Physical Therapy Management Of Piriformis Syndrome

What is Piriformis Syndrome:

Piriformis syndrome (PS) is a condition that is characterized by a combination of symptoms that include low back or buttock pain that refers down the leg. Piriformis syndrome is caused by a tight, inflamed and tender piriformis that can result in compression of the sciatic nerve due to its proximity to, or in some cases coursing through the muscle.¹ The major symptoms of piriformis syndrome include pain and/or paresthesia radiating from sacrum through gluteal area and down posterior aspect of thigh, difficulty walking, numbness in the foot, and weakness of the ipsilateral lower extremity.⁴

Guide to Physical Therapist Practice:

Through the process of their examination the physical therapist will classify piriformis syndrome under Pattern 5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated With Peripheral Nerve Injury. The findings from the examination (history, systems review, and tests and measures) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs.⁵

The Physical Therapy Guide lists the following therapeutic interventions for patients with practice pattern 5F:⁵

• Aerobic and endurance conditioning or reconditioning
• Balance, coordination, and agility training
• Body mechanics and postural stabilization
• Flexibility exercises
• Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles
• Relaxation

The Physical Therapy Guide anticipates improvement with the following goals for patients with practice pattern 5F:⁵

• Impact on pathology/pathophysiology (disease, disorder, or condition)
o Pain is decreased
o Soft tissue swelling, inflammation, or restriction is reduced
• Impact on impairments
o Gait, locomotion, and balance are improved
o Motor function (motor control and motor learning) is improved
o Muscle performance (strength, power, and endurance) is increased
o Sensory awareness is increased
• Impact on functional limitations
o Ability to perform physical actions, tasks, or activities related to self-care, home management, work (job/school/play), community, and leisure is improved
o Tolerance of positions and activities is increased
• Impact on disabilities
o Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved
• Risk reduction/prevention
o Risk of recurrence of condition is reduced
• Impact on health, wellness, and fitness
o Physical function is improved
• Impact on societal resources
• Patient/client satisfaction

The Physical Therapy Guide recommends the following manual therapy techniques for patients with practice pattern 5F:⁵

Interventions
• Massage
o connective tissue massage
o therapeutic massage
• Mobilization/manipulation
o soft tissue
• Passive range of motion

The Physical Therapy Guide recommends the following modalities for patients with practice pattern 5F:⁵

Interventions
• Biofeedback
• Electrical stimulation
• Athermal agents
o pulsed electromagnetic fields
• Cryotherapy
o cold packs
o Ice massage
• Hydrotherapy
o whirlpool tanks
o contrast bath
• Sound agents
o phonophoresis
o ultrasound
• Thermotherapy
o hot packs

Piriformis Syndrome Specific treatment:

Physical therapy has become the main focus for conservative treatment of patients with piriformis syndrome. Focusing treatment on relieving the pain through stretching and decreasing swelling should lead to decompression of the sciatic nerve and thus relieve symptoms. Due to the anatomical location of the piriformis, lying deep to the gluteus maximus, moist heat or ultrasound is often used prior to stretching in order to preemptively loosen the muscle.¹ Hip and knee stretches utilizing the fair (flexion, abduction, internal rotation) position are done in the sitting and standing positions to effectively relax the tight piriformis. After stretching it is important to incorporate lumbosacral stabilization, hip strengthening exercises, and myofascial release.¹

Standard physical therapy program for patients with piriformis syndrome from Fishman et al:²

Table 1: Physical Therapy Protocol for Patients
With Piriformis Syndrome*
Place patient in contralateral decubitus and FAIR position.†
1. Ultrasound 2.0 to 2.5W/cm2 applied in broad strokes
longitudinallyalong the piriformis muscle from the conjoint
tendon to the lateral edge of the greater sciatic foramen for
10 to 14 minutes.†
2. Wipe off ultrasound gel.‡
3. Hot packs or cold sprayat the same location for 10 minutes.
4. Stretch the piriformis muscle for 10 to 14 minutes by
applying manual pressure to the muscle’s inferior border,
being careful not to press downward, rather directing
pressure tangentially toward the ipsilateral shoulder.§
5. Myofascial release at lumbosacral paraspinal muscles.
6. McKenzie exercises.
7. Use lumbosacral corset when treating patient in the FAIR
position._
Duration: 2 to 3 times weeklyfor 1 to 3 months.

• Patients usuallyrequire 2 to 3 months of biweekly therapy for 60%

to 70% improvement.
† Because it is painful, patients often subtly shift to prone. This must
be avoided because it places the affected leg in abduction, not
adduction, greatly reducing the stretch placed on the piriformis
muscle.
‡ Cavitation is unreported in more than 20,000 treatments.
§ Unless explicitly stated, therapists maytend to knead or massage
the muscle, which is useless or worse. The muscle must be stretched
perpendicular to its fibers, in a plane that is tangent to the buttock at
the point of intersection of the piriformis muscle and the sciatic
nerve, but approximately1 to 1.5-in deep to the buttock (ie, just
below the gluteus maximus).
_ It is particularly important to avoid inducing lumbar hypermobility
in patients with histories of laminectomy, fusion, or spondylolisthesis.

Stretching Exercises

Piriformis stretching exercises should be performed in order to reinstate pain free ROM. These exercises should be used both in clinic and as a home exercise program for the patient. To begin the stretches should be done to the tolerance of the patient, but some general starting guidelines are 3 sets of 5-10 reps 3 times a day. As the patient progresses more aggressive stretching techniques can be used such as the PNF contract relax technique.⁶ Some effective and easy stretches include:

//http://www.spine-health.com/wellness/exercise/exercise-sciatic-pain-piriformis-syndrome

Sit with one leg straight out in front. Hold onto the ankle of your other leg and pull it directly towards your chest.//

//http://www.spine-health.com/wellness/exercise/exercise-sciatic-pain-piriformis-syndrome

Lie face down and bend one leg under your stomach, then lean towards the ground.//

//http://www.spine-health.com/wellness/exercise/exercise-sciatic-pain-piriformis-syndrome

Lie on your back and cross one leg over the opposite knee, pull the bottom leg towards your stomach.//

//http://www.spine-health.com/wellness/exercise/exercise-sciatic-pain-piriformis-syndrome

Keep unaffected leg straight then bend the affected leg and cross it over the straight leg. Pull the crossed leg till a stretch is felt.//

For home exercise prescription it is important for the physical therapist to make sure that the patient understands how to properly perform each exercise. The physical therapist should observe the patient the first time that they perform the exercises to make sure that they are correctly performing the stretch.⁴

Strengthening:

A strengthening program for the piriformis can be initiated early in the rehabilitation process. When strengthening the piriformis most exercise should be done either with the hip flexed, which is used to focus on abduction, or with the hip in neutral which emphasizes external rotation exercises. Resistance can be applied in different ways, including; manually, with weights, or with thera-bands. The patient should be advanced as tolerated. Other strengthening options can include the use of D2 flexion and D2 extension PNF diagonal patterns.⁶

⁶

Myofascial Release

Tightening of the fascia is a protective mechanism that results from an injury. As a result of the tightening the fascia loses its pliability and becomes restricted. Overtime this causes poor muscular biomechanics, decreased ROM, altered structural alignment, and decreased strength, endurance and motor coordination. In order to combat this the myofacial release technique is used. Using myofacial release the fascia is stretched allowing a re-establishment of the health and length of the tissue. This will allow for a return in the mobility of the joint as well as decreased pressure on nerves and blood vessels. The myofascial release is performed by using a sustained pressure to the restricted tissue, holding for about 90 – 120 seconds. This length of time is sufficient for lengthening changes to occur. This technique is then moved to a new tissue barrier and held again. After being repeated a few times the tissue will become softer and more movable.⁷

Combined Therapies:

Physical therapy is now being combined with other treatments to increase the effectiveness of a conservative treatment program. Fishman et al looked at the combination of using a standard physical therapy treatment with a lidocaine and triamcinolone acetonide blended injection. This blend utilizes a local anesthetic and a corticosteroid to maximize symptom relief. The symptom relief allows for more aggressive physical therapy, which will theoretically yield faster and better recovery. The study then followed up with each subject at 6, 12, 24, 36, and 48 months in order to track sustained affects. The study showed that 79% of patients improved at least 50% with the combined treatment.²

Recent literature suggests the use of botox in combination with physical therapy. Botox inhibits the release of ACH before the synapse, which leads to the affected muscle being paralyzed. The weakness, atrophy and relief of the sciatic nerve compression are all result of the botox, which essentially reverses the underlying pathophysiology of PS.¹ In a 10 year cohort study it was reported that patients who received the botox injection had immediate pain relief, however without physical therapy the pain returned in a few weeks. When the injections were combined with physical therapy 65% of patients who tested positive for piriformis syndrome initially had their symptoms improved by 50% or more.³

Treatment Goals

Initial Goals:⁶

- Decreasing Inflammation
- Decreasing Pain
- Decreasing spasm

Goals are then modified to each patient accordingly after initial symptoms subside

Conclusion:

Conservative treatment is aimed at lengthening the piriformis muscle and decreasing pressure on the sciatic nerve. It is important for the patient to know that even though the piriformis is loosening, their symptoms may linger for a bit do to the sciatic nerve being damaged and requiring time to heal. Physical therapy has been shown to be a very effective minimally invasive treatment that provides long lasting symptoms relief.⁴

References:

1. Kirschner JS, Foye PM, Cole JL. Piriformis syndrome, diagnosis and treatment. Muscle Nerve. 2009;40(1):10-18.
2. Fishman LM, Dombi GW, Michaelsen C, et al. Piriformis syndrome: Diagnosis, treatment, and outcome — a 10-year study. Arch Phys Med Rehabil. 2002;83(3):295-301.
3. Fishman LM, Anderson C, Rosner B. NoTox and physical therapy in the treatment of piriformis syndrome. AmJ Phys Med Rehabil 2002;81:936-942.
4. Boyajian-O'Neill L, McClain RL, Coleman MK, Thomas PP. Diagnosis and management of piriformis syndrome: An osteopathic approach. JAOA J AM OSTEOPATH ASSOC. 2008;108(11):657-664.
5. Guide to Physical Therapist Practice. American Physical Therapy Association. 2012. Accessed March 10, 2012.
6. Keskula D, Tamburello M. Conservative Management of Piriformis Syndrome. Journal of Athletic Training. 1992;27(2): 102-110.
7. Barnes MF. The basic science of myofascial release: morphologic change in connective tissue. Journal of Bodywork and Movement Therapies. 1997: 231-238