PIRIFORMIS SYNDROME

KASHISH SINGH
MPT 4 th SEM
INTRODUCTION

• Piriformis syndrome is a clinical condition of sciatic nerve entrapment

at the level of the ischial tuberosity. While there are multiple factors
potentially contributing to piriformis syndrome, the clinical
presentation is fairly consistent, with patients often reporting pain in
the gluteal/buttock region that may "shoot," burn or ache down the
back of the leg (i.e. "sciatic"-like pain).
ETIOLOGY
• Sciatic nerve entrapment occurs anterior to the piriformis muscle or posterior
to the gemelli-obturator internus complex at the level of the ischial tuberosity.
• The piriformis can be stressed due to poor body mechanics in a chronic
condition or an acute injury with the forceful internal rotation of the hip.
• Causes of piriformis syndrome include the following:
• Trauma to the hip or buttock area
• Piriformis muscle hypertrophy (often seen in athletes during periods of
increased weightlifting requirements or pre-season conditioning)
• Sitting for prolonged periods (taxi drivers, office workers, bicycle riders)
• Anatomic anomalies:Bipartite piriformis muscle
Contd.
• Sciatic nerve course/branching variations with respect to the
piriformis muscle In >80% of the population, the sciatic nerve courses
deep to and exits inferiorly to the piriformis muscle belly/tendon.
• Early (proximal) divisions of the sciatic nerve into its tibial and
common peroneal components can predispose patients to piriformis
syndrome, with these branches passing through and below the
piriformis muscle or above and below the muscle
EPIDEMIOLOGY
• Piriformis syndrome may be responsible for 0.3% to 6% of all cases of
low back pain and/or sciatica. With an estimated amount of new
cases of low back pain and sciatica at 40 million annually, the
incidence of piriformis syndrome would be roughly 2.4 million per
year. In the majority of cases, piriformis syndrome occurs in middle-
aged patients with a reported ratio of male to female patients being
affected 1:6.
PATHOPHYSIOLOGY
• The piriformis muscle is flat, oblique, and pyramidal-shaped. It originates anterior to
the vertebrae (S2 to S4), the superior margin of the greater sciatic foramen, and the
sacrotuberous ligament.
• The muscle then crosses through the greater sciatic notch and then hooks on the
greater trochanter of the femur.
• When there is an extension of the hip, the muscle acts primarily as an external
rotator, but when the hip is in flexion, the piriformis muscle acts like a hip adductor.
• The piriformis muscle receives innervation from nerve branches coming off L5, S1, and
S2. When the piriformis muscle is overused, irritated, or inflamed, it leads to irritation
of the adjacent sciatic nerve, which runs very close to the center of the muscle.
• Sciatic nerve entrapment occurs anterior to the piriformis muscle or posterior to the
gemelli-obturator internus complex, which is in line with the anatomical location of
the ischial tuberosity. Piriformis can be stressed due to poor body posture chronically
or some acute injury that results in a sudden and strong internal rotation of the hip.
TYPES OF PIRIFORMIS SYNDROME
• Primary piriformis syndrome - This designation would apply to
piriformis syndrome resulting from intrinsic pathology of the
piriformis muscle itself, such as myofascial pain, anatomic variations,
and myositis ossificans.
• Secondary piriformis syndrome (pelvic outlet syndrome) - This
classification would encompass all other etiologies of piriformis
syndrome, with the exclusion of lumbar spinal pathology.
SIGNS AND SYMPTOMS
• Patients with piriformis syndrome may present with the following:
• Chronic pain in the buttock and hip area
• Numbness
• Pain when getting out of bed
• Inability to sit for a prolonged time
• Pain in the buttocks that is worsened by hip movements

• Patients will often present with symptoms of sciatica, and it can often be difficult to
differentiate the origin of the radicular pain secondary to spinal stenosis versus the
piriformis syndrome. The pain may radiate into the back of the thigh, but at times it
may also occur in the lower leg at dermatomes L5 or S1.
• The patient may also complain of buttock pain, and typically the palpation may reveal
mild to moderate tenderness around the sciatic notch.
EVALUATION
• On physical examination, try to perform stretching maneuvers to irritate the
piriformis muscle. Furthermore, manual pressure around the sciatic nerve may
help reproduce the symptoms.
• These stretches include:
• Freiberg (forceful internal rotation of the extended thigh)
• Pace (resisted abduction and external rotation of the thigh)
• Beatty (deep buttock pain produced by the side-lying patient holding a flexed
knee several inches off the table)
• FAIR (flexion, adduction, internal rotation) maneuvers
• Some of the disorders that also need to be ruled out include facet arthropathy,
herniated nucleus pulposus, lumbar muscle strain, and spinal stenosis.
• Freiberg maneuver:-
• Starting position (SP): Supine position
• Movement: the physiotherapist passively positions the patient’s lower
limb in internal rotation in the hip joint, the knee joint remains in
extension.
• Interpretation: the test is positive when pain is provoked by
compression of the sciatic nerve.
• Pace maneuver test
• SP: sitting down with your legs down in 90°, your entire thigh resting on
the bench.
• Movement: hip abduction with resistance (therapist resists movement).
• Interpretation: with piriformis syndrome, pain in the buttock occurs
• Beatty maneuver
• SP: Lying on the painless side, lower limb set at 60° hip flexion and approx.
10° knee flexion.
• Movement: the patient actively abducts the lower limb (can also be
performed with resistance provided by the therapist).
• Interpretation: the test is positive when there is pain in the buttock but not
in the lumbar spine [42].
• FAIR test (flexion, adduction, internal rotation)
• SP: Supine position
• Movement: the physiotherapist passively positions the examined lower limb
– respectively: in flexion, adduction and internal rotation in the hip joint.
• Interpretation: Pain in the buttock area during the test indicates piriformis
syndrome
• Piriformis muscle flexibility test
• SP: lying on the untested side, at the edge of the bench, untested limb straightened
at the hip and knee joints.
• 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.
• Interpretation: in the case of pain in the buttock area or pain radiating along the
back of the lower limb test is considered positive.
• 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
Laseque’s sign can be performed – in order to exclude disorders, i.e. irritation of the
sciatic nerve or blockage of the sacroiliac joints
• Reference -Bartosz Barzak et al, The piriformis muscle syndrome – anatomy,
diagnosis and the role of physiotherapy. A Review ,2023
INVESTIGATION
• Diagnostic modalities such as ultrasound, MRI, CT, and EMG are
mostly useful in excluding other conditions, as above.
• The electrophysiologic approach(EMG) has been used to diagnose
piriformis syndrome by noting the presence of H waves.
• However, magnetic resonance neurography may show the presence
of irritation of the sciatic nerve just adjacent to the sciatic notch. At
this location, the sciatic nerve crosses just inferior to the piriformis
muscle.
DIFFERENTIAL DIAGNOSIS
• The differential diagnosis includes:
• Hamstring injury
• Lumbosacral disc injuries
• Lumbosacral discogenic pain syndrome
• Lumbosacral facet syndrome
• Lumbosacral radiculopathy
• Lumbosacral spine sprain
• Lumbosacral spondylolisthesis
• Lumbosacral spondylolysis
• Sacroiliac joint injury/dysfunction
• Inferior gluteal artery aneurysm or pseudoaneurysm
• Malignancy/tumors
• Arteriovenous malformations
TREATMENT
• Treatment includes :-
• short-term rest (not more than 48 hours),
• use of muscle relaxants,
• NSAIDs, and physical therapy (which entails stretching the piriformis muscle,
range of motion exercises, and deep-tissue massages).
• Ultrasound
• Hot packs or cold spray
• In some patients, injection of steroids around the piriformis muscle may help
decrease the inflammation and pain.
• Anecdotal reports suggest that botulinum toxin may help relieve symptoms.
However, the duration of pain relief is short-lived, and repeat injections are
required.
• Dry needling
• Acupuncture therapy
• Surgery(piriformis tenotomy and decompression of the sciatic nerve)
is the last consideration in patients with piriformis syndrome. It
should only be considered in patients who have failed conservative
therapy, including physical exercise. The surgery may help
decompress the nerve if there is any impingement, or the surgeon
may lyse any adhesions or remove scars from the nerve.
• However, the results after surgery are not always predictable, and
some patients continue to have pain.

• Reference -Neeraj Vij et al, Surgical and Non-surgical Treatment

Options for Piriformis Syndrome: A Literature Review,2021
• Mihiro Kaga 1, Takeshi Ueda 1 Effectiveness of Hydro-Dissection of the Piriformis
Muscle Plus Low-Dose Local Anesthetic Injection for Piriformis Syndrome,2022-
Hydro-dissection by ultrasound-guided injection of a very low concentration of
local anesthetic is effective and has lower risk of adverse effects, thus making it
more convenient for the treatment of piriformis syndrome than conventional
treatment methods, such as local anesthetic, steroids, and botulinum toxin
injection.
• Naveed Ahmad et al, Effectiveness of post facilitation stretch technique versus
myofascial release in piriformis syndrome: A Randomized controlled trial,2022-
Both myofascial release and post facilitation stretch technique were effective in
the treatment of piriformis syndrome. However, myofascial release was more
effective than post facilitation stretch technique for the mediation of pain
associated with piriformis syndrome.(Post facilitation stretch technique-
participant’s muscle of the affected side was positioned in the middle-range and
was advised to contract the “tightened muscle” isometrically against resistance
for at least “5 – 10 seconds”, followed by a rapid stretch in a new range which
was held for almost “10 seconds”. After this the patient was instructed to relax
for 10 seconds and the whole procedure was repeated “3 – 5 times”
POST OPERATIVE REHABILITATION
• Rehabilitation protocol
• Overall, we started the postoperative rehabilitation protocol the day
after surgery protecting the walking with crutches for 2 weeks until
the gait is normal and protect the wound during early healing.
• The range of motion of the hip is limited to 90° of flexion during the
first week to prevent pain and progressively increased.
• Similar caution was applied for internal rotation, external rotation of
30° and 30° of abduction for 3–6 weeks.
• Once the patient tolerates the walk with full support, therapy
progresses to achieve strength and full activity for 3–4 months.
PRECAUTIONS
• Athletes with piriformis syndrome may return to activities when they can demonstrate
the pain-free range of motion, increased strength of the affected side, and
performance without any discomfort.
• Patients must stretch and warm-up before the activity.
• The time to return to exercise or sporting events depends on the severity of symptoms
and the type of treatment undertaken. In general, the longer one does not seek
medical care or physical therapy, the longer is the course of rehabilitation.
• Patients with piriformis syndrome should adhere to the following:
• Avoid prolonged sitting
• Stretch exercises 2 to 3 times a day and before participating in sports
• The patient should be educated on a continual basis. Patients should be told about the
importance of maintaining compliance if they want a positive outcome.
• In most cases, recurrent pain can be prevented by performing stretching exercises for
at least 5 to 10 minutes prior to full participation and avoiding risk factors like
prolonged seating.
THANK YOU