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Piriformis Syndrome - Sciatica

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Charlotte Mills

on 19 September 2013

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Transcript of Piriformis Syndrome - Sciatica

Piriformis Syndrome - Sciatica
Background Information
Diagnosis and Treatment
Wrapping it Up
Epidemiology
Disc herniation (90%), spinal stenosis, pregnancy = common
PS = uncommon
Misdiagnosed due mimicking conditions
Sciatic compression due to soft tissue tension
Anatomical relationship between piriformis and sciatic
Overuse/trauma - shorten/spasm
Hip external rotator - stability
Sacrum - Greater trochanter
S1/2 inntervation
Inactivity + Overuse
Athletes = decreased lateral stretch/strengthen
Pudendal nerve
SIJ
Overpronation









Presentation
sharp, tingling pain 9/10
lower back and buttock area radiating down leg
numb spots throughout and in foot
worse with immobilizing
eased with walking
slightly antalgic due to TKR
difficulty with sit to stand and stand to sit
nil bowel and bladder dysfunction
Assessment/Diagnostic Tests
Medical Management
CONSERVATIVE: symptomatic relief of pain with NSAIDs, muscle relaxants and neuropathic pain agents

INJECTIONS (therapeutic): local anesthetic, corticosteroids, BTX or a combination

SURGERY: dissection of sciatic nerve or splitting of piriformis muscle
Clinical Reasoning
Physiotherapy
Goals = pain/symptom elimination and to regain normal function
1. Anti-inflammatory: rest, cryotherapy and electrical modalities
2. Gentle pain free stretching - vigorous stretching and heat subacute
3. Soft tissue mobilisation: increase piriformis extensibility
4. Strengthening: piriformis, surrounding muscles and core stability
5. Biomechanical corrections: through strengthening and stretching
6. Functional training: proprioception, balance, coordination
7. Home Program: independence, control and compliance
8. Modifications: temporary changes they may not expect
9. Manipulation: direct or indirect X for osteoporosis
10. Progression = essential
11. Intensity, frequency and duration should be individualised

Treatment Planning
1. 10min STM
2. 3x 2min Lumbar spine rotational PPIVMS in left side lying
3. Exercise prescription, education and facilitation
a) Piriformis stretch 30sec x 10 both sides twice daily
b) PPIVMS positional hold for 30sec x 10 twice daily
4. Reassessment = improved ROM and pain score
5. Discussed pain medication with doctors before D/C

Conclusion
Debilitating condition, impeding function
Physiotherapy = effective
lack of data and high quality up to date research
other treatment options as adjuncts to physio should be considered

References
Beaton, L.E., Anson, B.J. (1938). The sciatic nerve and the piriformis muscle: theirinterrelation a possible cause of coccygodynia. Journal of Bone Joint Surgery America. 20:686-688. Available at: http://www.ejbjs.org/cgi/reprint/20/3/686. Accessed September 9, 2008.

Benson, E.R., Schutzer, S.F. (1999). Posttraumatic piriformis syndrome: diagnosis and results of operative treatment. Journal of Bone Joint Surgery America. 81:941-949.

Benzon, H.T., Katz, J.A., Benzon, H.A., Iqbal, M.S. (2003). Piriformis syndrome: anatomic considerations, a new injection technique, and a review of the literature. Anesthesiology. 98: 1442-1448.

Chaitow L. (1988). Soft Tissue Manipulation: A Practitioner’s Guide to the Diagnosisand Treatment of Soft-Tissue Dysfunction and Reflex Activity. 3rd ed. Rochester, Vt: Healing Arts Press

Chang C.W., Shieh S.F., Li C.M., Wu W.T., Chang K.F. (2006). Measurement of motor nerve conduction velocity of the sciatic nerve in patients with piriformis syndrome: a magnetic stimulation study. Archives of Physical Medicine and Rehabilitation 87:1371–1375.

De Andres J., Cerda-Olmedo G., Valia J.C., Monsalve V., Lopez-Alarcon., Minguez A. (2003). Use of botulinum toxin in the treatment of chronic myofascial pain. Clinical Journal of Pain. 19:269-275.

DiGiovanna E.L., Schiowitz S., Dowling DJ. (2005). An Osteopathic Approach to Diagnosis and Treatment. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins.

Fishman L.M., Anderson C., Rosner B. (2002). BOTOX and physical therapy in the treatment of piriformis syndrome. American Journal of Physical Medicine and Rehabilitation. 81:936-942.

Fishman L.M., Dombi G.W., Michaelsen C., Ringel S., Rozbruch J., Rosner B. (2002). Piriformis syndrome: diagnosis, treatment, and outcome—a 10-year study. Archives of Physical Medicine and Rehabilitation. 83:295-301.


Case Description

BIBA with LBP referring down the back of right leg
6/52 post TKR
Outpatient rehab at Tamara Private - "pushing too hard"
Pain flare up whilst on low sitting stationary bike during rehab
Pain originating around L3-5 R) facet joints, worsening from the buttocks and down the leg
Pain worsens throughout the day and worst at night
Pt c/o tingling, P+N, numbness and general pain throughout right leg
GH: fibromyalgia and lymphodema accompanied by an extensive medication list for these conditions and other minor health problems



Definition
Peripheral neuritis of sciaitc nerve
Abnormal piriformis condition
Compression/irritation of sciatic nerve
Referred lower back/buttock pain, numbness & tingling
40-60yo
5-36% of LBP patients
Confused with other conditions
Women > Men
6-8% of sciatica cases

Aetiology & Pathophysiology
Symptoms
Pain/paresthesia radiating from sacrum through gluteal area, down post thigh, usually stops at knee
Pain improves with ambulation and worsens with no movement
Pain when rising from sit or squat
Change of position does not relieve pain completely
Contralateral sacroiliac pain
Difficulty walking (eg, antalgic gait, foot drop)
Numbness in foot
Weakness in ipsilateral lower extremity
Head, neck, abdominal, pelvic, and inguinal pain
Dyspareunia in women
Pain bowel movements

Signs
Tender SIJ, greater sciatic notch
Tender piriformis muscle
Palpable mass in same buttock
Traction provides moderate relief
Weakness in affected limb
Positive Lasègue, Freiberg, Beatty & Pace (FAIR) signs
Lumbosacral rotation towards contralateral side
Limited medial rotation of ipsilateral lower extremity
Ipsilateral short leg
Chronic gluteal atrophy
1. Physical Examination
Lasègue sign = localized pain when pressure is applied over the piriformis muscle
TOP of greater sciatic notch
Trigger point
Palpable mass
Gluteal atrophy
Reduced lumbar and hip ROM

No single test
Clinical diagnosis and exclusion
2. Neurological Examination
Thorough neuro examination should be performed
If weakness or sensory loss is found, PS diagnosis is unlikely except in chronic presentations

Specificity and sensitivity are unclear
1. Freiberg’s manoeuvre = internal rotation
2. FAIR manoeuvre = flxn, addn, IR - most reliable
3. Pace manoeuvre = abducting hip
4. Beatty test = side lying, lift leg


3. Provocative Manoeuvres
4. Diagnostic Modalities
CT, MRI, ultrasound and EMG to detect abnormalities and exclude other conditions.
1. MRI = enlargement of muscle and anatomic abnormalities
2. CT + US = detects lesions
3. EMG = show up as normal above piriformis and abnormal below. Can use in combination with special tests?

Formed a differential diagnoses:
1. Lumbar spine facet joint hypomobility
2. Lumbar spine disc herniation
3. Lumbosacral nerve root compression
4. Gluteal muscle dysfunction and inflammation
5. Erector spinae spasm or dysfunction
6. Piriformis syndrome
Piriformis + R) L/sp facet joint hypomobility

Case Conclusion
Represented to ED x2
CT showed widespread lumbosacral vert body degen
L4/5 disc herniation
Degen + disc + piriformis syndrome + fibromyalgia = complex
Rx slightly changed due to irritability
Mostly repeated due to previous effectiveness and easing qualities
Goals
1. Reduce pain
2. Improve patient comfort
3. Regain control of irritability
4. Regain normal ROM and functional movement
5. Improve muscle function
6. D/C pain free or near pain free
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