Piriformis syndrome

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Piriformis syndrome
Classification and external resources
Nerves of the right lower extremity Posterior view.
eMedicine pmr/106 

Piriformis syndrome is a neuromuscular disorder that occurs when the sciatic nerve is compressed or otherwise irritated by the piriformis muscle. This causes pain, tingling and numbness in the buttocks and along the course of the sciatic nerve. The syndrome may result from anatomical variations in the muscle-nerve relationship, or from overuse or strain. Recent uncontrolled studies advanced theories behind the disorder. However, following a large scale formal prospective outcome trial using Class A study design as outlined by the American College of Physicians, the weight of the evidence based medicine is that piriformis syndrome should be considered as a possible diagnosis when sciatica occurs without a clear spinal cause [1][2]

The need for controlled studies is supported by studies of spinal disk disease that show a high frequency of abnormal disks in asymptomatic patients.[3][4]

Contents

[edit] Pathophysiology

In 15% of the population the sciatic nerve passes through the piriformis muscle,[5] rather than underneath it. These people have been reported by some studies to have a greater incidence of piriformis syndrome than does the general population. Some researchers discount the importance of this relationship in the etiology of the syndrome.[6]

Inactive gluteal muscles also facilitate development of the syndrome. These are important in both hip extension and in aiding the piriformis in external rotation of the femur. A major cause for inactive gluteals is unwanted reciprocal inhibition from overactive hip flexors (psoas major, iliacus, and rectus femoris). This imbalance usually occurs where the hip flexors have been trained to be too short and tight, such as when someone sits with hips flexed, as in sitting all day at work. This deprives the gluteals of activation, and the synergists to the gluteals (hamstrings, adductor magnus, and piriformis) then have to perform extra roles they were not designed to do. Resulting hypertrophy of the piriformis then produces the typical symptoms.

Another purported cause for piriformis syndrome is stiffness, or hypomobility, of the sacroiliac joints. The resulting compensatory changes in gait would then result in shearing of one of the origins of the piriformis, and possibly some of the gluteal muscles as well, resulting not only in piriformis malfunction but in other low back pain syndromes as well.

Piriformis syndorme can also be caused by an overpronation of the foot.[7] When a foot overpronates it causes the knee to turn medially causing the piriformis to activiate in prevention of over rotating the knee. This causes the piriformis to become overused and therefore tight eventually leading to piriformis syndrome.

It is most frequently associated with fall injury.[8]

[edit] Other presentations

In addition to causing gluteal pain that may radiate down the leg, the syndrome may present with pain that is relieved by walking with the foot on the involved side pointing outward. This position externally rotates the hip, lessening the stretch on the piriformis and relieving the pain slightly. Piriformis syndrome is also known as "wallet sciatica" or "fat wallet syndrome," as the condition can be caused or aggravated by sitting with a large wallet in the rear pocket. [9]

[edit] Treatment

Treatment usually begins with stretching exercises and massage, and the avoidance of contributory activities such as running and bicycling. Some clinicians recommend formal physical therapy, including the teaching of stretching techniques, manual massage, and strengthening of the core muscles (abs, back, etc.) to reduce strain on the piriformis muscle. Recommended stretching exercises will usually target the piriformis muscle, but may also include the hamstrings and hip muscles, in order to adequately reduce pain and increase range of motion.

Patients with piriformis syndrome may also find some pain relief from ice and heat. Ice can be helpful right when the pain starts or immediately after an activity that usually causes pain (e.g., going up stairs). The ice may be in the form of an ice pack held to the area or an individual ice cube used in combination with a massaging motion. A heating pad may be alternated with the ice for relief from the pain.

Anti-inflammatory drugs (such as ibuprofen or naproxen) and/or corticosteroid injections can be used. Occasionally surgery may be recommended. The prognosis with treatment is generally good. Custom foot orthotics also help with the treatment and prevention. By correcting a persons gait, the use of the piriformis muscle is greatly reduced allowing the muscle to relax and heal itself. Ultrasound is another option for treatment as it speeds up the healing process.

Minimal access surgery using newly reported techniques has also proven successful in a large scale formal outcome published recently.[10]

[edit] See also

[edit] References

  1. ^ Filler AG, Haynes J, Jordan SE, et al (2005). "Sciatica of nondisc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment". Journal of neurosurgery. Spine 2 (2): 99–115. PMID 15739520. 
  2. ^ Lewis AM, Layzer R, Engstrom JW, Barbaro NM, Chin CT (2006). "Magnetic resonance neurography in extraspinal sciatica". Arch. Neurol. 63 (10): 1469–72. doi:10.1001/archneur.63.10.1469. PMID 17030664. 
  3. ^ Deyo RA, Weinstein JN (2001). "Low back pain". N. Engl. J. Med. 344 (5): 363–70. doi:10.1056/NEJM200102013440508. PMID 11172169. 
  4. ^ NEJM -- Table 2. Retrieved on 2007-11-16.
  5. ^ sciatic_2_roots
  6. ^ Benzon HT, Katz JA, Benzon HA, Iqbal MS (2003). "Piriformis syndrome: anatomic considerations, a new injection technique, and a review of the literature". Anesthesiology 98 (6): 1442–8. PMID 12766656. 
  7. ^ Colorado Runner -- Feature Article. Retrieved on 2007-11-16.
  8. ^ Kuncewicz E, Gajewska E, Sobieska M, Samborski W (2006). "Piriformis muscle syndrome". Annales Academiae Medicae Stetinensis 52 (3): 99–101; discussion 101. PMID 17385355. 
  9. ^ Piriformis Syndrome (Hip/Buttocks Pain)
  10. ^ http://www.jnsonline.org/spine/issues/v2n2/toc.html

[edit] External links

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