Piriformis Syndrome and Osteopathy: An Integrative Approach

Introduction

Piriformis syndrome, a delicate and sometimes overlooked condition, is characterized by compression or irritation of the sciatic nerve by the piriformis muscle. This pear-shaped muscle, which extends from the sacrum to the upper part of the femur, plays a crucial role in external rotation of the hip. Despite its small size, the piriformis can have a significant impact on the quality of life of individuals when it is involved in the development of the syndrome.

Symptoms of piriformis syndrome are diverse and may include localized pain in the gluteal region, numbness or tingling down the leg, and muscle weakness in the affected area. These manifestations can disrupt daily activities and limit mobility, creating an often painful experience for those who suffer from them.

The underlying causes of piriformis syndrome are varied. They can result from muscle tension from prolonged sitting, injuries, muscle spasms, or even repetitive activities that overuse the piriformis muscle. Diagnosing this condition can sometimes be complex due to the similarity of its symptoms to other lower back conditions, emphasizing the importance of a thorough medical evaluation.

Among the different therapeutic approaches aimed at relieving the symptoms of piriformis syndrome, osteopathy stands out as a holistic approach that seeks to restore the structural balance of the body. Osteopathic practitioners take a personalized approach, taking into account the severity of the situation, the patient’s medical history and underlying factors.

Osteopathy is based on a thorough understanding of the anatomy and mechanisms of piriformis syndrome. Osteopathy sessions may involve gentle joint manipulation, muscle stretching, and other techniques aimed at reducing tension and restoring mobility. By working on the entire body, osteopaths seek to identify and correct structural imbalances that could contribute to piriformis syndrome.

Historically, piriformis syndrome was introduced into medical terminology by British surgeon Sir Herbert William Ralston Yeoman in 1928. Since then, osteopathy has positioned itself as an effective complementary approach to relieving the symptoms associated with this condition.

Consulting a competent osteopath can provide several benefits, including an accurate diagnosis, designing a treatment plan tailored to the patient’s individual needs, and improving overall well-being. Collaboration between patient and osteopath plays an essential role in the healing process, allowing a better understanding of the triggering factors and contributing to an integrated approach to the management of piriformis syndrome. By choosing osteopathy, individuals can explore a holistic therapeutic pathway to alleviate the symptoms of this delicate condition.

Anatomy of the piriformis

The piriformis is a small muscle located deep in the pelvic region. It originates on the anterior surface of the sacrum, at the level of the S2 to S4 vertebrae, as well as on the sacrotuberal ligament. From there, it extends diagonally toward the upper portion of the greater trochanter of the femur, where it inserts.

The main function of the piriformis is to participate in the external rotation of the hip, thereby contributing to the stability of the hip joint. It is primarily innervated by the sciatic nerve, which may pass through or underneath the muscle in some people. Notably, due to its proximity to the sciatic nerve, excessive tension or contraction of the piriformis can sometimes lead to piriformis syndrome, causing pain and numbness along the path of the sciatic nerve.

The Crossing of the Sciatic Nerve by the Piriformis Muscle: Anatomical Variations

The sciatic nerve, an essential component of the peripheral nervous system, plays a crucial role in transmitting signals between the spinal cord and lower extremities. Its complex route through the human body can be subject to various anatomical variations, one of them being the crossing of the piriformis muscle. The piriformis, a small pear-shaped muscle located in the pelvic region, can sometimes become an unwitting player in sciatic nerve problems. In 10 to 20% of the population, the sciatic nerve passes through the piriformis muscle, creating a situation conducive to specific clinical manifestations. The interaction between the sciatic nerve and the piriformis muscle can result in symptoms such as sciatic pain, muscle stiffness, and even numbness in the lower extremities. Researchers have studied this condition to better understand its underlying mechanisms and improve treatment approaches.

Some studies, notably those carried out by Pecina et al. (1991), Szabo (1989) and Travel, Simons (1992), examined the prevalence of sciatic nerve crossing by the piriformis muscle. This work made it possible to determine that this anatomical variant is not rare, affecting a significant part of the population. When the sciatic nerve passes through the piriformis, it can be exposed to increased pressure, leading to unpleasant symptoms. Compression of the nerve can cause shooting pain along its path, often felt in the buttocks, lower back, and leg. Patients sometimes report a tingling or numbness sensation, which can compromise their daily quality of life. Health professionals, particularly osteopaths, play an essential role in managing problems related to the crossing of the sciatic nerve through the piriformis. Treatment approaches may include manual techniques to release muscle tension, improve nerve mobility, and relieve associated pain.

https://www.youtube.com/embed/XEk8pIu51NU?feature=oembed&enablejsapi=1Anatomy of the Piriformis

Pain cycle

Vicious cycle where excessive muscle contraction leads to compression of the sciatic nerve, causing impaired nerve transmission, which in turn can further influence muscle contraction.

In the specific context of the piriformis and sciatic nerve, this interaction may contribute to piriformis syndrome. When the piriformis muscle contracts excessively, it can compress the sciatic nerve, causing symptoms such as pain and numbness. These symptoms can in turn lead to a protective response, inducing an increase in muscle tension, which worsens the compression of the nerve and intensifies the symptoms. This cycle continues, creating a complex interrelationship between muscle contraction and impaired nerve transmission.

Mechanism of sciatic nerve compression

The mechanism of sciatic nerve compression in piriformis syndrome is generally associated with the anatomical proximity of the piriformis muscle to the nerve. Here’s how compression can occur:

1. Sciatic Nerve Passage: The sciatic nerve, which is the largest nerve in the body, usually passes under or through the piriformis muscle in the deep region of the buttocks.
2. Anatomy Varies: The anatomical relationship between the piriformis and the sciatic nerve can vary from person to person. In some cases, the sciatic nerve may pass through the muscle, while in other cases it may pass just underneath.
3. Muscle Contractions: The piriformis can spasm or contract involuntarily, often in response to overuse of the muscle, trauma, or strain. These contractions can cause the muscle to tighten.
4. Nerve Compression: When the piriformis muscle contracts excessively or for a prolonged period, it can put pressure on the sciatic nerve that passes nearby. This compression can cause irritation of the nerve, leading to symptoms such as pain, tingling, or numbness along the nerve’s path.
5. Inflammation and Swelling: Chronic compression can lead to inflammation of the sciatic nerve. Inflammation can increase pressure on the nerve, worsening symptoms and creating a vicious cycle of compression and inflammation.

Piriformis Syndrome vs. Piriformis Myofascial Syndrome: Two Close, But Distinct Conditions

Although Piriformis Syndrome and Piriformis Myofascial Syndrome share some symptoms and can be confused due to their anatomical proximity, they are two distinct conditions.

Piriformis syndrome is mainly characterized by compression or irritation of the sciatic nerve by the piriformis muscle, located in the gluteal region. This compression can cause pain in the lower back, buttocks and sometimes down the leg, mimicking the symptoms of sciatica. Risk factors for piriformis syndrome include prolonged sitting, specific physical activities, and muscle imbalances.

Piriformis myofascial syndrome , on the other hand, focuses on trigger points or muscle knots (trigger points) in the piriformis muscle. These trigger points can cause local pain, but they can also cause distant pain, making the differentiation between piriformis myofascial syndrome and other conditions, including piriformis syndrome, sometimes complex. Myofascial triggers can be caused by trauma, repeated strain, or overuse of the muscle.

Piriformis myofascial syndrome

Myofascial syndrome is characterized by the presence of trigger points, which are sensitive and tense areas in the muscles. When myofascial syndrome affects the piriformis muscle, it is often referred to as “piriformis myofascial syndrome.” In this condition, trigger points in the piriformis muscle can cause local pain in the gluteal region and can also lead to referred pain in the lower back, hips, and even along the sciatic nerve.

Treatment for piriformis myofascial syndrome may involve approaches to release tension in the muscle, reduce inflammation, and relieve trigger points. Massage techniques, stretching, physical therapy, and in some cases, trigger point injections may be used to alleviate symptoms.

Two localized trigger points

1. At the level of the lateral border of the sacrum and approximately one third of the medial part of the greater trochanter.
2. They involve the sacroiliac region, the buttocks and the hip joint, and sometimes extend to the proximal two thirds of the posterior part of the thigh.

In the presence of trigger points in the piriformis, the muscle tends to shorten and increase in volume, resulting in compression of the sciatic nerve.

The pain resulting from this compression spreads along the posterior aspect of the thigh to the calf and the sole of the foot. Therefore, pain can emanate from various sources simultaneously.

Causes of piriformis syndrome

Several factors can contribute to the development of this syndrome. First, physical trauma, such as falls or sports injuries, can cause inflammation of the piriformis muscle, leading to compression of the nerve. Additionally, muscular imbalances, often linked to a sedentary lifestyle or inadequate postural habits, may also play a role in piriformis syndrome. People who spend long hours sitting or have improper lifting habits can overstrain this muscle, contributing to its inflammation. Additionally, anatomical variations, such as the abnormal position of the sciatic nerve relative to the piriformis muscle, may increase predisposition to this syndrome. Additionally, certain repetitive activities, such as running, can also be a trigger. By understanding these different potential causes, it becomes possible to implement prevention and management strategies for piriformis syndrome, ranging from correcting postural habits to targeted exercises aimed at strengthening the muscles involved.

1. Individual Anatomy: The anatomical arrangement of the sciatic nerve in relation to the piriformis muscle can vary from person to person. Some individuals may have anatomy that increases the risk of nerve compression.
2. Overuse: Strenuous or repetitive physical activities, such as running, cycling, or other exercises that strain the piriformis muscle, can cause overuse of the muscle, leading to strain and compression of the nerve.
3. Trauma: Traumatic injuries, such as falls on the buttocks, car accidents, or sports injuries, can damage the piriformis muscle or cause muscle spasms that lead to compression of the sciatic nerve.
4. Muscle Contractions: Prolonged muscle contractions or spasms of the piriformis can result from strain, trauma, or excessive activity, leading to compression of the nerve.
5. Prolonged sitting: A sedentary lifestyle with long periods of sitting can contribute to muscle weakness and stiffness in the piriformis, thereby promoting the development of the syndrome.
6. Inflammation: Inflammation of the piriformis muscle due to trauma, infections, or inflammatory conditions can contribute to sciatic nerve compression.
7. Underlying musculoskeletal conditions: Disorders such as scoliosis, spinal abnormalities, or other musculoskeletal conditions can influence posture and muscle function, contributing to piriformis syndrome.
8. Heredity: There may be a genetic predisposition to develop musculoskeletal disorders, including piriformis syndrome.

It is important to note that piriformis syndrome can result from several of these factors combined. The presence of these causes does not necessarily guarantee development of the syndrome, and many people may have similar anatomy or activities without experiencing symptoms.

Symptoms of piriformis syndrome

Piriformis syndrome manifests itself by various symptoms, mainly linked to compression of the sciatic nerve by the piriformis muscle. One of the most common symptoms is localized pain in the gluteal region, often described as deep and throbbing. This pain may extend along the sciatic nerve, radiating down the leg to the foot, creating a burning or tingling sensation. People with piriformis syndrome frequently have difficulty sitting for long periods of time, as this often worsens the compression of the nerve. Additionally, the pain may intensify during specific activities such as walking, running, or climbing stairs. Muscle weakness in the affected leg may also be seen, sometimes accompanied by muscle cramps. Symptoms of piriformis syndrome may be made worse by prolonged sitting or sudden movements. Recognizing these signs is crucial for early diagnosis and appropriate intervention. Treatment approaches often include stretching and strengthening exercises, physical therapies, and in some cases, anti-inflammatory medications or corticosteroid injections. Managing the symptoms of piriformis syndrome aims to relieve pressure on the sciatic nerve and improve muscle function, thereby allowing a better quality of life for affected individuals.

1. Pain in the buttock: Deep pain in the buttock on the affected side is one of the most common symptoms. The pain can be felt in both the buttock and lower back.
2. Pain Radiation: Pain can radiate along the sciatic nerve, down the back of the thigh, calf, and sometimes down to the foot. The pain often follows the path of the nerve.
3. Tingling or numbness: Tingling or numbing sensations may be felt along the sciatic nerve. This can sometimes extend to the foot.
4. Pain exacerbated by certain activities: Pain may intensify during specific movements, such as externally rotating the hip or climbing stairs.
5. Pain with prolonged sitting: Pain can be made worse by long periods of sitting, especially on hard surfaces.
6. Difficulty sitting comfortably: Some people with piriformis syndrome may experience discomfort or pain when sitting.
7. Muscle stiffness: The piriformis muscle can become tight and stiff due to spasms, contributing to compression of the sciatic nerve.
8. Severe , radiating low back pain extending from the sacrum to the hip joint, over the gluteal region and the posterior part of the upper leg, to the popliteal space. In more severe cases, the patient will be unable to lie down or stand comfortably, and changes in position will not relieve the pain. Severe pain occurs when the patient is sitting or squatting because this type of movement requires external rotation of the upper leg and flexion of the knee.
9. Pain when getting out of bed
10. Numbness of the foot:  Compression of the sciatic nerve trapped by the piriformis muscle.
11. Pain at rest: Especially after sitting, standing, or lying down for more than 15 to 20 minutes. The pain usually improves once the patient begins to move and gradually gets worse without movement.
12. Contralateral sacroiliac pain
13. Positive piriformis sign: The contracted piriformis muscle causes ipsilateral external rotation of the hip. When a patient with piriformis syndrome is relaxed in the supine position, the foot is turned outward (a characteristic called the positive piriformis sign). Active efforts to bring the foot to the midline result in pain.
14. Difficulty Walking: Due to the tight piriformis muscle causing external rotation of the hip, the patient may experience difficulty walking and pain when internally rotated. Patients with piriformis syndrome may have an analgesic gait or foot drop. An analgesic gait refers to the type of gait that helps the patient minimize the amount of pain when walking. This is a type of gait abnormality where the stance phase is shortened compared to the swing phase. Foot drop occurs when the forefoot drops. A dull pain in the buttocks. Pain in the back of the thigh, calf and foot (sciatica)
15. Pain when climbing stairs or slopes
16. Reduced range of motion of the hip joint
17. Piriformis syndrome is usually unilateral.
18. Compression of the sciatic nerve causes pain and paresthesia in the posterior thigh, projecting toward the calf and sole of the foot. It is accompanied by numbness of the foot.
19. Compression of the pudendal nerve causes perineal and inguinal pain as well as dyspareunia (painful sexual intercourse for women) and impotence in men (Travel, Simons, 1992).
20. Active piriformis trigger points lead to pain in the lower back, buttocks, hip, and posterior thigh.
21. Pain often decreases with external rotation of the hip.
22. Difficulty performing abduction, flexion and internal rotation at the affected hip.
23. Sacroiliac joint dysfunction is frequently present due to piriformis contraction.
24. Abdominal, Inguinal and Pelvic Pain:  Piriformis spasm can cause tension on the sacrotuberous ligament resulting in compression of the pudendal nerves or tension on the innumerable bones, resulting in pelvic and groin pain.
25. May cause chest, neck and lumbosacral pain.
26. Headache

It is important to note that the symptoms of piriformis syndrome can sometimes be confused with those of other conditions, such as a herniated disc or spinal stenosis.

Piriformis syndrome, characterized by hip and gluteal pain, can be confused with other somatic dysfunctions such as spinal disc disease, lumbar radiculopathy, sacroiliac dysfunction, lumbosacral dysfunction, sciatica or trochanteric bursitis.

Incidence of piriformis syndrome

• Occurs most frequently in the fourth and fifth decades of life and affects people of all occupations and activity levels.
• Piriformis syndrome is more common in women than men, possibly due to the biomechanics associated with the wider quadriceps femoris muscle angle (i.e. “Q Angle”) in the os coxae (pelvis) of women.

Ballet and piriformis syndrome

Ballet practice, due to its specific movements and physical demands, can potentially influence the development of piriformis syndrome in some dancers. Here is how classical dance, especially ballet, may be linked to piriformis syndrome:

1. Foot Position and External Rotation: Ballet frequently involves externally rotated foot positions, which stresses the piriformis muscle. Repetition of these movements can lead to overuse of the muscle and, in some cases, contribute to the development of piriformis syndrome.
2. Repeated Flexion and Extension: Hip flexion and extension movements, common in ballet, can put increased stress on the piriformis muscle and sciatic nerve, especially if these movements are performed repeatedly and excessively.
3. Intense Stretching: Ballet dancers are often subjected to intensive stretching, which can potentially lead to muscle strain, including in the piriformis muscle.
4. Specific postures: Certain specific postures in ballet can involve significant external rotation of the hips, thereby straining the piriformis and increasing the risk of sciatic nerve compression.
5. Physical Demands: The high physical demands of ballet can lead to muscle overuse and fatigue, increasing the likelihood of strains and spasms in the piriformis muscle.

Although dancing can benefit physical and mental health, dancers, particularly ballet dancers, may be more susceptible to developing certain musculoskeletal conditions due to the specific movements of their art.

It is important for dancers, as well as dance professionals, to be aware of potential risks and take preventive measures, such as adequate warm-up, appropriate stretching, and careful management of exercise intensity.

Differential diagnoses

1. Lumbar herniated disc: A herniated disc can cause sciatic pain similar to piriformis syndrome by compressing the sciatic nerve in the spine.
2. Spinal Stenosis: Spinal stenosis, a narrowing of the spinal canal, can also cause sciatic pain and symptoms similar to piriformis syndrome.
3. Hip bursitis: Inflammation of the bursa (a small pocket of fluid) near the hip can cause pain similar to piriformis syndrome.
4. Osteoarthritis of the hip: Osteoarthritis of the hip can cause pain in the hip and buttocks area, which may be confused with piriformis syndrome.
5. Spondylolisthesis: A condition in which one vertebra slips forward relative to the lower vertebra can cause symptoms similar to piriformis syndrome.
6. Pudendal neuralgia: Irritation of the pudendal nerve can cause pain in the pelvic area and buttocks, which can be confused with piriformis syndrome.
7. Eosinophilic myofasciitis: Inflammation of muscle and fascial tissue can cause muscle pain and symptoms similar to piriformis syndrome.
8. Cauda Equina Syndrome: Compression of the nerve roots at the base of the spine can cause symptoms similar to piriformis syndrome.
9. Muscle or ligament injuries: Injuries to the muscles or ligaments around the hip can cause pain in the gluteal area.

Recommendations

• Avoid activities that cause piriformis syndrome. So, if the syndrome is triggered by cycling, look for another way to exercise, at least for a few days.
• Do a deep tissue massage of the hips and buttocks.
• Get up from your chair often.
• Stand, walk and stretch. This is especially important for people who sit at work, such as truck drivers and office staff.
• Sit on a chair that is cushioned. At work, used an ergonomic chair.
• Do not put the wallet in the back pocket, this will have the effect of compressing the sciatic nerve further.
• Have a healthy weight.
• Do recommended stretches for piriformis syndrome

How long does piriformis syndrome last?

Several factors influence the temporality of this condition, making each case a unique experience. Understanding the potential duration of piriformis syndrome is crucial for affected individuals and healthcare professionals seeking to provide effective care.

The first variable to consider is the severity of the condition. Mild cases, where compression of the sciatic nerve by the piriformis muscle is minimal, can often resolve more quickly. On the other hand, more severe situations, involving significant compression and more pronounced symptoms, can prolong the duration of the syndrome. The intensity of symptoms, such as shooting pain, muscle stiffness and numbness, can influence recovery.

How quickly piriformis syndrome is diagnosed and treated also plays a key role in how long it lasts. Early diagnosis allows a treatment plan to be initiated more quickly, which can contribute to a faster recovery. Unfortunately, the insidious nature of some symptoms can sometimes delay diagnosis, thereby prolonging the duration of the condition.

Individual response to treatment is a third crucial variable. Each person responds differently to therapeutic interventions. Treatment approaches, such as manual techniques used by osteopaths to release muscle tension and improve nerve mobility, may have varying effects from one individual to another. Some patients may experience rapid relief, while others may require more extensive follow-up to achieve optimal results.

In general, the medical literature indicates that piriformis syndrome can last from a few weeks to several months. Acute cases, properly diagnosed and quickly treated, tend to resolve more quickly. However, more complex situations, associated with factors such as significant anatomical variations or complications, can prolong the duration of the syndrome.

It is important for healthcare professionals, particularly osteopaths, to consider these nuances when managing piriformis syndrome. A personalized approach, taking into account the severity of the condition, timeliness of diagnosis and treatment, and individual response to treatment, is essential to optimize clinical outcomes.

Screening test

Freiberg maneuver

Forced horizontal adduction of the flexed thigh – pain during testing indicates piriformis syndrome (stretching of the muscle).

Hibbs maneuver

Patient is lying on his stomach, knee flexed to 90°, the examiner then stabilizes the patient’s pelvis with one hand and slowly pushes the patient’s ankle in a lateral direction (the internal rotation of the femur causes stretching of the piriformis muscle, which can compress the sciatic nerve)

https://youtube.com/watch?v=KH1T6ZDG9fE%3Fstart%3D2%26feature%3Doembed

Exercises and Stretches

Here are some exercises and stretches that are often recommended for piriformis syndrome:

Muscle Strengthening Exercises:

1. Side plank exercise:
   • Lie on your side with your elbow directly under your shoulder.
   • Lift your hips off the floor, forming a straight line from foot to shoulder.
   • Hold the position for a few seconds, then lower back down.
   • Repeat on the other side.
2. Leg raise in quadruped position:
   • On all fours, lift one leg backwards while keeping your back straight.
   • Hold the position at the top for a few seconds before lowering back down.
   • Alternate legs.

Stretching:

1. Seated stretch for the piriformis:
   • Sit with the affected leg crossed over the other.
   • Hold your opposite knee with the arm on the opposite side and gently twist your torso toward the crossed leg.
   • You should feel a stretch in your buttock.
2. Pigeon stretch:
   • In a quadruped position, bring the knee of the affected leg forward and outward.
   • Stretch the leg back while lying on your side.
   • You should feel a stretch in your buttock.

Flexibility Exercises:

1. External rotation of the hip while seated:
   • Sit with your legs apart.
   • Turn the affected leg outward, keeping the knee bent.
   • Hold for a few seconds and return to the starting position.
2. Internal rotation of the hip while seated:
   • Sit with your legs apart.
   • Turn the affected leg inward, keeping the knee bent.
   • Hold for a few seconds and return to the starting position.

These exercises and stretches aim to strengthen the surrounding muscles, improve flexibility and reduce tension in the piriformis region. However, their effectiveness can vary from person to person, and it is essential to do them correctly to avoid any aggravation.

Osteopathic approach

1. Muscle energy

• Lay the patient supine, the therapist stands on the same affected piriformis side.
• Flex the knee on the affected side and place the foot on that side on the lateral aspect of the opposite knee.
• The therapist pushes the knee medially until it meets the restrictive barrier.
• Ask the patient to push against the practitioner’s resistance for 3 to 5 seconds, allow a period of isometric relaxation, then engage a new barrier; repeat three times[10].

2. Combined ischemic compression (elbow or thumb)

Treatment of the piriformis muscle and its central trigger points can be usefully accomplished by direct pressure from the elbow, applied to the area of ​​the main trigger point in the muscle belly, while the leg of the patient lying on the side is rotated. to internally rotate the hip, in order to lengthen the muscle.

3. Strain Counterstrain

• Lay the patient in a supine position and instruct the practitioner to sit on the same side as the affected piriformis muscle.
• Locate the tender point of the piriformis muscle.
  Classically, it is found 2 or 3 inches medial and slightly cephalad to the greater trochanter.
• Instruct the practitioner to suspend the patient’s lower extremity over the edge of the table, flexing the hip (approximately 135 degrees) while abducting and externally rotating as needed until tenderness is relieved.
• Hold the position for 90 seconds and slowly return the patient to neutral position.
• Reassess the patient’s sensitivity.

References

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