexion, Extension, Abduction, Adduction,

Internal & External Rotation

➢ Hip Flexion

Pain and discomfort may increase during hip flexion, especially when sitting for prolonged periods or during

activities like cycling.

➢ Hip Extension

Activities involving hip extension, such as walking, running, or climbing stairs, can exacerbate pain due to

increased tension on the piriformis muscle.

➢ Hip Abduction

Abduction can be painful and difficult, affecting activities such as side-stepping or certain exercises.

➢ Hip Adduction

Adduction movements can increase pressure on the piriformis muscle, leading to pain and discomfort.

➢ Hip Internal Rotation

Internal rotation can stretch the piriformis muscle and compress the sciatic nerve, causing pain during

movements like crossing the legs.

➢ Hip External Rotation

External rotation directly involves the piriformis muscle, leading to pain during activities that require

rotating the leg outward, such as turning while walking or pivoting in sports.

Impact of Piriformis Syndrome While Performing Following Activities:

➢ Sitting

Prolonged sitting can compress the piriformis muscle and the sciatic nerve, causing increased pain and

discomfort, especially if sitting on hard surfaces or with poor posture.

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➢ Standing

Standing for long periods can lead to muscle fatigue and spasm in the piriformis, exacerbating symptoms.

➢ Walking

Walking can aggravate piriformis syndrome due to repetitive hip movements, especially on uneven surfaces

or during long walks.

➢ Running

Running increases the strain on the hip muscles, including the piriformis, leading to pain and potential

worsening of symptoms.

➢ Stair Climbing

Stair climbing requires hip flexion and extension, which can aggravate the piriformis muscle and cause pain.

➢ Squatting

Squatting places significant stress on the hip muscles, including the piriformis, leading to increased

discomfort and pain.

➢ Crossing Legs

This movement stretches the piriformis muscle, potentially causing pain and discomfort.

Clinical Implications:

• Altered Gait: Due to pain and discomfort, individuals may adopt a limping gait, which can lead to

secondary issues in the lower back, hips, knees, and ankles.

• Muscle Compensation: Other muscles may compensate for the weakness or pain in the piriformis,

potentially leading to overuse injuries in the compensating muscles.

By addressing these affected movements through targeted therapy and lifestyle adjustments, individuals with

piriformis syndrome can manage symptoms more effectively and improve their overall function and

mobility.

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EPIDEMIOLOGY

Piriformis syndrome is estimated to account for 5-6% of cases of sciatica. However, some reports suggest

that it might be involved in up to 15-17% of low back pain cases with sciatica. The condition is more

frequently identified in clinical settings focused on musculoskeletal disorders, sports medicine, and physical

therapy. Women are more commonly affected than men. Studies suggest that women are approximately six

times more likely to develop piriformis syndrome (male : female ratio 1:6). This higher prevalence may be

due to anatomical differences in the pelvis and hormonal influences on muscle and ligament laxity.

Piriformis syndrome is most diagnosed in individuals aged 30-50 years. It can occur in younger athletes and

older adults, but this age range is most typical. The incidence of piriformis syndrome in patients with sciatica

is 6%. The overall incidence of piriformis syndrome has been estimated at 2.4 million per year. Most cases

occur in middle-aged patients

The epidemiology of piriformis syndrome is challenging to define precisely due to the condition’s often

underdiagnosed and misdiagnosed in nature. The clinical prevalence of piriformis syndrome varies widely in

the literature due to challenges in diagnosis and the overlap of symptoms with other conditions such as

lumbar radiculopathy and herniated discs. There is no universally accepted diagnostic test or criteria for

piriformis syndrome, making it difficult to determine true prevalence accurately. There is a need for

standardized diagnostic criteria and reporting methods to better understand the true prevalence and impact of

piriformis syndrome. Long-term studies are needed to understand the natural history, recurrence rates, and

outcomes of different treatment modalities.

Improved diagnostic criteria, awareness, and comprehensive studies are needed to fully understand its

epidemiology and develop effective management strategies.

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CLINICAL FEATURES

Piriformis syndrome is characterized by a range of symptoms primarily related to the irritation or

compression of the sciatic nerve by the piriformis muscle. Piriformis syndrome presents with characteristic

buttock pain, sciatica, and sometimes lower back pain, often exacerbated by activities involving hip

movement and prolonged sitting. Here are the key clinical features of piriformis syndrome:

1. Buttock Pain:

Deep, aching pain in the buttock, usually on one side. The pain can be sharp or dull and may vary in

intensity.

2. Radiating Pain:

Pain radiates from the buttock down the back of the thigh and into the leg, following the path of the

sciatic nerve. It can affect the hip, thigh, and calf, and may extend to the foot.

3. Low Back Pain: (Referral Pain)

Pain may be felt in the lower back, though this is less common than buttock and leg pain.

4. Paraesthesia:

Numbness and tingling or a pins-and-needles sensation may be felt along the path of the sciatic

nerve. Often affects the posterior thigh and calf, and sometimes the foot.

5. Muscle Weakness:

Weakness in the hip, thigh, or leg may occur, especially during prolonged activity. Difficulty with

activities that require hip movement, such as walking, running, or climbing stairs.

6. Tenderness:

Tenderness may be noted over the piriformis muscle on deep palpation

7. Exacerbation of Pain in Sitting:

Sitting for prolonged periods often aggravates symptoms, such as driving or working at a desk. Pain

may worsen when sitting, especially on hard surfaces, and may improve with standing or lying down.

8. Pain during Physical Activity:

o Movements that involve hip rotation, such as walking, running, or climbing stairs, can

increase pain.

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 o Activities like squats, lunges, or cycling may worsen symptoms.

o Pain may be triggered or worsened by crossing the affected leg over the other.

o Positions that stretch or put pressure on the piriformis muscle can aggravate symptoms.

Other characteristics include the following:

• A study has confirmed that piriformis syndrome consists of a quartet of symptoms and the syndrome

is also associated with changes in the piriformis muscle /sciatic nerve relations. The quartet consists

of buttock pain(same side), pain aggravated on sitting, external tenderness at the level of greater

sciatic notch , pain aggravated on sitting and any maneuvers that cause pain due to increased

piriformis muscle tension.

• Limited straight-leg raise.

• Piriformis syndrome can exist without radiation.

• Depending on the patient, lying down, bending the knee or walking can reduce pain. However, some

patients cannot tolerate the pain in any position and can only find relief when they’re walking.

• Piriformis syndrome is not characterized by neurological deficits typical of a radicular syndrome,

such as declined deep tendon reflexes and myotomal weakness.

• The patient may present with a limp when walking or with their leg in a shortened and externally

rotated position while supine. This external rotation while supine can be a positive piriformis sign,

also called a splay foot. It can be the result of a contracted piriformis muscle.

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RISK FACTORS

Piriformis syndrome can develop due to a variety of risk factors. These factors often relate to physical

activity, anatomical variations, and lifestyle choices. Here’s a detailed list of the common risk factors

associated with piriformis syndrome:

Physical Activity and Overuse

➢ Repetitive Movements:

o Athletes: Runners, cyclists, and rowers who perform repetitive hip and leg movements.

o Occupational Activities: Jobs that require repetitive motion, such as lifting, twisting, or prolonged

standing.

➢ Prolonged Sitting:

o Sedentary Lifestyle: Long periods of sitting, particularly with poor posture, can place stress on the

piriformis muscle.

o Desk Jobs: Office workers who sit for extended periods without breaks.

Biomechanical Factors

➢ Muscle Imbalance:

Weakness in the gluteus maximus or medius can lead to overcompensation by the piriformis muscle.

Tightness in the hip flexors can alter pelvic alignment and increase stress on the piriformis muscle.

➢ Poor Posture and Gait:

Abnormal Walking Patterns, Conditions like leg length discrepancy or flat feet can change the

biomechanics of the lower body. Poor Posture, Slouching or improper sitting posture can place undue

stress on the lower back and buttock muscles.

Trauma and Injury

➢ Direct Trauma:

o Injuries: Falls or direct blows to the buttock can cause inflammation or spasms in the piriformis

muscle.

➢ Microtrauma:

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 o Repetitive Strain: Overuse injuries from activities that place repeated stress on the hip and buttock

muscles.

Medical and Surgical Factors

➢ Previous Surgeries:

o Hip or Pelvic Surgeries: Surgical procedures in these areas can lead to scar tissue formation and

altered biomechanics.

➢ Iatrogenic Causes:

o Medical Interventions: Injections or other medical treatments in the gluteal region can inadvertently

affect the piriformis muscle.

Systemic and Inflammatory Conditions

➢ Inflammatory Diseases:

Conditions like rheumatoid arthritis or ankylosing spondylitis can cause inflammation in the pelvic

region. Bursitis or tendinitis in the hip can indirectly affect the piriformis muscle.

Lifestyle Factors

➢ Lack of Physical Activity

o Inactivity: Lack of regular exercise can lead to muscle weakness and imbalances.

➢ Poor Ergonomics:

o Work Environment: Poorly designed workspaces that do not support good posture and movement can

increase the risk of piriformis syndrome.

Psychological Factors

➢ Stress and Muscle Tension: Psychological Stress: High levels of stress can lead to increased muscle

tension, which may affect the piriformis muscle.

By understanding and addressing these risk factors, individuals can take steps to prevent piriformis

syndrome or manage it more effectively if it develops. Regular exercise, proper ergonomics, and attention to

posture can be key components in reducing the risk.

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COMPLICATIONS

Piriformis syndrome, if not properly managed, can lead to several complications that affect the quality of life

and functional abilities of individuals. Here are the key complications associated with piriformis syndrome:

1. Chronic Pain:

o Persistent Symptoms: Untreated or poorly managed piriformis syndrome can lead to chronic buttock

and leg pain.

o Impact on Daily Activities: Chronic pain can interfere with daily activities, reducing mobility and

overall function.

2. Sciatica:

o Radiating Pain: Continuous irritation or compression of the sciatic nerve can cause persistent sciatica,

with pain radiating from the buttock down the leg.

o Neurological Symptoms: Prolonged sciatic nerve compression can lead to numbness, tingling, and

weakness in the affected leg.

3. Muscle Weakness:

o Weakness in Lower Limb: Ongoing pain and nerve irritation can lead to muscle weakness, particularly

in the hip, thigh, and calf muscles.

o Functional Limitations: Weakness can affect gait and balance, increasing the risk of falls and further

injury.

4. Reduced Mobility:

o Decreased Range of Motion: Pain and muscle tightness can reduce the range of motion in the hip and

lower back.

o Activity Avoidance: Fear of pain may lead individuals to avoid certain activities, resulting in decreased

physical fitness and muscle atrophy.

5. Altered Gait:

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 o Compensatory Movements: To avoid pain, individuals may develop compensatory movements or an

altered gait, leading to further musculoskeletal issues.

o Secondary Problems: An altered gait can cause secondary problems in the lower back, hips, knees, and

ankles due to abnormal biomechanics.

6. Psychological Impact:

o Stress and Anxiety: Chronic pain and functional limitations can lead to increased stress and anxiety.

o Depression: Long-term pain and disability can contribute to depression and decreased quality of life.

7. Secondary Musculoskeletal Issues:

o Overuse Injuries: Compensatory use of other muscles and joints can lead to overuse injuries and

additional musculoskeletal pain.

o Joint Problems: Altered biomechanics can increase the risk of joint problems, such as hip and knee

osteoarthritis.

8. Prolonged Recovery Time:

o Delayed Treatment: Delayed diagnosis and treatment can prolong recovery time and make management

of the syndrome more challenging.

o Chronic Condition: In some cases, piriformis syndrome can become a chronic condition requiring long-

term management strategies.

9. Dependency on Medications:

Long-term use of pain medications, including NSAIDs or opioids, can lead to dependence and potential

side effects. Side Effects: Chronic use of medications can cause gastrointestinal, renal, or cvs issues.

10. Surgical Complications:

In rare cases, surgical intervention may be necessary if conservative treatments fail. Surgery carries risks

of complications such as infection, nerve damage, or poor surgical outcomes. Recovery from surgery

requires extensive rehabilitation and carries its own set of challenges and risks.

By addressing piriformis syndrome early and comprehensively, the risk of complications can be significantly

reduced, leading to better outcomes and improved quality of life.

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DIFFERENTIAL DIAGNOSIS

The differential diagnosis includes:[11]

• Hamstring injury and Tendinopathy

• Lumbosacral disc injuries and discogenic pain syndrome

• Lumbosacral facet syndrome

• Lumbosacral radiculopathy

• Lumbosacral spine sprain

• Lumbosacral spondylolisthesis and spondylolysis

• Lumbar Spinal Stenosis

• Sacroiliac joint injury/dysfunction

• Inferior gluteal artery aneurysm or pseudoaneurysm

• Malignancy/tumors

• Arteriovenous malformation

• Trochanteric Bursitis

• Diseases such as appendicitis, pyelitis, hypernephroma, uterine disorders, prostate disorders ,

Osteoarthritis Of Hip

• Renal Stones

• Lumbar osteochondrosis (Osteochondritis Dissecans)

• Greater Trochanteric Pain

• Deep Gluteal Syndrome

• Ischiofemoral Impingement

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DIAGNOSIS

The diagnosis is primarily clinical and is one of exclusion. On physical examination, the practitioner should

try to perform stretching maneuvres to irritate the piriformis muscle. Furthermore, manual pressure around

the sciatic nerve may help reproduce the symptoms. Clinical maneuvers with variable sensitivity and

specifcity may identify whether PM is involved in the presenting gluteal pain.

Radiographic studies have limited application to the diagnosis of piriformis syndrome. Although magnetic

resonance imaging (MRI) and computed tomography (CT) may reveal enlargement of the piriformis muscle,

these imaging technologies are most useful in this setting when ruling out disc and vertebral pathologic

conditions. Diagnostic imaging of the lumbar spine is necessary to exclude disc herniation, arthritis,

fractures and pathological masses. Electrodiagnostic testing is beneficial in differentiating piriformis from

other conditions. Nerve impingements are usually accompanied by EMG abnormalities, muscle weakness,

and atrophy of muscles distally and proximally to piriformis, whereas piriformis syndrome typically exhibits

weakness and atrophy only in distal musculature. The electrodiagnostic evaluation may show signs of

denervation in the muscles innervated by the sciatic nerve. Involvement of the paraspinal muscles argues

against a diagnosis of piriformis syndrome. Additionally, H reflex may be prolonged or absent in the affected

limb. Work done by Fishman has suggested that a prolonged H latency in the adducted and flexed hip is

suggestive of piriformis syndrome.

(The H-reflex (Hoffmann reflex) is an electrical analogue of the monosynaptic stretch reflex. It's used in

clinical and research settings to assess the function of the spinal cord and peripheral nerves.)

(H-latency refers to the time interval between the electrical stimulation of a peripheral nerve and the

recorded response in the corresponding muscle.)

A thorough physical examination should include a detailed assessment of both hips and the lumbar spine,

examination of hip range of motion, assessment of strength in all planes, and observation of gait.

Several clinical tests have been described to identify symptoms of PS. Among them we can primarily

include:

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➢ Freiberg Manoeuvre

o Starting Position: Supine position

o Movement: the physiotherapist passively positions the patient’s lower limb in internal rotation in the

hip joint, the knee joint remains in extension.

o Interpretation: the test is positive when pain is provoked by compression of the sciatic nerve.

➢ Pace Manoeuvre Test

o Starting Position: sitting down with your legs down in 90°, your entire thigh resting on the bench.

o Movement: hip abduction with resistance (therapist resists movement).

o Interpretation: with piriformis syndrome, pain in the buttock occurs

o The modified Pace test will assess the piriformis muscle as a rotator. The patient in a supine relaxed

position with the legs hanging off the table at the knees will be asked to push his legs medially against

29
 the resistance provided by the examiner’s hands. This movement will produce pain in the deep buttock

if there is a piriformis syndrome

➢ Beatty Manoeuvre

o Starting Position: Lying on the painless side, lower limb set at 60° hip flexion and approx. 10° knee

flexion.

o Movement: the patient actively abducts the lower limb (can also be performed with resistance provided

by the therapist).

o Interpretation: the test is positive when there is pain in the buttock but not in the lumbar spine.

o Modified Beatty manoeuvre is when the examiner exerts a slight resistance to the abduction with a

hand placed on the knee of the patient. The manoeuvre is positive when the pain is reported in the

buttock and not in the lumbar spine, while the patient actively abducts the leg

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➢ FAIR Test (flexion, adduction, internal rotation)

o Starting Position: Supine position/ Side Lying position

o Movement: the physiotherapist passively positions the examined lower limb – respectively: in flexion,

adduction, and internal rotation in the hip joint.

o Interpretation: Pain in the buttock area during the test indicates piriformis syndrome

➢ Piriformis Muscle Flexibility (Stretch) Test

o Starting Position: Lying on the untested side, at the edge of the bench, untested limb straightened at

the hip and knee joints.

o Movement: The physiotherapist passively bends the tested lower limb to an angle of 60° in the hip

joint, then stabilizes the pelvis with one hand, and presses the tested lower limb knee towards the

ground with the other hand.

o Interpretation: In case of pain in the buttock area or pain radiating along the back of the lower limb

test is considered positive.

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➢ Seated Piriformis Stretch Test

o Starting Position: The piriformis test can also be examined in a seated position on the chair with

back upright and feet resting on the ground.

o Movement: The test is performed by crossing the affected leg and placing the ankle of the affected

leg on the unaffected knee. One hand of the examiner is at the ankle to stabilize the part while the

other hand is placed on the lateral side of the knee. The patient is then asked to bend forwards o feel

the stretch in the gluteal region or the examiner pulls the knee towards the chest.

o Interpretation: This can indicate piriformis syndrome, as the piriformis muscle might be

compressing the sciatic nerve. A reduced ability to lower the knee toward the floor can also suggest

tightness or dysfunction of the piriformis muscle.

o Note: A positive test does not establish the diagnosis of piriformis syndrome on its own; it may

even represent other pathologies, such as lumbar radiculopathy or disorders of the hip joint.

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➢ Bonnet test

o Starting Position: Supine Position

o Movement: The examiner realizes a straight leg raise on the affected side, with the hip adducted and

realizes an internal rotation of the thigh by supporting with one hand the calf and with the other hand

stabilizing the knee.

o Interpretation: The test will be positive if pain or paraesthesia are reported, being specific for sciatica

and piriformis syndrome

➢ Mirkin test: The examiner exerts a pressure into the buttock where the sciatic nerve crosses the

piriformis muscle and asks the patient to bend slowly to the floor. If the movement elicits a deep

buttock pain the test is positive

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The above tests stretch the piriformis muscle – therefore, if they contribute to the reproduction of pain

symptoms in the buttock, thigh, or distal part of the lower limb – they are considered positive.

Additionally, the “fingers-to-floor” test, sacroiliac joint compression test, or Lasegue’s sign can be

performed to exclude disorders, i.e. irritation of the sciatic nerve or blockage of the sacroiliac joints

➢ Fingers To Floor Test (Thomayer Test)

o Starting Position: Standing upright, arms along the body.

o Movement: the patient bends his chin towards the sternum, then bends torso forward trying to reach

the floor with his fingertips while doing so.

o Interpretation: the test is positive when the contraction of the hamstring muscles makes it impossible

to touch the ground with the fingertips – which may also be accompanied by pain and a feeling of

pulling on the back of the lower limb.

➢ Lasegue Test

The Lasegue test, often referred to as a Straight Leg Raise or SLR test, is a clinical manoeuvre for the

diagnosis of lumbar radiculopathy and mostly linked with sciatica, which is usually caused by a herniated

disc in the lower back. It is performed as:

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o Patient Position: Supine position.

o Movement: The examiner raises the patient's straightened leg while keeping the knee extended. This

is done slowly to observe any pain response

o Angle of Pain: The angle at which the patient starts to experience pain is noted. Pain that radiates

down the leg at an angle between 30 and 70 degrees of hip flexion is typically considered positive for

sciatic nerve irritation or lumbar radiculopathy.

o Pain Localization: The pain is usually located along the distribution of the sciatic nerve, which can

include the lower back, buttocks, and down the back of the leg to the foot.

o Interpretation: Pain is reproduced along the sciatic nerve path, indicating possible lumbar disc

herniation or other causes of sciatic nerve irritation.

o Variations

1. Crossed Straight Leg Raise (Crossed Lasegue Test): The unaffected leg is raised. Pain felt in the

affected leg during this manoeuvre strongly indicates a herniated disc.

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 2. Bragard's Test: After a positive SLR test, the leg is lowered slightly, and the foot is dorsiflexed.

Increased pain with dorsiflexion supports the diagnosis of sciatica.

The Lasegue test is carried out to offer a differential diagnosis that separates nerve root irritation from other

probable causes of pain among patients with cues and complaints of lower back and leg pain.

➢ SI Joint Compression Test

o Starting Position: Side Lying on the side of being tested.

o Movement: The examiner stands behind the patient and places both hands on the patient's uppermost

iliac crest (the top part of the hip bone). The examiner applies downward and inward pressure on the

iliac crest, compressing the SI joint on the side the patient is lying on. The examiner observes the

patient’s response to the pressure, looking for signs of pain or discomfort.

o Interpretation: If the patient experiences pain in the sacroiliac joint area, the test is considered

positive. This suggests that the SI joint may be the source of the pain.

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TREATMENT

Throughout the physical evaluation of patients, clinicians should maintain a high index of suspicion for

piriformis syndrome. Before treating PS, it is of paramount importance to classify it. In case of primary

piriformis syndrome, treatment should focus on intrinsic piriformis muscle pathology only, however

secondary piriformis syndrome deserves treatment for associated conditions. Early conservative treatment is

the most effective treatment. Patients with piriformis syndrome had symptom reduction with use of

nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, ice, and rest.

Currently it is recommended that patients begin with conservative treatment and then progress to invasive

treatment it symptoms fail to resolve. Patients without significant symptoms can begin by engaging in

conservative management with a relatively high success rate. Initially short-term rest can provide symptom

relief.

Commonly used pharmacological and non-pharmacological modalities that are found to be useful in

Piriformis Syndrome NSAIDs, analgesics (including adjuvants), piriformis stretching exercise, activities of

daily living modification; however, intra-lesional steroid-lidocaine combination and botulinum toxin-A

injections are reportedly most effective in the disorder

Stretching of the Piriformis Muscle and Strengthening of abductor and adductor muscles should be included

in patients treatment plan. A manual medicine approach may combine muscle stretches, Gebauer’s spray and

stretch technique, and soft tissue, myofascial, muscle energy, and thrust techniques to address all somatic

dysfunctions in the patient with piriformis syndrome

Additional Measures that can be utilised before medical management focus on mobilising the affected area.

Mobilising soft tissue restrictions and trigger points can be beneficial but should be avoided in patients that

have significantly irritable symptoms. If motion is restricted, Mobilizing the hip and Lumbosacral region

may also help.

If the patient does not respond adequately to manual treatment, then acupuncture and trigger point injection

with lidocaine hydrochloride, steroids, or botulinum toxin type A (BTX-A) may be considered. If all of the

pharmacologic and manual medicine treatments fail, the final treatment option is surgical decompression.

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Conservative Management

o Rest: Rest is a key component in the conservative management of piriformis syndrome, especially

during the initial phase of treatment when symptoms are most severe, to reduce inflammation and to

prevent further injury. Avoid activities that trigger or worsen symptoms, such as prolonged sitting,

running, heavy lifting, or climbing stairs. Resting intermittently during the day may be more useful than

continuous resting. Avoid stiffness and poor circulation by alternating rest with gentle movement.

o NSAIDS & Analgesics: When managing piriformis syndrome, nonsteroidal anti-inflammatory drugs

(NSAIDs) and analgesics can play a role in relieving pain:

NSAIDs (Nonsteroidal Anti-Inflammatory Drugs): These medications, such as ibuprofen, aspirin,

and naproxen, help reduce inflammation and decrease pain1.

Analgesics: Analgesics, like acetaminophen, block pain signals to the brain, providing pain relief.

o Muscle Relaxants:

Baclofen which is an antispastic muscle relaxer that treats spasms, pain, and stiffness. You take it as a

tablet.

Cyclobenzaprine, which is an antispasmodic that blocks nerve impulses to your brain to relieve pain

o Heat and Cold Therapy

Cold Therapy: Apply ice packs to the buttock area for 15-20 minutes several times a day to reduce

inflammation.

Heat Therapy: Apply a heating pad to the affected area to relax the muscle and improve blood flow.

o Physical Therapy: Physical therapy is an important part of treating piriformis syndrome. A

trained physical therapist can treat patient with exercises that strengthen and stretch your muscle to

relieve pain. Other therapies such as Iontophoresis use a mild electric current to help muscles relax

Stretching Exercises:

Piriformis Stretch And Hip Rotator Stretch

Manual Therapy:

Soft Tissue Mobilisation (Massage Therapy) And Joint Mobilisation Technique

Strengthening Exercises

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o Injection Therapy

Corticosteroid Injections: To reduce inflammation and pain. This is often guided by ultrasound to

ensure accurate placement.

Botox Injections: To relieve muscle spasms and reduce pain.

Injections of local anaesthetics, steroids, and botulinum toxin into the Piriformis muscle can serve both

diagnostic and therapeutic purposes.

An ultrasound-guided injection technique has recently been utilized. This technique has been shown to

have both diagnostic and therapeutic value in the treatment of Piriformis Syndrome.

o Activity & Lifestyle Modification

Avoid Aggravating Activities: Identify and limit activities that exacerbate symptoms, such as prolonged

sitting, running, or climbing stairs.

Ergonomic Adjustments: Modify workstations and seating arrangements to reduce strain on the

piriformis muscle.

Weight Management: Maintaining a healthy weight to reduce stress on the hips and lower back.

Regular Exercise: Engage in low-impact activities like walking, swimming, or cycling to maintain

overall fitness and reduce muscle tension.

Correct Posture: Training to maintain proper posture while sitting, standing, and walking.

Regular follow-up with a healthcare provider, such as a physical therapist or physician, is important to

monitor progress and adjust the treatment plan as needed.

These conservative measures can often effectively manage and alleviate symptoms of piriformis syndrome.

If conservative treatments fail to provide relief, further interventions such as surgery might be considered.

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Surgical Management

Surgical interventions should be considered only when nonsurgical treatment has failed and the symptoms

are becoming intractable and disabling. Surgery for piriformis syndrome is relatively rare and typically

considered a last option of treatment.

o Indications for Surgery:

Classic indications for surgical treatment include abscess, neoplasms, hematoma, and painful vascular

compression of the sciatic nerve caused by gluteal varicosities

Surgical treatment is considered when:

Non-surgical approaches (such as medication and physical therapy) have been ineffective over several

months.

Symptoms have worsened over time.

The patient’s quality of life is significantly impacted due to pain and functional limitations.

Radiographic imaging (CT scan or MRI) confirms sciatic nerve compression or injury by the piriformis

muscle.

Anatomical variations causing piriformis syndrome are identified through imaging.

o Types Of Surgical Procedures

Piriformis Release Surgery: The surgeon makes an incision near the buttock to access the piriformis

muscle. The muscle is either cut or partially removed to relieve pressure on the sciatic nerve.

Tenotomy: Surgical release with tenotomy of the piriformis tendon to relieve the nerve from the

pressure of the tense muscle resultes in immediate pain relief

Minimally Invasive Techniques: Laparoscopic or endoscopic techniques can be used to minimize tissue

damage and reduce recovery time.

Sciatic Nerve Decompression: In addition to releasing the piriformis muscle, the surgeon may remove

any fibrous bands, scar tissue, or other structures compressing the sciatic nerve.

Neurolysis: The surgeon carefully dissects and frees the sciatic nerve from surrounding tissues that may

be causing compression.

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Recovery Time varies depending on the surgical technique used and the individual’s overall health.

Generally, it takes several weeks to a few months for full recovery. A structured rehabilitation program is

essential to regain strength and mobility. It typically includes stretching, strengthening, and functional

exercises. Regular follow-up with the surgeon is needed to monitor healing and progress.

Surgical intervention for piriformis syndrome generally has good success rates, with many patients

experiencing significant pain relief and improved function. Long-term outcomes depend on factors such as

the extent of nerve compression, the precision of the surgical technique, and adherence to postoperative

rehabilitation. The postoperative management consists of partial weight-bearing using crutches for 2 weeks

and unrestricted range of motion exercises. The treatment algorithm for retro-trochanteric pain syndrome

(Piriformis Syndrome):

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PHYSIOTHERAPY INTERVENTION

For managing piriformis syndrome through physiotherapy, setting clear short-term and long-term goals is

essential for effective treatment and recovery.

Short-Term Goals

1. To Reduce Pain: Alleviate pain and discomfort in the buttocks and lower back through techniques

like heat therapy, massage, and anti-inflammatory medications.

2. To Reduce Inflammation: Reduce inflammation using modalities such as ice therapy and ultrasound.

3. To Improve Flexibility: Begin gentle stretching exercises to improve the flexibility of the piriformis

muscle and surrounding areas.

4. Posture Correction: Educate the patient on proper body mechanics and posture to reduce strain on the

piriformis muscle.

Long-Term Goals

1. To Strengthen Muscles: Focus on strengthening the core and hip muscles to support the lower back

and pelvis, preventing recurrence.

2. To Increase Mobility: Achieve full range of motion in the hip joint through progressive stretching and

strengthening exercises.

3. Lifestyle Modifications: Implement long-term changes such as regular exercise, maintaining good

posture, and avoiding prolonged sitting to prevent future episodes.

4. Patient Education: Provide ongoing education about the condition, self-care techniques, and the

importance of adhering to the exercise regimen.

These goals help create a structured and effective physiotherapy plan tailored to the needs of individuals

with piriformis syndrome.

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Physiotherapy Mx

Physical therapy is an important part of treating piriformis syndrome. A trained physical therapist can work

with you on exercises that strengthen and stretch your muscle to relieve pain.

Initially patients do not allow for the exercises and stretching manoeuvres due to severe pain caused by

muscle hypertrophy or spasm or irritation of sciatic nerve. In this Situation, Therapist Focuses on reduction

of Pain by using Pain Relief Physiotherapy manoeuvrers which benefits the patient to reduce pain and to

perform stretches and exercises for long term relief. There are various Physiotherapy Approaches to get

relieve from piriformis syndrome and to alleviate the symptoms.

After a diagnosis of piriformis syndrome has been made, the patient should be instructed to rest from

offending activities and initiate physical therapy treatment. Physical therapy modalities are often beneficial

forms of treatment when used in conjunction with stretching and manual therapy.

▪ ACUTE PHASE

Goals

1. Reduce pain and inflammation

2. Protect the affected area and

3. Prevent further injury.

To Reduce Pain and Inflammation:

o Applying Heat pack can relax the muscle and Cold packs reduces the inflammation and sharp/ numb

pain

o Electrotherapy Modalities Such as

1. TENS (Transcutaneous electrical nerve stimulation) can be an effective treatment for managing pain

associated with piriformis syndrome. A TENS device sends small electrical charges through the skin to

the nerves underneath. The electrical energy stimulates the nerves and interferes with pain signals to the

brain. TENS works by delivering low-voltage electrical currents to the affected area, which can help

block pain signals from reaching the brain. The electrical stimulation can help relax the piriformis

muscle, reducing spasms and tension.

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 Proper electrode placement is crucial for effective TENS therapy in managing piriformis syndrome.

Electrode Placement

Place one electrode on your lower back, just above the buttocks. Place the second electrode on the

buttock area where you feel the most pain or discomfort or along the course of the sciatic nerve.

Settings: Start with the lowest intensity setting and gradually increase it until you feel a comfortable

tingling sensation. Avoid settings that cause pain or discomfort. Use a frequency range of 80-120 Hz for

acute pain relief. For chronic pain, a lower frequency range of 2-10 Hz may be more effective. Set the

pulse width (duration of each electrical pulse) between 100-200 microseconds. This range is typically

effective for muscle pain and spasms. Begin with sessions of 15-30 minutes, and can gradually increase

the duration based comfort

2. IFT (Interferential Therapy) is a common modality used to manage pain associated with piriformis

syndrome. IFT works by delivering low-frequency electrical currents to the affected area, which can help

reduce pain and inflammation, improve blood flow, and promote healing.IFT can help alleviate pain by

stimulating the nerves and blocking pain signals from reaching the brain. The electrical currents can help

relax the piriformis muscle, reducing spasms and tension. IFT can enhance blood flow to the affected

area, promoting healing and reducing inflammation.

Electrode Placement

Place the electrodes in a diagonal pattern around the painful area. This ensures that the currents intersect

at the site of pain, creating the therapeutic interferential current

Electrode 1: Place on the lower back, just above the buttocks.

Electrode 2: Place on the opposite side of the lower back.

Electrode 3: Place on the buttock area where you feel the most pain.

Electrode 4: Place on the opposite side of the buttock area

Setting: Start with a low intensity and gradually increase it until you feel a comfortable tingling

sensation. Avoid settings that cause pain or discomfort.

Typical session durations range from 10-20 minutes.

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3. Ultrasound Therapy can be an effective treatment modality for piriformis syndrome. It uses sound

waves to generate deep heat within the tissues, which can help reduce pain, inflammation, and muscle

spasms. The deep heat generated by ultrasound can help alleviate pain by increasing blood flow and

reducing muscle tension. Ultrasound can help decrease inflammation in the piriformis muscle, which can

reduce pressure on the sciatic nerve.

Setting: Use a frequency of 1 MHz for deep tissue penetration, as the piriformis muscle is located deep

within the buttock. Set the intensity between 0.8 to 1.5 W/cm². Start with a lower intensity and gradually

increase based on the patient’s comfort and response. Typical treatment sessions last between 5-10

minutes. Adjust the duration based on the severity of the symptoms and the patient’s response.

4. Ultrasound guided dry needling treatment

DN treatment is a treatment method where MTrPs are stimulated using acupuncture needles or injection

needles. It can be performed according to anatomical indicators, as well as with ultrasound and

fluoroscopy. It can also be performed with blinding, but the success probability of reaching the right

region with this method is low compared to the ultrasound-guided DN. Besides, there is a risk of

damaging neighbouring neurovascular structures. DN should be included in our treatment modalities as a

microinvasive, inexpensive and effective method in the treatment of PS.

5. Phonophoresis is a therapeutic technique that combines ultrasound therapy with the application of

topical medications to enhance their absorption through the skin. This can be particularly beneficial for

managing piriformis syndrome. A topical anti-inflammatory or analgesic medication (i.e. Diclofenac gel)

is applied to the skin over the piriformis muscle. Ultrasound waves are then used to drive the medication

45
 deeper into the tissues, enhancing its effectiveness. The ultrasound waves help the medication penetrate

deeper into the muscle tissue, providing more effective pain relief and reducing inflammation.

6. Iontophoresis is a treatment modality that can be used for managing piriformis syndrome. It involves the

use of a mild electrical current to deliver medication through the skin directly to the affected area. A

medicated gel or solution, often containing anti-inflammatory drugs, is applied to the skin over the

piriformis muscle. By delivering anti-inflammatory medication (e.g. Dexamethasone) directly to the

piriformis muscle, iontophoresis can help reduce pain and inflammation.

Setting: Use a direct current (DC) for iontophoresis. Set the current intensity between 1-4 mA. Start with a

lower intensity and gradually increase based on the patient’s comfort and response. Typical treatment

sessions last between 10-20 minutes. Adjust the duration based on the severity of the symptoms and the

patient’s response.

Choosing the most effective treatment for piriformis syndrome among TENS, IFT, ultrasound, iontophoresis,

and phonophoresis depends on individual patient needs and responses.

▪ SUBACUTE PHASE

Goals

1. Restore range of motion

2. Reduce muscle tightness and

3. Begin strengthening exercises.

Manual Therapy treatment for piriformis syndrome

Treatment for a tight piriformis that is causing piriformis syndrome is directed at loosening the muscle. A

tight piriformis can be treated very successfully with moist heat, soft tissue manipulation, and stretching.

Moist heat is effective to initially warm up and relax the piriformis; application of a hydrocollator pack for

approximately five minutes is sufficient. Whenever deep pressure is used, it is important to grade up to it by

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beginning with light and then medium pressure. Once deeper pressure is used, be sure to sink slowly into the

piriformis and surrounding musculature. It is important to work as much of the piriformis as can be reached.

o Massage Therapy:

Massage therapy can be very effective in managing piriformis syndrome by reducing muscle tension,

improving blood flow, and alleviating pain. Here are some techniques:

1. Deep tissue massage can be beneficial for relieving symptoms associated with piriformis syndrome.

This type of massage targets the deeper layers of muscle and connective tissue, helping to alleviate

tension in the piriformis muscle and surrounding areas. By reducing muscle tightness, it may help

improve flexibility and decrease pain radiating from the buttocks down the leg.

2. Trigger point therapy can be an effective treatment for piriformis syndrome, This therapy involves

identifying and applying pressure to specific trigger points in the piriformis muscle and surrounding

areas, promoting muscle relaxation and pain relief. It can help reduce referred pain that radiates down the

leg, It can be performed by a trained therapist or through self-massage techniques.

3. Myofascial release can be an effective treatment for piriformis syndrome, This technique focuses on

releasing tension in the fascia, the connective tissue surrounding muscles. It can help improve mobility

and reduce pain. This technique involves applying gentle sustained pressure into the myofascial

connective tissue, aiming to relieve tension and restore normal function. It may help release tightness in

the piriformis muscle, improve flexibility, and alleviate symptoms.

4. Foam Roller It can help reduce muscle tightness and relieve pressure on the sciatic nerve. To use it,

position the roller under your glutes and gently roll back and forth, focusing on any tight spots.

5. Tennis Ball Massage: Using a tennis ball for self-massage can effectively relieve tightness in the

piriformis muscle, which may help alleviate symptoms of piriformis syndrome. To do this, sit on the

floor with your legs extended. Place the tennis ball under the buttock area of the affected side. Slowly

lean into the ball, allowing it to press into the muscle. You can adjust your position and shift your weight

to target specific areas of tension. Roll gently over the ball for a few minutes, focusing on breathing and

relaxing the muscle. Be cautious and stop if you experience sharp pain.

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6. Ice Massage: Ice massage is a simple and effective way to relieve acute buttock pain caused by

piriformis syndrome. The cold temperature of the ice helps reduce inflammation and numb the pain.

To perform an ice massage, Make an ice massage applicator at home. Lie on your back and extend the

leg on the painful side. Place the ice massage applicator directly on the buttock. Apply mild pressure to

the applicator and massage the area in a circular motion. Limit the ice massage therapy to about 5

minutes at a time (to avoid an ice burn). Remove the ice pack and let the area return to its normal

temperature. Repeat the ice massage two to five times a day with at least 20 to 30 minutes of rest

between applications. Ice application should be avoided by patients with certain medical conditions, such

as patients who have rheumatoid arthritis, Raynaud’s Syndrome, or areas of impaired sensation.

7. Thai massage: Thai massage combines the benefits of gentle yoga stretching with massage strokes. The

massage is delivered along specific energy or "sen" lines of the body. In Thai massage, the patient

performs passive yoga stretches, while the therapist massages specific areas of the body to relieve stress.

Yoga massage can help strengthen and stabilize your core muscles, increase flexibility in your hip and

spine, and reduce lower back pain and buttock pain. Thai yoga massage also eases muscle stiffness

through assisted yoga stretches to make muscles more flexible and promote improved blood circulation.

8. Neuromuscular Massage: Neuromuscular massage therapy (NMT), also called myofascial trigger point

therapy, is a therapeutic massage that works on the principle of applying sustained pressure using the

thumb for 30 seconds to 2 minutes on a muscle’s ‘trigger points’ to alleviate pain and tension.

Neuromuscular therapy to release a tight piriformis muscle involves applying pressure to trigger points

in the center of the buttock. A physical therapist or massage therapist trained in NMT can accurately

identify muscle trigger points. When the sustained pressure is released, the muscle fibers are loosened,

blood flow is stimulated into the area, and patients tend to feel immediate pain relief. Neuromuscular

therapy may also lead to a greater range of motion in the joints from relaxed muscle tissues

Massage helps ease the symptoms of and sore muscles through the following changes in the body:

o Loosen and relax muscles. When the piriformis muscles are tight, they can spasm and compress the

sciatic nerve. Massage therapy can stretch, loosen, and elongate tight muscles, improving the pain and

function in your buttock, hip, and leg on the affected side.

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o Facilitate the circulation of healing nutrients. Hands-on soft tissue manipulation from massage

stimulates the blood vessels in your skin and deeper tissues. There is increased circulation of blood,

oxygen, and other nutrients to the sore area, promoting healing.

o Release endorphins. Massage stimulates specific pressure receptors in your brain, which are special

nerve fibers. Stimulating these pressure receptors helps reduce pain by releasing endorphins, the body’s

natural feel-good hormone.

It is essential to use proper techniques when performing self-massage, as improper techniques may cause

more harm and further injure the affected area. Self-massage techniques are generally safe but should be

stopped immediately if you experience any signs of worsening pain

Massage therapy may be more effective when combined with other standard back pain treatments, such

as pain-relieving medications, guided physical therapy, and a daily routine of stretching and exercise.

POSTURAL ADJUSTMENTS

Postural adjustments for piriformis syndrome focus on reducing strain on the piriformis muscle and

improving spinal alignment. Key adjustments include maintaining a neutral spine while sitting or standing,

using ergonomic, and avoiding prolonged sitting or crossing legs

➢ Focus On Good Posture: Especially when sitting, driving, or standing and Sleeping,

Sitting Posture

Sit with a neutral, upright spine to distribute weight evenly through the spine and pelvis. Avoid slumping

or bending forward. Ensure your feet are flat on the ground and your thighs are parallel to the floor. Use

a lumbar support cushion to maintain the natural curve of your lower back.

Standing Posture

Stand with your weight evenly distributed on both feet. Avoid leaning to one side. Keep your pelvis in a

neutral position, avoiding excessive tilting forward or backward.

Driving Posture

Adjust your car seat to ensure your back is supported and your knees are slightly bent. Take regular

breaks to stand and stretch if you are driving for long periods

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 Sleeping Position

Sleep on your side with a pillow between your knees to keep your hips aligned. If you sleep on your

back, place a pillow under your knees to reduce strain on your lower back.

➢ Lift objects properly by bending your knees and squatting, keeping your back straight.

Lifting Techniques: When lifting objects, bend your knees and squat down, keeping your back straight.

Hold objects close to your body to reduce strain on your back and hips. Turn your whole body instead of

twisting your spine while lifting.

➢ Warm up before physical activity and stretch after.

For managing piriformis syndrome, it’s crucial to warm up before physical activity to increase blood

flow to the muscles and prepare them for movement. Dynamic stretching or light cardio, like walking or

cycling for a few minutes, can be beneficial. After physical activity, static stretching focused on the hip

and gluteal muscles, including stretches specifically for the piriformis, can help alleviate tightness and

discomfort. Maintaining flexibility in these areas is important for relief.

FLEXIBILITY EXERCISES

o Stretching of Piriformis and Hip Rotators

Deep tissue mobilization with regular stretching sessions decreases the compression of sciatic nerve with

proper posture and movement awareness so as to prevent unwanted spasm in the muscle. Regular

stretching with

Awareness of movement decreases worsening of the condition. Cold and heat application on the irritated

and tight piriformis muscle before and after physical therapy helps in lessening the discomfort felt after

therapy. Botulinum toxin injected in piriformis muscle along with physiotherapy manoeuvre decreases

the irritation on the sciatic nerve and radiating pain along the nerve by relaxing the tensed muscle.

1. Knee-To-Shoulder Piriformis Stretch

Lie flat on your back with your legs straight. Lift your leg and bend your knee. With your opposite

hand, pull your knee toward your opposite shoulder. Hold for 30 seconds. Do this on each side three

times, twice a day.

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2. Ankle-Over-Knee Piriformis Stretch

Lie flat on your back with both knees bent. Cross your ankle over your opposite knee. Grab the back of

your thigh area behind your opposite knee. Gently pull your thigh straight toward your chest. Hold for

30 seconds. Do this on each side three times, twice a day.

3. Standing Piriformis Stretch

Stand with feet hip width apart next to a prop to help with balance. Place leg with pain over the knee of

your other leg (you should look like a big 4). Drop your hips down and back as far as you can while

bending the leg you’re standing on Hold this position for 30 seconds. Repeat with the other leg.

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4. Standing Step Behind Piriformis Stretch

Stand with feet hip width apart. Step back then internally rotate your hip pointing your toes inward.

Then internally rotate front foot by turning toes inward. Rotate your hips to the side of your back leg

then shift your weight on your back leg. Hold for 30-60 seconds

5. Short Adductor Stretch

Sit on the floor and bring feet together in front of you with the soles of your feet touching. Push down

on your knees as far as comfortable. Hold for 20-30 second.

52
6. Long Adductor Stretch

Sit on the floor then bring legs straight out in front of you spreading them as far as you can Lean

forward as far as comfortable. Hold this position for 20-30 seconds.

7. Half Spinal Twist

Sit up straight with both legs out in front. Cross one leg over the other to the outer thigh. Rotate

towards your crossed leg placing your elbow on your knee and your other hand on the floor behind you

hold for 30 seconds. Repeat with the other leg.

53
8. Lying Knees Side Stretch

Lie down on the floor with your legs straight. Bend your knees bringing them towards your chest.

Bring arms out to your sides. Rotate your kees to the side so they rest on the ground. Hold for 30-60

seconds

9. Knee to Chest

Lie down on back with legs stretched out. Bring affected leg up towards your chest. Pull knee towards

opposite shoulder. Hold for 30 seconds. Repeat with other leg

10. Sleeping Pigeon Stretch

Get down on the floor on your hands and knees. Bring your sore leg’s knee up towards your hands then

fold knee under the middle of your body with your outer ankle against the floor. Straighten out your

other leg behind you while placing your elbows on the ground in front of you. Lean down and push

hips towards the floor. Hold this position for 30-60 seconds. Repeat with the other leg.

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11. Outer Hip Piriformis Stretch

Lie down on your back then turn on your side bringing your sore leg’s foot up placing the top of your

foot on the back of your upper calf. Place your hand on your sore leg’s knee pressing towards the floor.

Reach up with your other arm, keeping it straight and rotate away to the other side as far as possible.

Hold this stretch for 20-30 seconds. Repeat with the other leg.

12. Seated Piriformis Stretch

Sit up in a chair then cross your sore leg over your other leg placing your outer ankle on the knee. Keep

your back straight then lean forward. Hold this position for 30-60 seconds. Repeat on the other side.

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13. Modified Pigeon Stretch

Sit down then with knees bent. Lower knee on the the floor straight in front of you so that your ankle

outer ankle is against the floor with your knee bent at 90 degrees. Bring other leg behind you with your

knee bent. Lean forward. Hold for 30 seconds. Repeat with the other leg.

14. Seated Piriformis Leg Cradle Stretch

Sit down on the ground with legs out in front of you. Bend knee and bring foot up towards your chest.

Placing your hands on your bent leg's calf/ankle pull towards you. Hold for up to 30 seconds. Repeat

with the other leg.

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15. Side Lying TFL Stretch

Sit down with legs out in front of you. Then cross one leg over your other so that your ankle is against

your knee. Rotate towards your straight leg using your hands to brace you. Hold for 30 seconds.

16. Prone Adductor Stretch

Lie on stomach then brace yourself with your forearms on the ground. Bring one knee out and up to the

side until you feel the piriformis stretch. Hold for 30-60 seconds. Repeat with the other leg.

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 17. Kneeling Lunge Stretch (HIP Flexors)

You will kneel on the ground with one foot flat on the floor. Place both hands on one thigh with your

weight evenly distributed between your legs. You will shift your hips forward until a gentle stretch is

felt through the front of your hip. You can hold the stretch for up to 30 seconds on each side.

A few guided flexibility techniques include:

➢ Stretching the piriformis through reciprocal inhibition

Reciprocal inhibition occurs when the contraction of one muscle leads to the relaxation of its opposing

muscle. This type of muscle relaxation is a normal reflex that helps optimize muscle function and

prevent injuries. In the treatment of piriformis syndrome, reciprocal inhibition can help relax the

piriformis muscle and reduce muscle spasm and pain in the buttock—thereby improving hip and thigh

range of motion. Reciprocal inhibition of the piriformis muscle is caused by contracting the hip flexors,

which helps relax the piriformis muscle.

➢ Stretching the piriformis by post-isometric relaxation

Post-isometric relaxation (PIR) is a technique that involves contracting a muscle for a specific period,

followed by a passive stretch of that muscle. The idea behind PIR is that the muscle may relax more after

the contraction, creating a greater range of motion during the stretch. Post-isometric relaxation is

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 beneficial for the piriformis muscle because it is a small muscle located deep in the buttock, which can

otherwise be hard to stretch effectively. Performing PIR on the piriformis muscle involves contracting

the muscle by squeezing it as tightly as possible for 6-10 seconds, followed by a passive stretch of the

muscle with an exercise like the seated piriformis stretch while the muscle is in a relaxed state.

➢ Releasing the piriformis muscle through neuromuscular massage

Neuromuscular massage therapy, also called myofascial trigger point therapy or myofascial release, is a

specialized form of massage therapy used to relieve pain and tension in the muscles and connective

tissue (fascia) of the body. It involves applying sustained pressure to specific points in the muscle or

fascia, known as “trigger points,” to release tension and improve mobility.

How to release the piriformis muscle through neuromuscular massage: Piriformis muscle release can

be performed using a foam roller or a tennis ball to apply sustained pressure to focal areas of painful

muscle spasm in the buttock. Another way to perform neuromuscular massage therapy on the piriformis

muscle is through therapist-assisted stretching, where a trained physical therapist uses hands-on

techniques to apply pressure on the muscle to release tension.

Benefits Of Stretching Piriformis

A tight piriformis muscle can lead to debilitating pain making life miserable. It is important to keep this

muscle limber. The benefits of piriformis stretches or piriformis exercises can really enhance quality of life

for some. Here is a look at a few of the benefits of piriformis stretches.

➢ Helps to Alleviate Ankle and Knee Pain: When the piriformis muscle becomes tight the simple daily

activity of walking can be a real pain. The knee joint can be under too much strain creating an

unbalanced joint. The outside of the knee joint becomes too tight making the inside of the joint weaker.

This imbalance can lead to ankle and knee pain.

➢ Relieves Sciatic Pain: Previously mentioned the sciatic nerve runs through the piriformis area and

whenever there is added pressure due to tight piriformis muscles there’s a chance to experience sciatic

like pain. This miserable pain can make your hips and glutes numb or send shooting pain down your

legs. By relaxing the piriformis muscle, the strain on the sciatic nerve can be reduced.

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➢ Reduce Lower Back Pain: Tight piriformis and glute muscles can cause lower back pain. By relaxing

the piriformis muscles, you can reduce stress on your lower back as your hips will move with more range

of motion.

➢ Eases Plantar Fasciitis: Plantar fasciitis is when the fascia (a thin layer of connective tissue that has

nerves) becomes inflamed. People with very tight piriformis muscles can end up walking like ducks

which puts extra stress on the soles of the feet. Loosening up the piriformis can fix your body mechanics

thus reducing nagging injuries like plantar fasciitis.

➢ Reduce Risk of Injury: By stretching or exercising the piriformis muscles you will lower the chances of

experiencing potential injuries. People who enjoy sports or activities involving running or any sudden

change of direction need to stretch their piriformis muscles to avoid injuries or muscle tears.

➢ Better Overall Muscular Function: Tight piriformis muscles will cause limited range of motion in the

lower back and hips. Piriformis stretches and exercises can help us move better through a fuller range of

motion.

▪ RECOVERY PHASE

Goals

Strengthen the piriformis and surrounding muscles to support the hip and pelvis.

➢ Strengthening Exercises

Strengthening exercises that target the piriformis and larger buttock muscles are crucial for building

muscle strength and developing resilience in the lower back, pelvis, and hip. The piriformis muscle

plays a crucial role in proper body function. It aids in hip rotation, balancing, and lower body mobility.

Thus, maintaining adequate muscle strength in the piriformis is essential for an active and pain-free

lifestyle. Engaging in targeted strengthening exercises can help improve piriformis muscle strength,

reduce discomfort associated with piriformis syndrome, and enhance overall muscular balance.

One such benefit of strengthening the piriformis muscle is preventing and alleviating piriformis

syndrome. This condition occurs when the muscle becomes tight or spasms, irritating the sciatic nerve,

causing pain in the buttocks, and radiating down the leg. Although this condition is quite rare, it can be

60
 extremely painful and limiting. By incorporating strengthening exercises into a regular fitness routine,

individuals can alleviate the symptoms of piriformis syndrome and improve their overall quality of life.

Moreover, strong piriformis muscles contribute to better posture and body alignment. As the piriformis

muscle stabilizes the sacroiliac joint and pelvis, a strong piriformis muscle will reduce strain and stress

on the lower back and hips. This balance between muscle groups is particularly important for anyone

who performs repetitive or high-impact activities, as it helps to avoid overuse injuries. Additionally,

improved muscle strength in the piriformis can lead to enhanced athletic performance. Since the

piriformis muscle plays a vital role in hip movement, a well-conditioned piriformis can improve

efficiency and power in activities like running, jumping, and changing direction.

1. Bridging Exercise

To perform glute bridges, start by lying on the back with both legs straightened out and flat on the

ground. Slowly bend both knees while keeping feet flat on the ground and toes pointed straight forward.

Lay the arms flat on the side of the body with palms facing down. Slowly raise the hips while engaging

the abdominal and buttock muscles.

Lift the hips as high as possible, without pain, to make a straight line from the shoulder to the knee. Hold

this position for 5 seconds. Gently lower the hips back to the ground.

Begin holding the bridge position for 5 seconds initially and slowly work up to 30 seconds. Aim to

complete a set of three stretches daily.

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▪ Straight Leg Raise

To perform the straight leg raise exercise, start by lying on the back with legs straightened out and flat on

the ground. Bend one leg and place the foot flat on the floor. Raise the opposite leg making an angle of

approximately 45˚ with the floor. Hold the raised leg for 5 seconds and return to the starting position.

Hold the stretch for 5 seconds initially and slowly work up to 30 seconds. Repeat the exercise with the

opposite leg. Aim to complete one set of three stretches on each side.

▪ Side Leg Raise

To perform the side leg raise exercise, start by lying on the right side and placing a towel under the head

to support the head and neck. Place the right hand on the hip or in front of the waist to stabilize the upper

body. Extend the body to form a straight line with legs stacked on top of each other. Engage the core and

slowly begin to raise the right leg 10-15 inches away from the ground. Perform 10-15 leg raises and

repeat with the opposite leg. Aim to complete 3 sets of repetitions daily.

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▪ Clamshell Lifts

To perform the clamshell lift exercise, start by lying on the right side of the body with the right leg on

top of the left leg and knees slightly bent. Keep both feet together and lift the right knee until it’s parallel

with the hip. Engage the core and buttock muscles throughout the exercise. Slowly lower the right knee

back to the initial position. Perform 10-15 clamshell lifts and repeat with the opposite leg. Aim to

complete 3 sets of repetitions daily. A variation of this exercise is to use a resistance band around the

knees while performing the clamshell lifts.

▪ Bird Dog Exercise

To perform the bird-dog exercise, start by getting on all fours with arms and legs shoulder-width apart in

the quadruped position. Extend the right leg outward with a straight back and toes pointing away from

the body. Simultaneously, extend the left arm out in front of the body. Hold the stretch for 5 seconds

initially and slowly work up to 30 seconds. Repeat with the opposite arm and leg. Aim to complete one

set of three stretches on each side. Incorporating strengthening exercises into a daily routine effectively

improves muscle balance and alignment in the hip, thigh, and leg. Strengthening exercises help reduce

the strain on the piriformis muscle and prevent it from becoming tight spasming.

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➢ Kick Back

Get on your hands and knees with your hand stacked under your shoulders. Lift your sore leg up off the

ground then kick up and back away from you until your leg is fully extended. Slowly lower to starting

position. Repeat for desired reps then switch sides.

➢ Fire Hydrant

Get on your hands and knees. Lift leg out to your side as far as comfortable keeping your knee bent.

Lower back to starting position. Repeat for desired reps then switch side

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➢ Banded Lateral Walks

Place a resistance band around your thighs, just above your knees. Stand with your feet hip-width apart

and slightly bent knees. Step to the side, maintaining tension in the band, and then step the other foot to

meet it. Continue stepping side to side. 10-15 steps in each direction.

▪ HIP Hike

Stand on a yoga block using one foot, engaging your core for stability. Let the hip, that is in the air, drop,

use the elevated hip to lift your hips up. This activates your Gluteus Medius and provides gentle traction

to the piriformis muscle. Lower the hip back down with control, feeling the muscles at work, and raise

again.

65
➢ Seated Hip Abductions With Feet Externally Rotated

Place the band around your thighs, just above your knees. Keep your back straight. Support your upper

body with your arms if you need to. Slightly rotate your feet out. Engage your core to maintain stability.

You should feel the side of your hips working as you press against the band. Complete 8-10 slow and

controlled repetitions.

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▪ Advances in Strengthening Exercises for Piriformis Muscle

➢ Single-leg Romanian deadlift (RDL)

This exercise targets the hamstrings, glutes, and core while also working the piriformis. To perform the

single-leg RDL, stand on one leg with a slight bend in the knee and hinge forward at the hips, keeping

your back straight and your core engaged. Lower the weight towards the ground while lifting your back

leg behind you, then return to the standing position. Repeat for 10-12 reps on each leg.

-+

➢ Curtsy Lunge

This movement targets the glutes, hips, quads, and inner thighs. To perform a curtsy lunge, start standing

and cross one leg behind the other, bending both knees as if curtsying. Return to standing position and

repeat on the other side. Aim for 10-12 reps on each leg.

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➢ Lateral Step Downs On A Bosu Ball

Lateral step downs on a bosu ball are a great way to strengthen the hips and glutes while also challenging

your balance and stability. To perform this exercise, stand on a bosu ball with one foot and slowly lower

your other foot to the ground, tapping your toe before returning to the standing position. Repeat on the

other side for 10-12 reps. As you progress, you can add weight or increase the height of the step to make

the exercise more challenging.

RECENT ADVANCES IN PHYSIOTHERAPY INTERVENTIONS

➢ Pin and stretch technique

The pin and stretch technique is a movement-based muscle lengthening technique used in therapy. Pin

and stretch technique is also very effective at loosening tight areas within the piriformis for the patient

with piriformis syndrome, especially trigger points and taut bands located more laterally within the

muscle. To apply pin and stretch to the piriformis with the client prone, first relax and slacken the muscle

by passively laterally rotating the thigh at the hip joint, then place the contact into the muscle and apply

firm pressure to pin the muscle at that point, then stretch the pinned piriformis by medially rotating the

thigh at the hip joint.

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➢ Aerobic Exercises

Aerobic activities, also called endurance or cardiovascular exercises, involve the rhythmic movement of

large muscles for a sustained period of time. In treating piriformis syndrome, aerobic exercises can help

improve muscle function and increase blood flow to the buttock, pelvic, and hip areas, promoting

healing. Aerobic exercise is generally considered most beneficial when done for a minimum of 20 to 30

minutes, about 3 to 5 times a week.1 Running, brisk walking, bicycling, playing sports, dancing, and

swimming are common examples of aerobic activities.

• Water Therapy

Water therapy consists of exercises performed in a pool. Water therapy is especially beneficial in cases

where a land-based exercise program may be limited because of the intensity of the pain or disability.

Water counteracts the effect of gravity and helps support the body’s weight, and the buoyancy of water

makes it easier to perform an exercise.

• Walking

Walking is a simple yet effective way to treat piriformis syndrome and improve overall health. Walking

is a low-impact exercise that people of all ages and fitness levels can do. Walking helps strengthen the

muscles in the legs and buttocks, including the piriformis muscle. Walking reduces muscle tightness and

spasm in the piriformis, thereby improving lower back and hip flexibility.When starting a new walking

exercise routine, it is recommended to start slow and gradually increase the duration and intensity of the

walk.

➢ Integrated Neuromuscular Inhibition Technique

The patient was managed using INIT. In addition, stretching exercises were also administered to the

patient. Extension of techniques that are used to ameliorate somatic dysfunction.

According to Chaitow et al. , INIT involves the combination of two manual therapy techniques (muscle

energy technique - MET) and positional release technique - PRT) which must be delivered in a single

coordinated manner to achieve the most effective approach to treating trigger points (TrPs) and tissue

dysfunctions. Positional release technique has been investigated as one of the most effective manual

therapy techniques for the management of PS . This technique involves the identification of TrPs,

69
followed by the application of ischemic compression to reproduce the nociceptive response. The limb is

then placed in such a way as to minimize the tension in the affected muscle and subsequently, the painful

TrP is deactivated. The possible underlying

effect of TrP ischemic compression was documented by a study which indicated that pain and muscle

spasm relief from ischemic compression may be due to the reactive

hyperemia produced in the area of the lesion, or from the spinal reflex arc.

On the other hand, MET has also been indicated in the management of PS. The concept behind using

MET is to achieve sufficient muscle relaxation and lengthening either by using post-isometric relation

(PIR) or reciprocal inhibition (RI). Post-isometric relation refers to the immediate decrease in the tone of

the agonist muscles following isometric contractions that happens due to the effects of stretch receptors

(Golgi tendon organs) which react to excessive stretching of the muscles by counteracting longer muscle

contractions. This is a natural self-defense mechanism and has a lengthening effect due to the immediate

relaxation of the whole muscle under tension. On the other hand, RI refers to the inhibition of the

antagonist muscles due to isometric contractions of the

agonist muscles which happens due to stretch receptors within the muscle spindles which work to

maintain steady muscle length by providing information on the nature of the contraction. When stretched

out, muscle spindles produce nerve impulses, which augment contractions and thus prevent excessive

stretching. Better relief in pain and/or spasm in the muscles housing TrPs is achieved when MET is

applied while the muscle is in a stretched position It has been thought that all the effects of INIT due to

the administration of MET and PRT have significantly assisted in the restoration of pathological changes

of the piriformis muscle and also lessened compressive forces on the sciatic nerve.

Procedure :

The patient was placed in a prone position with the hip flexed to approximately 60° to 90° and abducted.

The treated leg (right leg) was allowed to hang off the table with the knee bent and resting on the thigh of

the physiotherapist who was seated on the tender point side. The tender point or trigger point (TrP) was

palpated in the fibers of the piriformis muscle from its attachment around the lateral angle of the sacrum

to the greater trochanter of the femur. Once the most dominant tender point or fasciculation (or both) was

determined, the therapist then used one hand to apply a light intermittent or sustained pressure with the

70
 pad(s) of the finger(s) at the location of the trigger point and maintain the pressure for 20 - 60 seconds.

Finetuning involving hip internal or external rotation by the therapist other hand based on the location of

the TrP was applied to maintain the position of most ease (position of less sensitivity). When referred or

local pain started to reduce in intensity, the compression treatment stopped and then the patient was

instructed to use no more than 20% of available strength to attempt to take the limb away from the

restriction barrier, while the therapist maintained his hands positions and held the patient’s limb firmly to

create isometric contraction which was maintained for 7 to 10 seconds. Following the contraction, a

reduction in tone was

achieved in the piriformis and then the hypertonic or fibrotic fibers were further stretched and lengthened

using Ruddy’s reciprocal antagonist facilitation (RRAF) method (8, 13). The patient was instructed to

push his against the therapist resistance for 20 counts in 10 seconds, starting and stopping, without

movement taking place, but a rather repetitive contraction and relaxation. These contractions activated

the hip flexors while producing an automatic reciprocal inhibition of the piriformis. Three repetitions

were performed for 10 minutes at two sessions a week for 6-weeks.

➢ Sciatic Nerve Mobilisation

Neural mobilization or nerve mobilization is a technique used for treating nerves that are irritated,

inflamed, or adherent. It consists of two methods: nerve gliding and nerve tensioning. Neural

mobilization helps in relieving the nerve and restoring the normal flow of impulse through it, thereby

reducing the symptoms.

Nerve gliding involves using two joints, and movement is performed in such a way that one joint is

moved causing elongation of neural structures at one end and shortening at the other end of the joint

simultaneously. Nerve tensioning involves executing joint motions that lengthen the nerve till symptoms

develop and then mobilizing with the articular joint distal to where symptoms are thought to originate.

Scholars say that the gliding technique provides less strain to the nerve than the tensioning technique,

whereas nerve excursion is more in the gliding technique than in the tensioning technique without the

potentially large increases in nerve strain. As the piriformis muscle spasms, the symptoms of sciatica are

most commonly observed. This can also be treated by piriformis stretching. Stretching enhances

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flexibility, physical performance, injury prevention, and muscular discomfort. Few of the many types of

piriformis stretching are SFCO stretching with coxal articulation flexion over 90° and muscle energy

technique (MET) application (SFCU) stretching with coxal articulation flexion under 90°. The patient

rests supine with both legs bent and one leg placed on the contrary side knee that will be graded for the

SFCO. The patient next bends his knee over 90° till he feels tightness in the same direction as the

stretched leg's shoulder and holds this position for 30 seconds. For SFCU, the patient in the supine

position crosses the leg to be stretched over to the opposite side knee. For 30 seconds, the individual

must touch the exterior of the knee of the leg being stretched with the contrary side hand and press the

knee toward the floor. In order to perform MET, the subject lies in the supine position, bends the coxal

articulation and knee joint of the leg being tested, and places the testing side foot outside the opposite

side knee so that the foot contacts the ground. The coxal articulation's flexion angle should not exceed

60°.The therapist limits pelvic movement by placing one hand on the opposite side's anterior superior

iliac spine. The therapist does abduction for 10 seconds with the opposite side hand outside the bent knee

and applies a pushing pressure during the piriform muscle contraction. Following contraction, the

therapist performs adduction until the resistance on the investigated leg is felt and is maintained for 20

seconds.

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PREVENTION

The most common etiology of piriformis syndrome is that resulting from a specific previous injury due

to trauma. Large injuries include trauma to the buttocks while "micro traumas" result from small repeated

bouts of stress on the piriformis muscle itself. To the extent that piriformis syndrome is the result of some

type of trauma and not neuropathy, such secondary causes are considered preventable, especially those

occurring in daily activities: according to this theory, periods of prolonged sitting, especially on hard

surfaces, produce minor stress that can be relieved with bouts of standing. An individual's environment,

including lifestyle factors and physical activity, determine susceptibility to trauma of any given type.

Although empirical research findings on the subject have never been published, many believe that taking

sensible precautions during high-impact sports and when working in physically demanding conditions may

decrease the risk of experiencing piriformis syndrome, either by forestalling injury to the muscle itself or

injury to the nerve root that causes it to spasm. In this vein, proper safety and padded equipment should be

worn for protection during any type of regular, firm contact (e.g. American football). In the workplace,

individuals are encouraged to make regular assessments of their surroundings and attempt to recognize those

things in their routine that may produce micro or macro traumas. No research has substantiated the

effectiveness of any such routine, however, and participation in one may do nothing but heighten an

individual's sense of worry over physical minutiae while have no effect in reducing the likeliness of

experiencing or re-experiencing piriformis syndrome.[citation needed]

Other suggestions from some researchers and physical therapists have included prevention strategies

including warming up before physical activity, practising correct exercise form, stretching and

doing strength training, though these are often suggested for helping treat or prevent any physical injury and

are not piriformis-specific in their approach. As with any type of exercise, it is thought that warmups will

decrease the risk of injury during flexion or rotation of the hip. Stretching increases range of motion, while

strengthening hip adductors and abductors theoretically allows the piriformis to tolerate trauma more readily.

73
PHYSIOTHERAPY ASSESMENT

ORTHOPEDIC PHYSIOTHERAPY EVALUATION FORM

Name: Date:

Age: Gender: M/F IP/OP

Occupation: Referred by:

Address: Phone Number:

Registration Number:

Civil Status: Diagnosis:

• Chief Complaints:

• Past Medical History:

• Personal History:

• Family History:

• Socioeconomic History:

• Symptoms History:

Side: Site:

Onset: Duration:

Type: Severity:

Aggravating Factors:

Relieving Factors:

74
Mark The Body Chart Deformities Or Joint Anomaly, Back Deformities or anomalies, Edema, Shoulder

Subluxation Etc.

• Pain Evaluation:

• Vital Signs:

Temprature: Heart Rate:

Blood Pressure: Respiratory Rate:

75
➢ Objective Evaluation

• On Observation

Built:

Wasting:

Oedema:

Any bandages, Scars:

Attitude of the Limbs:

Type of gait:

Bony contours:

Deformities:

• On Palpation

Tenderness

D/F tissue tension and texture:

Spasm:

Type of Skin:

Swelling:

Crepitus, Abnormal sounds:

• On Examination

1. Motor Assessment

• Range Of Motion (ROM)

JOINT MOVEMENT ACTIVE PASSIVE END FEEL LIMITATION

RT/LT RT/LT

HIP

KNEE

ANKLE

FOOT

76
• Manual Muscle Testing (MMT)

MUSCLES Right Left

HIP
Flexors
Extensors
Internal Rotators
External Rotators
Abductors
Adductors
KNEE
Flexors
Extensors
ANKLE
Plantarflexors
Dorsiflexors
FOOT
Invertors
Evertors
Extrinsic
Intrinsic

• Reflexes

Reflex Left Right

SUPERFICIAL Abdominal

Plantar

DEEP Biceps

Brachioradialis

Triceps

Knee

Ankle

77
• Muscle Girth

Area Right (cm) Left (cm)

Thigh

Calf

• Limb Length Discrepancies

Side Right Left

True

Apparent

2. Sensory Assessment

Pain:

Temperature:

Tenderness:

3. Gait Analysis

Stance Phase Base Width

Swing Phase Cadence

Step Length Gait Pattern:

Stride Length

4. Investigation:

5. Special Test:

6. Problem List:

78
7. Functional Diagnosis

8. Goals

Short Term Goals

Long Term Goals

9. Treatment Plan

10. Home Program

Date: Physiotherapist’s Name & Signature

79
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