Piriformis Syndrome: Controversies Continue

By Carol Marleigh Kline, Editor, JACA Online

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he piriformis syndrome attracts controversy. And what you hear about it, says Stephen Perle, DC, depends on whos doing the talking. To the medical community, the controversy is straightforward: surgery or no surgery? To the chiropractic community, that particular controversy is predictably not very high on the list. As Dr. Perle says, Generally, its an easy condition to treat from a conservative standpoint. In the light of newer knowledge, however, there is 1 controversy that does affect chiropractic. The question is whether the condition currently called piriformis syndrome is properly namedand if not, what term that possibly suggests more treatment options comes closer to reality. Dr. Perle and Warren Hammer, DC, refer readers to a 2001 British Journal of Sports Medicine editorial by Peter McCrory that concludes with: Given the anatomical relationship of the piriformis to the various nerves in the deep gluteal region, it is possible that the buttock pain represents entrapment of the gluteal nerves, and the hamstring pain entrapment of the posterior cutaneous nerve of the thigh, rather than the sciatic nerve alone. This would explain the clinically observed phenomenon in the absence of distal sciatic neurological signs. Whether the piriformis muscle is the cause of the compression has not been clearly established. It is possible that the obturator internus/gemelli complex is an alternative cause of neural compression. For this reason, I suggest that sports medicine clinicians consider using the term deep gluteal syndrome rather than piriformis syndrome.1

formis is related to many other nerves in that area. In other words, he says, its not always the sciatic nerve thats involved and yet youre getting findings that appear to be related to that nerve. In 1 study, for example, they found that the internal obturator was more involved and pressing on the sciatic nerve than the piriformis actually was.2 Dr. Hammer lists all of the followingin descending orderas more powerful external hip rotators than the piriformis muscle: gluteus maximus, quadratus femoris, obturator internus, posterior fibers of the gluteus medius and the gluteus minimus, iliopsoas, obturator externus, and all of the adductors except the pectinius and gracilus. The piriformis, he says, is a very, very weak external hip rotator. For the sake of clarity, however, the condition will be referred to in this article as piriformis syndromeif only to coincide with what most doctors of chiropractic call it. Women, Athletes, and Everyone Else Women develop piriformis syndrome over men, 6:1. Why? No one seems to agree on a reason, although Dr. Perle offers the thought that women may be under-muscled in the area. Part of the problem lies in the fact that female and male athletes tend to focus on very specific movements. In other words, they dont develop muscles that go outside [a particular] plane of movement. Years ago, Dr. Perle treated a female weight lifter for a piriformis-related condition. The woman could squat 350 lbs., was about 54, and had very large, well-muscled thighsbut absolutely no strength when it came to hip abduction. Dr. Perle says all of her movements were essentially in the sagittal plane, which is true of runners, as welland thats why the condition is so common in that population: I think that alAPRIL2007

Dr. Hammer prefers the term deep gluteal syndrome because its extremely rare for the sciatic nerve to actually go through or above the piriformis muscle and because the piri2

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most every long-distance runner has [piriformis syndrome] to some degree. When runners train, Dr. Perle says, they tend to aggravate the piriformis by running in circles around a track. Remember that if youre doing something thats in 1 plane only, you still have to do something thats in other planes. If were talking about the hip joint, which is a ball and socket, it has to be controlled in all planes even if youre only moving in 1. Dr. Perle points out that many athletes who go to gyms never bother to strengthen their internal and external rotators because those arent known in body-building circles as mirror muscles. In other words, no matter how hard you work them, they arent something you can show off. Although Sheila Wilson, DC, president of the ACA Sports Council, says buttock pain can be the result of lumbar facet syndrome, spondylolisthesis, general myofascial pain, and even bursitis, she never overlooks the possibility that some kind of trauma is the culprit. Fifty percent of cases of piriformis syndrome have been attributed to traumaa fall, a sports injury, or blunt trauma to the area. She says it could easily result from a slip or a twist that the patient shrugged off when it happened. With athletes, it can come from a change in their training. With the regular patient population, it can be a change in lifestylea sudden increase in exercise or its oppositetoo much sitting. Dr. Wilson says it often develops because of a previous injury. Maybe that injury resulted in a little bit of a leg-length discrepancy, which can lead to lumbar and some sacroiliac joint dysfunction related to piriformis syndrome. Diagnosis by Exclusion: Testing Testing for piriformis syndrome causes further controversy because diagnosis by exclusion is a less-than-satisfactory approach. Dr. Wilson says that it can be frustrating because there
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arent any imaging studies or any specific tests that tell us, Yes, here it is. Dr. Perle says that although this condition is often diagnosed by exclusion, he tends to think piriformis when he sees an athlete simply because problems with the piriformis are so common.If the athletes got pain in the buttocks going down the back of the leg, you have to ask yourself, Is that disc? Or is it referral from a joint in the low back or the sacroiliac joint? You definitely want to rule those out. Paces sign or Freibergs sign are good ways to diagnose it.4 I think the simplest approach is just palpation. Put your thumb into the affected buttock and push. If it hurts, its probably the piriformis. But, he says, thats not necessarily a clear-cut indication, and symptoms should not be used to determine a diagnosis. No tests currently in use are 100% dependable but they are improving. Dr. Perle likes to use the FAIR test (flexion, adduction, internal rotation) to detect compression of the sciatic nerve at the piriformis. The FAIR position entails placing the patient side-lying with the involved extremity up. The patients involved extremity is then brought into a position of flexion, adduction, and internal rotation; pain is elicited at the intersection of the sciatic nerve and the piriformis during the test. That test result, he says, is considered positive. The FAIR test has been demonstrated to have a sensitivity of .88, a specificity of .83. Thats a positive likelihood ratio of 5.2 and a negative likelihood ratio of .14. Those figures are actually phenomenal from a clinical epidemiological perspective. His preference for the FAIR test comes from the fact that the whole concept behind the test is that it puts significant pressure on the piriformis, says Dr. Perle. External/Internal Rotators Dr. Hammer says that a doctor of chiropractic who is testing a patient with buttock pain
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should keep in mind the change of function the piriformis muscle undergoes as the hip flexes. Lets say the patient is lying supine and the leg is straight. During hip flexion from 0 degrees to around 60 degrees, the piriformis acts as an external hip rotator. Past 60 degrees, especially as you get into increased flexion, it functions as an internal hip rotator. So, he says, if a DC uses muscle testing or tries to aggravate the piriformis by stretching, results depend on what angle of hip flexion youre at when you perform these tests. The following is a quick-reference guide. Controversy exists in this area, as well. With hip flexion at 60 degrees, says Dr. Hammer, some people say the piriformis is a pure abductorits not necessarily considered an internal or external rotator. So with the patient supine and the hip flexed 60 degrees and the knee flexed, you can passively adduct the thigh at the knee. By passively adducting it, he adds, you could see the resistance because if its tighter during adduction than the other side, you could possibly say its the piriformis because its a pure adductor on that side. Dr. Hammer adds that Pecinas3 study suggests that if the sciatic nerve passes between the 2 tendinous heads of the piriformis, stretching the piriformis may compress the nerve and elicit symptoms; and causing the piriformis to contract by way of a muscle test may increase the space and actually reduce the pain. Above all, he says, the doctor will want to go into the sciatic area where the piriformis is and be able to press it and reproduce the pain. A good way to palpate the piriformis is with the patient on his side with the involved hip up. The patient flexes the hip, and you palpate at the midpoint between the ischeal tuberosity and the greater trochanter. This position seems to displace the gluteus maximus superiorly to partially uncover the sciatic notch for palpation of the piriformis and sciatic nerve. Youll also look for the trigger points around the area that
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might be tender to palpation because this is a site for a lot of referred pain. Treatment Although ice and passive stretching are the accepted approaches to an acute condition of this type, most patients who come to a doctor of chiropractic with piriformis-related pain have already moved into the chronic phase, for which a variety of treatments are available. Dr. Perle says that a plus for working the piriformis as a DC is that even with chronic cases, its possible to help the patient considerably with very few visits. One of his runner patients had had sciatica-like symptoms for 6 to 9 months that sent her to orthopedists, neurosurgeons, neurologists, a physiatrist, a podiatrist, and 2 physical therapists. After her 1st visit with Dr. Perle, she was 75% better, he says. I basically treated her for 4 visits. Dr. Perle goes after a myofascial trigger point in the piriformis with post-isometric relaxation. He believes that Graston technique could be effective at this point, but he usually prefers to take up the slack and increase the muscles length after the muscle relaxes. Dr. Hammer also likes to use post-isometric relaxation technique, again depending on whether the muscle is acting as an internal or external rotator, or both. He also tends to use Graston technique to break down restrictions in the connective tissue fascia that surround the nerves and tissues in the area, followed by a stretching technique. When you stimulate the tissue with Graston technique or increase the fibroblastic proliferation, which helps you create new collagen and extracellular matrix, stretching helps all of this new-formed tissue to form in the normal lines of stress, creating normal remodeling, he adds. Dr. Wilson also uses soft-tissue mobilization, myofascial release techniques, stretching, strengthening exercises, and ultrasound.
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Another aspect of treatment, says Dr. Perle, could be properly made orthotics. He recommends that doctors of chiropractic identify good local podiatrists both from the standpoint of making sure patients get expert care and because referring to a podiatrist establishes a relationship: A podiatrist who receives a referral is likely to send patients back to a doctor of chiropractic. Runners, he says, should keep in mind that shoes will make or break them. A lot of people tend to put too much mileage on a shoe. The shoe breaks down, and the runner hyperpronates. That puts the leg into internal rotation, which then places the piriformis under more tension. For scheduling proper shoe rotation, Dr. Perle suggests the following site: http://runningshoesresearch.com/2006/02/. Rehabilitation A patient who would rather avoid a recurrence of piriformis syndrome will need to perform stretching and strengthening exercises at home or on the road. Although Dr. Perle says evidence for the value of stretching before strengthening exercises is weak at best, he suggests that patients still stretchperhaps after completing the exercises. He says he often suggests rubber tubing for strengthening exercises. For example, the patient will stand, knee bent, with rubber tubing thats attached to something off to the side and looped around the ankle. The patient then performs internal rotation exercises. You want to get the patient to strengthen the piriformis and strengthen the area around the hip, says Dr. Perle. An exercise I recently learned from Stuart McGill, a PhD biomechanist, is one Ive been teaching my students. He calls it glute airplanes. Imagine a person standing on 1 leg, bent over at the hip. The upper body and the other leg are almost parallel to the floor. The patient does hip internal and external rotation, but the hips now at 90 degrees, so its really horizontal adducJOURNALOFTHEAMERICANCHIROPRACTICASSOCIATION

tion/abduction. Its an excellent exercise using body weight alone to strengthen the glutes, piriformis included. All the external rotators do a little abduction. But in the horizontal position, they do a little more horizontal abduction. Dr. Wilson says one of her favorites, one thats easy to describe to a patient, is to cross the affected leg over the other one and bend forward. A patient will feel the stretch in the gluteal area, in the piriformis, and in the hip rotators, she says. That should be followed by crossing the non-affected leg over the affected leg and repeating the stretch. Like Dr. Perle, she recommends an exercise program made up of stretching and strengthening exercises using tubing or Therabands. Dr. Hammer says that some good resistive internal or external rotation hip exercises can help avoid future problems. Piriformis and Pregnancy Anne Packard Spicer, DC, works primarily with pregnant women and babies. She sees a great deal of piriformis syndrome among her pregnant patients, although she, like Dr. Perle, does not assume that she knows what shes dealing with simply because the symptoms are there. But for most of her patients, piriformis syndrome is the result of lordosis that develops from the shifting center of gravity that puts womens hips into a more flexed position, and the hormone relaxin that causes pelvis stretch and possibly more open sacroiliac joints. Those things combined, she says, wreak havoc on the piriformis. Hormone changes are both good and bad from the DCs point of view. Relaxin makes a womans joints so loose they tend not to hold an adjustment. We can adjust, and then she rolls over in bed, gets out of a chair, or climbs out of a carand it goes out of alignment. We can get excellent pain relief, but were not going to get rehabilitation during pregnancy.
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If a patient is not getting stable pain relief, Dr. Packard Spicer says a trochanteric belt is a possibility. For some, she says, it sounds counter-intuitive because it also compresses slightly on the piriformis, but because its approximating the origin insertion of the piriformis, that is a better benefit than whatever negative effect there may be from compression. During the 8- to 12-week postpartum period, the flow of relaxin into the bloodstream gradually diminishes, causing joints to become increasingly tight until they are normal again. So, she says, we have an opportunity in that phase to reposition spinal and pelvic segments and have them tighten up in a more and more normal position than they might have been previously. In that regard, relaxin provides a great benefit. Some women who do not suffer from piriformis syndrome during their pregnancies, says Dr. Packard Spicer, will develop it as a result of the positions they assume during labor. A cesarean section or other type of surgical delivery also increases the likelihood that the piriformis will be compromised. Rehabilitation Dr. Wilson says that she has seen pregnant women develop not just unilateral piriformis syndrome but an extremely painful bi-lateral spasm. For these patients, she recommends a stability ball and pelvic tilt exercises.

Dr. Packard Spicer emphasizes the importance of movement during rehabilitation. Exercise is critical. The bodys not made for sitting for long periods of time. Its made for movement. Life is movement. She says that even though new mothers dont want to move much during the early postpartum period because they are still recovering and because they arent getting enough sleep with a new baby in the house, thats exactly the time to keep movement in mind.. Standing and holding the baby and rocking the pelvis around and doing some stretches in the upright posture are great. There are stretches we do stretching buttocks, stretching the glutes and piriformis equally, hip stretches, and low-back stretches. All of that makes a difference.
Dr. Hammer is in private practice in Norwalk, Connecticut. He is also the author of Functional Soft Tissue Examination & Treatment by Manual Method, 3rd ed., Sudbury, Mass., Jones & Bartlett. 2007. Dr. Anne Packard Spicer is an associate professor and senior clinician at Northwestern Health Sciences University, and is in private practice in Bloomington, Minnesota. Dr. Perle is a professor at Bridgeport University School of Chiropractic. He is also the author of the segment on piriformis syndrome in Hyde and Gengenbachs 2nd edition of Conservative Management of Athletic Injuries, published by Jones & Bartlett in 2007. Dr. Sheila Wilson is in private practice in Indianapolis, Indiana.

References
1. McCrory P. The piriformis syndromemyth or reality? Brit J Sports Med 2001 Aug;535(5):209-10. 2. Windisch G, Braun EM, Anderhuber F. Piriformis muscle: clinical anatomy and consideration of the piriformis syndrome. Surg Radiol Anat 2007 Feb;29(1):37-45). 3. Pecina MM, Krntotic-Nemanic J, Markiewitz AD. Tunnel Syndromes: Peripheral Nerve Compression Syndromes. 2nd ed. Boca Raton FL: CRC Press;1997. 4. Cleland J. Orthopedic Clinical Examination: An Evidence-based Approach for Physical Therapists. Carlstadt NJ: Icon Learning Systems. 2005.

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Functional Testing of Piriformis

Passive Testing Range 0 to 60 degrees 60 degrees+ What Tested External rotation Medial rotation How Tested/Aggravated Internal hip rotation External hip rotation/adduction

Resisted Testing Range 0 to 60 degrees 60 degrees+

What Tested External rotation Internal rotation

How Tested/Aggravated Hip at zero degrees, patient supine, knee flexed to 60 degrees Patient supine, knee and hip flexed and tested past 90 degrees

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