PIRIFORMIS SYNDROME -Â Compression of the sciatic nerve by the piriformis muscle
Piriformis Syndrome Massage: Functions of the Piriformis:
- The piriformis restrains rapid internal rotation of hip ( occurs with running)
- The piriformis externally rotates femur when hipÂ is neutral or extended
- The piriformis horizontally abducts thigh when hip is flexed to 90 degrees
Piriformis Syndrome Massage: Anatomy – What Happens?
- Â The sciatic nerve supplies sensory and motor function to skin andÂ muscles of the posterior thigh, leg and foot.
- Â The Sciatic Nerve is made up of nerve roots L4-S2(S3)-Â it alsoÂ contains fibres from both the anterior and posterior divisions of the lumbosacral plexus.Â The sciatic nerve is comprised of 2 peripheral nerves ( common peroneal and tibial) which travel together until the knee.
- Piriformis muscle inserts on anterior surface of sacrum and medial greater trochanter.
- Sciatic nerve travels under the piriformis and goes distally. In 20% of people, the nerve runs through piriformis
- Increased tension in piriformis can lead to displacement ofÂ the sacroiliac (SI)Â joint ( pulling the SI away towards it <tense piri>) which leads to more trigger pointsÂ (TP) in piriformis and SI joint dysfunction
- TP in theÂ piriformis are often at lateral border of sacrum and 1/3 of the way medial from greater trochanter. ( closer to GT ) These TP cause the muscle to shorten and become bulkier, compressing the nerve.
CAUSES of Piriformis Syndrome:
- Â Anomalies in course of nerve ( penetrates piriformis muscle)
- Â Direct and indirect trauma to piri ( infl, ischemia, spasm, adh, tpâ€”all causing mm to tighten)
- Â Infammation in the piriformis or adjacent joints ( hip, SI)
- Overuse of the piriformis muscle
- Postural concerns ( flat feet cause internal rotation and adduction of the thighs when walking, piriformis overworks to correct this)
- Â Trigger points in piriformis ( main thing!)
- Â Prolonged compression of the nerve may cause sciatic nerve lesion which in turn causes atrophy of the muscles being supplied by the sciatic nerve
Â SYMPTOMS of Piriformis Syndrome:
- Usually unilateral
- Pain and paresthesia in the posterior thigh, calf, foot. If severe, loss of strength in lower leg, drop foot.
- Pain in the lower back, buttocks, hip and post thigh. Possibly in inguinal area and at greater trochanterÂ due to piriformis trigger points.
- Pain aggravated by: sitting, prolonged hip flexion, adduction and internal rotation, arising from seated position, standing.
- Pain decreased with passive external rotation of hip.. ( active external rotation will hurt â€“recruitment of the muscles)
- Weakness in abduction, flexion and internal rotation of the affected hip
- SI joint dysfunction due to theÂ shortening and tension in the piriformis
Piriformis SyndromeÂ Massage: OBSERVATION
- Guarding of affected limb
- Ataxic gait due toÂ pain
- Difficulty sitting/standing prolonged due toÂ pain
- Torsion of hips (Â because ofÂ SI joint dysfunction ) ( kind of rotated)
- When Supine,Â external rotationÂ of theÂ affected leg
- May be swelling in lower limb with extreme long-term nerve compression
Â Piriformis SyndromeÂ Massage: PALPATION
- Trigger Points and Hypertonicity in the piriformis, also in gluteals, quads, psoas, quadratus lumborum
- Tenderness over the piriformis
- Swelling at piriformis or lower limb ( edema- lack muscular pump)
Â Piriformis SyndromeÂ Massage: ORTHOPEDIC TESTING
- AF and PR ROM decreased in internal rotation of the affected hip
- AR testing of affected hip weak and painful
Â SPECIAL TESTS:
- Pace abduction test
- Piriformis length test
- Freiburgâ€™s Variation of SLR
- Gaenslenâ€™s PiriformisÂ Â Massage Therapy Treatment
Differentiating Radiating Pain:
ïƒ˜ Compression of nerve from herniated disc- similar symptoms. Valsalvaâ€™s, Kempâ€™s, Kernigâ€™s, Slump, SLR (+), no tenderness on the piriformis area, pain inÂ lower backÂ area
ïƒ˜ Facet Jt. Irritation â€“ Kempâ€™s/ Quadrants (+), no tenderness at the piriformis area.
Â Piriformis Massage Therapy Treatment:
- Treat around the Greater trochanterâ€”lots of muscle attachments
- Â Ligaments- sacrotuberous ( ischial tuberosity to the sacrum) to release sacrum..
- Â Fascial work over buttocks ( fascial spreading)
- Entire gluteal area treated using petrissage
- Treat glute max thoroughly so piriformis can be reached. Treat glue medius and minimus.
- General Massage Treatment – Along iliac crest, Around sacrum, Around gr. Trochanter
- Landmark piriformis, ask patient to externally rotate hip so that the piriformis muscle contracts.
- Treat piriformis usingÂ origin and insertion, Â finger kneading, muscle stripping, ischemic compressions to piriformis trigger points – follow up with piriformis stretch
- Passively rotate patient’s hipÂ internally and externallyÂ while applying pressure to piriformis ( with fist works well)
- To Stretch piriformis -Â ( move hip into internal rotation)
Piriformis SyndromeÂ Massage: SELF CARE
- Self stretch to the piriformis
- Tennis ball to glutes and piriformis
- Avoid sitting with knees rolling out to the side
- Sleep with pillow between knees to avoid internal rotation of the hip ( stretching the piriformis for too long will irritate it, better to be in neutral)
- Take breaks from aggressive activities/Â runningÂ to stretch
- Chiro adjustment for SI joint displacement