Post on 01-Feb-2016
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An Alternative Treatment An Alternative Treatment Approach to Piriformis Approach to Piriformis
SyndromeSyndromeKorey Pieper, DPT, OCSKorey Pieper, DPT, OCS
Marie Potter, DPT, OCS, ATCMarie Potter, DPT, OCS, ATC
Rick J Rafael, DPT, OCS, CSCSRick J Rafael, DPT, OCS, CSCS
Jason Tonley, DPT, OCSJason Tonley, DPT, OCS
Kaiser Permanente West Los Angeles Orthopaedic Kaiser Permanente West Los Angeles Orthopaedic Residency ProgramResidency Program
September 2008 September 2008
Piriformis SyndromePiriformis SyndromeDefinedDefined
““Neuritis of the branches of the sciatic Neuritis of the branches of the sciatic nerve, caused by pressure of an injured nerve, caused by pressure of an injured or irritated piriformis muscleor irritated piriformis muscle11.”.”
SymptomsSymptoms
Radiating pain from the low back down Radiating pain from the low back down over the sacrum into the buttocks and over the sacrum into the buttocks and hip region, as well as down the hip region, as well as down the posterior portion of the upper leg to the posterior portion of the upper leg to the popliteal regionpopliteal region11..
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AnatomyAnatomy
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Possible Causes of Piriformis Possible Causes of Piriformis SyndromeSyndrome
Anatomical variationAnatomical variation
L/S dysfunctionL/S dysfunction
Muscle tightness and/or spasmMuscle tightness and/or spasm
OveruseOveruse
Post surgical injuryPost surgical injury
SIJ dysfunctionSIJ dysfunction
Trauma/fallTrauma/fall
DifferentialDifferential DiagnosisDiagnosis
Differential Diagnosis of Hip painDifferential Diagnosis of Hip pain7,87,8::Intra-articular & Extra-articular (Often Managed Operatively) :Intra-articular & Extra-articular (Often Managed Operatively) :– Labral TearsLabral Tears– Loose BodiesLoose Bodies– Femoroacetabular Impingement (FAI)Femoroacetabular Impingement (FAI)– HypermobilityHypermobility– Capsular LaxityCapsular Laxity– Ligamentum Teres TearLigamentum Teres Tear– Chondral DamageChondral Damage– Snapping Hip SyndromeSnapping Hip Syndrome– IT Band SyndromeIT Band Syndrome– Greater Trochanteric BursitisGreater Trochanteric Bursitis– Gluteal Tendon InjuryGluteal Tendon Injury
DifferentialDifferential DiagnosisDiagnosis
Differential Diagnosis of Hip painDifferential Diagnosis of Hip pain7,87,8::Extra-articular Causes (Often Managed Non-Extra-articular Causes (Often Managed Non-Operatively):Operatively):– Femoral Neck Stress FractureFemoral Neck Stress Fracture– Adductor StrainAdductor Strain– Piriformis SyndromePiriformis Syndrome– Sacroiliac Joint SyndromeSacroiliac Joint Syndrome– Tendonitis (hip flexors, abductors, adductors)Tendonitis (hip flexors, abductors, adductors)
DifferentialDifferential DiagnosisDiagnosis
Other Competing Diagnosis: Other Competing Diagnosis: Lumbar Facet SyndromeLumbar Facet SyndromeLumbar Disc HerniationLumbar Disc HerniationNerve entrapmentNerve entrapmentIschial Tuberosity BursitisIschial Tuberosity BursitisLumbar radiculopathyLumbar radiculopathySpinal stenosisSpinal stenosisSpondylolisthesisSpondylolisthesisOsteoarthritisOsteoarthritis
Common Treatment OptionsCommon Treatment Options
Treatment Options:Treatment Options:2,3,4,5,62,3,4,5,6
InjectionsInjectionsL/S stabilization exercisesL/S stabilization exercisesMobilization/manipulation L/SMobilization/manipulation L/SMobilization/manipulation SI jointMobilization/manipulation SI jointFoot orthoticsFoot orthoticsSoft tissue mobilizationSoft tissue mobilizationStrengtheningStrengtheningStretchingStretchingSurgical / arthroscopic releaseSurgical / arthroscopic releaseUltrasoundUltrasound
Common assumption guidingCommon assumption guidingtreatment approachestreatment approaches
The piriformis is shortened or in The piriformis is shortened or in “spasm” and is compressing the “spasm” and is compressing the sciatic nervesciatic nerve
Purpose of studyPurpose of study
To create a case series using an To create a case series using an alternative treatment approach to alternative treatment approach to piriformis syndromepiriformis syndrome
Inclusion Criteria: Inclusion Criteria: Objective ExamObjective Exam
Unilateral pain from lower lumbar/buttock Unilateral pain from lower lumbar/buttock region to the legregion to the leg
Symptoms not reproduced from lumbar, SI Symptoms not reproduced from lumbar, SI joint, and/or hip joint examinationsjoint, and/or hip joint examinations
Inclusion Criteria: Inclusion Criteria: Objective ExamObjective Exam
Lumbar ExamLumbar Exam– Negative AROM with OPNegative AROM with OP– Negative PA examNegative PA exam– Neurological testing negative for nerve root lesionNeurological testing negative for nerve root lesion
SIJ ExamSIJ Exam– Negative clusterNegative cluster
Hip ExamHip Exam– Negative ROM, excluding quadrantNegative ROM, excluding quadrant
Inclusion Criteria: Inclusion Criteria: Objective ExamObjective Exam
Reproduction of symptoms with:Reproduction of symptoms with:– Palpation of piriformis musclePalpation of piriformis muscle– Piriformis stretch testPiriformis stretch test– FAIR TestFAIR Test
Demonstrates movement dysfunction of Demonstrates movement dysfunction of ADD and/or IR and reproduction of ADD and/or IR and reproduction of symptoms with step down testsymptoms with step down test
Decreased reproduction of symptoms with Decreased reproduction of symptoms with corrected movement during step down testcorrected movement during step down test
Objective ExamObjective Exam
Patient to fill out disability questionnaires:Patient to fill out disability questionnaires:
– Oswestry Disability IndexOswestry Disability Index
– Lower Extremity Functional ScaleLower Extremity Functional Scale
Treatment ApproachTreatment Approach
Isolated strengthening for hip extensors, Isolated strengthening for hip extensors, abductors, and external rotatorsabductors, and external rotators
Functional movement re-education for Functional movement re-education for decreasing hip adduction and internal decreasing hip adduction and internal rotationrotation
NO!!!!!NO!!!!!– StretchingStretching– Soft tissue massageSoft tissue massage– ModalitiesModalities
Treatment ApproachTreatment Approach ExamplesExamples
Hip strengthening:Hip strengthening:– ClamsClams– BridgingBridging– Prone hip extensionProne hip extension– Quadruped hip extensionQuadruped hip extension– Hip abductionHip abduction
Treatment Approach ExamplesTreatment Approach Examples
Movement Re-education:Movement Re-education:– Postural correctionPostural correction– Sit to stand transitionsSit to stand transitions– Single leg sit to standsSingle leg sit to stands– LungesLunges– Plyometrics if indicatedPlyometrics if indicated
Patient DataPatient Data
7 Patients7 Patients
Age: mean 56 (range 31 - 69)Age: mean 56 (range 31 - 69)
Duration of symptoms: 197 days Duration of symptoms: 197 days (range 45 – 730)(range 45 – 730)
# of visits: 5 (range 2-8)# of visits: 5 (range 2-8)
Duration of visits: 9 weeks (range 3-16)Duration of visits: 9 weeks (range 3-16)
Average LE Functional ScaleAverage LE Functional Scale
Range: initial (37-70) discharge (54-80)
Average VAS (Pain Scale)Average VAS (Pain Scale)
Range: initial (6-10/10) discharge (0-4/10)
AnalysisAnalysis
Movement assessment allowed proper Movement assessment allowed proper physical therapy diagnosis and treatmentphysical therapy diagnosis and treatment
Patient’s can have multiple positive tests, Patient’s can have multiple positive tests, but movement reproduces primary pain but movement reproduces primary pain complaintcomplaint
Ceiling effect of questionnaires affects Ceiling effect of questionnaires affects data analysisdata analysis
Future ResearchFuture Research
Prevalence of movement dysfunction in Prevalence of movement dysfunction in patient’s diagnosed with piriformis patient’s diagnosed with piriformis syndromesyndrome
Most effective treatment modality for Most effective treatment modality for movement dysfunction: strength training movement dysfunction: strength training vs. movement re-educationvs. movement re-education
ConclusionConclusion
Movement re-education and strengthening Movement re-education and strengthening can be a successful way to treat piriformis can be a successful way to treat piriformis syndrome when a patient presents with a syndrome when a patient presents with a coordination deficit.coordination deficit.
ReferencesReferences1.1. Edwards, F.O.: Piriformis syndrome. Academy of Applied Osteopathy. Yearbook, 1962, pp 39-41.Edwards, F.O.: Piriformis syndrome. Academy of Applied Osteopathy. Yearbook, 1962, pp 39-41.
2.2. Parizale JR, Hudgins TH, Fishman LM: The Piriformis Syndrome. Am J. Orthrop, 1996:25:819-823.Parizale JR, Hudgins TH, Fishman LM: The Piriformis Syndrome. Am J. Orthrop, 1996:25:819-823.
3.3. Parizale JR, Hudgins TH, Fishman LM: The Piriformis Syndrome A Review. Paper.” The. Am J of Orthop. Parizale JR, Hudgins TH, Fishman LM: The Piriformis Syndrome A Review. Paper.” The. Am J of Orthop. 2002:25:1-112002:25:1-11
4.4. Bird JW: Piriformis Syndrome. Oper Tech Sports Med 2005 13 71-79Bird JW: Piriformis Syndrome. Oper Tech Sports Med 2005 13 71-79
5.5. Mayrand N, Fortin J, Descarreaux M, Normand MC. Diagnosis and management of posttraumatic piriformis Mayrand N, Fortin J, Descarreaux M, Normand MC. Diagnosis and management of posttraumatic piriformis syndrome: a case study. J. Manipulative Physiol Ther. 2006 Jul-Aug;29(6):486-91syndrome: a case study. J. Manipulative Physiol Ther. 2006 Jul-Aug;29(6):486-91
6.6. Keskula DR, Tamburello M: Conservative Management of Piriformis. Keskula DR, Tamburello M: Conservative Management of Piriformis. Syndrome. J Athl Train. 1992; 27(2):102, Syndrome. J Athl Train. 1992; 27(2):102, 104, 106-107, 110104, 106-107, 110
7.7. Lisa M Tibor, Jon Sekiya. Differential Diagnosis of Pain Around the Hip Joint. The Journal of Arthroscopic and Lisa M Tibor, Jon Sekiya. Differential Diagnosis of Pain Around the Hip Joint. The Journal of Arthroscopic and Related Surgery. 2008;19:1-15Related Surgery. 2008;19:1-15
8.8. Michael K Shindle, Benjamin G Domb, Bryan T Kelly. Hip and Pelvic Problems in Athletes. Oper Tech Sports Michael K Shindle, Benjamin G Domb, Bryan T Kelly. Hip and Pelvic Problems in Athletes. Oper Tech Sports Med. 2007; 15: 195-203.Med. 2007; 15: 195-203.