Orthopedics-Online

Piriformis Syndrome

definition

In piriformis syndrome, irritation of the sciatic nerve results in pain radiating from the hip, which is similar to a herniated disc in the lumbar spine, but which must be viewed spatially and causally independently of this.
It gets its name from the piriformis muscle (pear-shaped muscle), which exerts or transmits internal or external pressure on the sciatic nerve and thus irritates the nerve.

Epidemiology

There are different statements about the frequency of a lumbar syndrome.
In a family doctor's practice, around every twelfth patient complains of deep back pain radiating into the buttocks and legs.

Incidentally, 25% of all work stoppages due to illness can be traced back to such complaints.
About 42% of all patients with the appearance of pain in the area of the lumbar spine up to the course of the sciatic nerve, but which has been proven to have no herniated disc as a cause, suffer from piriformis syndrome.

causes

There can be many causes responsible for piriformis syndrome.
Accidents or falls on the buttocks can trigger the pain syndrome due to pressure on neighboring parts of the sciatic nerve, but also lower pressure over a corresponding period of time on a certain area of the buttocks, such as sitting on a purse in the back pocket or one-sided buttock stress when sitting, can also be causes described.
With prolonged, monotonous exertion, such as endurance running, frequent lifting activities with the legs apart, or prolonged, bent-forward work, the piriformis syndrome can occur.
In addition, muscle shortening of the holding muscles occurs quite frequently in old age, including the piriformis muscle, which can exert increased pressure on the sciatic nerve.

Anatomically, the piriformis muscle pulls from the lower, lateral inner surface of the sacrum over to the inner surface of the large rolling hillock on the thigh bone and is responsible for internal rotation, lateral splaying and rearward extension of the thigh.
Directly beneath him, also coming from the sacrum, the sciatic nerve runs deep in the buttocks to the back of the leg.
In most cases, this anatomical neighborhood is one of the causes of the piriformis syndrome, as well as the fact that the sciatic nerve is not very flexible and is therefore susceptible to the effects of force. In anatomical variations, the sciatic nerve can even run directly through the piriformis muscle or over its upper edge, which promotes the development of the pain syndrome.

You can find more on the subject at:

Causes of Piriformis Syndrome
Pinched sciatic nerve

Piriformis Syndrome from Jogging

Piriformis syndrome is a typical jogger disease. In this sport, the piriformis muscle is heavily involved in the movement pattern, which is why the muscle tensions more often. In addition, jogging uses and trains the muscle, which can cause it to press on the sciatic nerve, causing pain.

Most of the time, the piriformis syndrome occurs suddenly when jogging after having to overcome a small bump in the ground. The pelvis has to react to the unfamiliar movement; the piriformis muscle, among other things, suddenly becomes tense.

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Illustration piriformis syndrome

Piriformis Syndrome

Lumbar spine (lumbar spine)
Iliac scoop -
Ala ossis ilii
Femoral head (= femoral head) -
Head femoris
Pear-shaped muscle -
Piriformis muscle
Great Rolling Hill -
Greater trochanter
Ischium - ischium
Sciatic nerve -
Sciatic nerve
Femoral shaft -
Corpus femoris
Lumbar cruciate ligament kink -
Promontory
Sacrum - sacrum
Gluteus Muscle -
Gluteus maximus muscle
A - pelvis side view
B - Female pelvis from behind

You can find an overview of all images from Dr-Gumpert under: medical images

Symptoms

The piriformis syndrome is often similar to a herniated disc with pain in the lumbar region, the back of the buttocks and the possibility of radiating into the leg.
As is usual with nerve pain, the character of the pain is light and piercing; the pain is often transmitted according to the course of the nerves upwards towards the lumbar spine and down towards the leg.
The pressure on the nerves can cause a "tingling sensation" in the leg's typical skin supply area, with paralysis of the leg muscles hardly being observed at all. In addition, the pain is increased especially when climbing stairs, cycling, running, swimming or lying on the affected side.

Further information on this:

Symptoms of Piriformis Syndrome
Herniated disc of the lumbar spine

Pain in piriformis syndrome

Pain is the main symptom of piriformis syndrome. The pain is caused by the tension in the piriformis muscle. There is severe pain, especially in the buttock region. They can also radiate into the back of the thigh. Occasionally the pain even extends to the knee. Some of the affected people also complain of pain in the lumbar region, but these are usually quite unspecific.

Another characteristic of piriformis syndrome is an intensification of the pain symptoms through certain movements. Rotary movements in particular can trigger or intensify the pain. This includes, for example, crossing your legs or turning over in bed. Often, both sides are not equally affected by the pain in affected people. Usually the piriformis syndrome is only noticeable on one side, but the opposite side can occasionally also be affected.

The pain is triggered by pressure on the sciatic nerve, which pulls past the piriformis muscle. Incorrect posture or violent movements result in strong tension in the muscle, which presses on the sciatic nerve and causes shooting pain.

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Pinched sciatic nerve

Numbness

With piriformis syndrome, in addition to the typical pain symptoms in the buttocks, numbness can also occur.

These sensory disorders affect the area supplied by the sciatic nerve, so numbness occurs in the legs. The compression (pressure and narrowing) of the sciatic nerve by the piriformis muscle can disrupt the conduction pathways in it. Touches on the legs can no longer be passed on to the brain and numbness occurs.

tingle

The tingling of the legs due to piriformis syndrome is also due to an entrapment of the sciatic nerve.

Due to the compression of the nerve by the piriformis muscle, information can no longer be correctly transmitted from the nerve to the brain. Instead, information about touch or temperature is only incompletely sent to the brain. The brain now has to get by with a fraction of the actual information and therefore interprets false perceptions into this “information gap”.

Duration of piriformis syndrome

How quickly a piriformis syndrome will heal can hardly be predicted. Even with good therapy, the disease can take several weeks to even months to heal. If the pain has persisted for 3 - 6 months, it is referred to as chronic pain.

In any case, the success of the treatments (especially because of the lengthy healing of the pain) is heavily dependent on the cooperation of the patient and consistent treatment. In addition, in addition to the piriformis syndrome, existing complaints in the spinal area have a poor prognosis, especially for complaints in the lumbar spine and sacrum area. If these are not available, significant pain relief can often be achieved in around 3 weeks with appropriate treatment.

diagnosis

As described at the beginning, the piriformis syndrome is often mistaken for a herniated disc, as this is a more common cause of comparable pain in comparison.
Nevertheless, after clarification and exclusion of a herniated disc, a piriformis syndrome must be considered.
Tension pain in the area of the piriformis muscle, palpation of a hardened muscle belly, as well as pain when bending, internal rotation and bringing the affected leg closer to the other, many criteria speak for the syndrome, which makes appropriate treatment sensible. Furthermore, the diagnosis of the piriformis syndrome can be carried out by triggering stretching pain. Overall, there are various tests for piriformis syndrome that can help make the diagnosis.

The Lasegue test, in which an examiner slowly moves the leg extended in the knee towards the ceiling with the patient lying on their back, can provide non-specific information by provoking pain in the irritated and tense sciatic nerve.
When performing the external rotation test, the patient lies on his back. The lower legs hang over the edge of the examination table. During the test, the doctor presses the inner ankles with both hands and asks the patient to pull their feet inward. This results in an external rotation in the hip joint, which is very painful when the piriformis syndrome is present.
The diagnosis of piriformis syndrome can also be carried out by checking the abduction. The abduction test is performed while sitting. While the doctor presses his hands on the outside of the patient's knees, the patient must try to move the legs away from the body axis.

The success of the treatment is ultimately conclusive, since imaging or other diagnostics do not indicate a painful but harmless disease in this case.
If the treatment options for piriformis syndrome are exhausted, it may be a chronic pain syndrome that has arisen, or there is the possibility of another cause of the sciatic nerve irritation, such as a herniated disc, a sacrum and iliac joint blockage, a slipping of the vertebral body, however Another kind of inflammation of the nerves, such as Borrelia.

Tests for Piriformis Syndrome

Tests for piriformis syndrome aim to stretch the piriformis muscle. In this way it can be determined whether there is painful tension in this muscle.
The piriformis muscle is required for abduction (splaying) of the hips when the hip is flexed, and for external rotation in the hip joint when the hip is extended.

Spreading test:
In order to test the abduction, the hip must first be flexed; the examination situation is therefore easiest when sitting. The doctor then presses against the knee on the painful side from the outside. The affected person tries to bring the leg outwards against this pressure. A decrease in strength compared to the healthy side in this test indicates a malfunction of the piriformis muscle.
External rotation test:
To test the external rotation, the person concerned lies on their back, while the lower legs are allowed to hang down over the lower edge of the examination table. In order to achieve external rotation in the hip, the drooping feet must now be pressed inwards. Here, too, a reduction in strength or increased pain compared to the opposite side is indicative of a piriformis syndrome.
Freiberg test:
The third test is known as the Freiberg mark. The examiner stretches the piriformis muscle. The test is also carried out in the supine position with the lower legs hanging down; the lower legs are pushed outwards by the examiner. If this stretching provokes pain in the area of the piriformis muscle, piriformis syndrome can also be suspected.

Read our article on this:

Tests for Piriformis Syndrome

MRI for piriformis syndrome

Piriformis syndrome is usually a diagnosis of exclusion. It is suspected if no other cause of the sciatic symptoms can be found. Therefore, an MRI of the pelvic region is usually only done after many examinations have already been carried out, for example on the back.

Various functional tests that specifically target the piriformis muscle are performed before imaging. This is how the suspicion of piriformis syndrome can be confirmed.
The piriformis syndrome cannot always be clearly identified on the MRI images. You can tell whether the piriformis muscle is thickened or shortened. However, this only allows the assumption that this is where the cause of the sciatic symptoms lies.

Piriformis Syndrome or Herniated Disc - How Do I Tell the Difference?

A herniated disc and piriformis syndrome cause very similar complaints in the area of the sciatic nerve. Both trigger the typical nerve pain that can pull down to the tips of your toes.
Usually the first suspicion is a herniated disc when such symptoms occur. This must be excluded with imaging (for example, an MRI of the spine).

If you cannot find a cause that could explain the symptoms, the piriformis muscle is usually the source of the symptoms. Specific tests can stimulate the muscle and diagnose piriformis syndrome.

Piriformis Syndrome or SIJ Block - How Do I Tell the Difference?

An ISG blockade, like the piriformis syndrome, often arises from a rapid, uncontrolled movement in which the spine and hips have to support the body. In the case of an ISG blockade, the sacrum (end of the spine) and the ileum (part of the pelvic bones) become entangled, so that any movement of these bones against each other is painful.

The blockage usually triggers strong reactive tension in the lumbar spine.
Therefore, in contrast to piriformis syndrome, the lower back is usually more affected.

Illustration piriformis muscle

Piriformis muscle

Pear-shaped muscle -
Piriformis muscle
Iliac scoop -
Ala ossis ilii
Posterior sacrum holes -
Foramina sacralia posteriora
Sacrum -
Sacrum
Great Rolling Hill -
Greater trochanter
Small rolling hill -
Lesser trochanter
Femoral shaft -
Corpus femoris
Ischium -
Os ischii (ischium)
Fifth lumbar vertebra -
Vertebra lumbalis V

You can find an overview of all Dr-Gumpert images at: medical illustrations

Therapeutic measures

At the beginning of a treatment there is a pause from activities that further irritate the sciatic nerve through the activity of the piriformis muscle.
In general, physiotherapy for piriformis syndrome is also a good way of relieving the symptoms.
Stretching maneuvers and other manual measures that the patient can carry out independently, but are also used with the help of a doctor and physiotherapist and are instructed to do them independently, can provide relief very quickly, especially for older patients, whose shortened holding muscles are the cause of the nerve irritation.

In addition, pain reliever and anti-inflammatory drugs (NSAIDs) such as diclofenac, ibuprofen or celecoxib can be used and can promote faster pain relief and a decrease in inflammatory nerve irritation while taking physical care. Despite their partial over-the-counter market, they should be used carefully and according to a doctor's recommendation due to their side effects.
In addition, after finding out how effective it is, the patient can use moderate heat or cold to relieve their symptoms on site.

A local injection of a local anesthetic and / or cortisone can quickly relieve pain if the piriformis muscle and the adjacent sciatic nerve are well reached and have a long-term positive effect on the local inflammation - until other methods can also be used. However, the success is heavily dependent on the skills of the doctor using it and involves the risk of consequential damage to nerves and vessels.

Surgery is rarely mentioned as a therapeutic means, but its risk is usually not compatible with the severity of the disease, but with the aforementioned positional anomalies of the sciatic nerve, an exception to be considered if necessary.

Ultimately, the treatment and resolution of piriformis syndrome takes a lot of time and can take several weeks to months, which is why consistency and patience are important criteria for the success of a cure for both doctor and patient.

stretching

Simple stretching exercises can often help prevent the development of piriformis syndrome. In addition, these stretching exercises can help to alleviate existing symptoms and positively influence the healing process. In order to be able to achieve a long-term effect, the stretching exercises should be integrated into every workout and performed regularly. In the following, three stretching exercises are explained that can be used quickly for people with piriformis syndrome.

Exercise 1

During this stretching exercise, the patient with piriformis syndrome should first sit upright and bring one leg in front of the body. This leg should be placed so that the knee joint is at an angle of approximately 90 degrees. At the same time, the other leg must be stretched back as far as possible. During this stretching exercise, it is particularly important that the outside of the thigh is always in direct contact with the floor. Otherwise, the stretch will be ineffective.

Once this starting position has been reached, the patient must slowly bend the upper body forward. In the meantime, your hands may be placed on the floor for support.

A slight pull should be felt on the outside of the buttocks on the front leg. The intensity of this stretching exercise can be increased by letting the patient slowly move the upper body towards the foot.
In order to achieve the highest possible effect, the stretching exercise should be held for a period of about 20 seconds and performed at least 2 to 3 times per side.

exercise 2

In this stretching exercise, the patient has to lie on their back with their left leg bent on the floor. At the same time, the right leg should be positioned so that the ankle is behind the left knee.

As soon as this starting position can be kept relaxed, the right foot must be pulled towards the hip. Then the left leg should be pulled towards the body with both hands. If this stretching exercise is carried out correctly, the patient will feel a stretch in the right buttock and in the area of the right hip.
The intensity of this stretch can be increased by gently pressing the right elbow against the right knee.
This exercise must also be held for about 20 seconds and performed 2 to 3 times per side.

Exercise 3

The patient must lie down on the floor sideways. The head can be placed on a pillow as an aid. Then the upper leg must be bent to an angle of approximately 90 degrees while the lower leg remains straight. At the same time, both arms should be stretched in front of the body so that a 90 degree angle is formed between the arms and the trunk.

As soon as this basic position can be kept relaxed, the patient must rotate the upper arm in a straight axis to the other side. The head should also be rotated with this movement. The best effect is achieved in this stretching exercise when the rotational movement is carried out so far that a stretching resistance can be felt. This position should then be held for a period of approximately 5 seconds. Ideally, the patient repeats this stretch 20 times per side.

physiotherapy

The exact cause of the piriformis syndrome has not yet been conclusively clarified scientifically. It is believed, however, that the sciatic nerve is narrowing as it passes through the pelvis. This is where the piriformis muscle sits. If this is shortened, thickened or tense, it presses on the sciatic nerve and provokes irritation.

Physiotherapy aims to stretch and relax the piriformis muscle. Moving the affected leg in physiotherapy is also important, as the exercises can alleviate leg pain.

Please also read the article:

Physiotherapy for piriformis syndrome

Exercises with a tennis ball

Since the cause of the piriformis syndrome is usually a hardening of the piriformis muscle, a self-massage with a tennis ball can alleviate the symptoms.
The tension in the muscle creates various painful points, which are also called trigger points. By massaging these trigger points, the piriformis muscle can relax.

Since the piriformis muscle is hidden under the gluteal muscles, a hard massage ball is required for massage. Even a tennis ball is hard enough to reach the muscle.

The self-massage is carried out as follows: You lie on your back on a hard surface and place the tennis ball under your sore buttocks. The body weight is now shifted onto the ball.
The trigger points can be found by slightly changing the position. Then you massage these trigger points with small rolling movements.

Exercises with a fascia roller

Like a tennis ball, the fascia roller is suitable for massaging trigger points of the piriformis muscle.
To do this, lie down with your back on a hard surface and place the fascia roll under your buttocks. Then you shift your body weight onto the roller.
When you have found a trigger point, you remain on the painful point for a few seconds.
The point can also be massaged by gently moving it back and forth. This self-massage of the piriformis muscle can relieve tension.

Heat treatment

Warmth is a commonly used therapeutic tool to relieve muscle tension. Since the piriformis syndrome is often due to tension and hardening of the muscle, the application of heat can provide relief.
However, the piriformis muscle is a small muscle that is well hidden in the pelvis. Seen from the outside, it is also under the gluteal muscles.
Therefore it is not easy to reach this muscle with a heat pack. Nevertheless, a heat pad that is placed on the buttocks can penetrate the piriformis muscle with the heat.

acupuncture

Complaints that are caused in the course of the piriformis syndrome do not have to be treated extensively in every case. In mild cases, acupuncture treatment can help to effectively relieve the symptoms.

Under the term "acupuncture“One understands a sub-area of traditional Chinese medicine. This teaching assumes that the body's life energy circulates on defined channels and has a controlling influence on all body functions. The local stimulation of different acupuncture points could thus have a positive influence on the organism.
These acupuncture points are stimulated by inserting fine needles into the surface of the skin. In the field of medicine, acupuncture has enjoyed increasing enthusiasm for years. This treatment method is also said to be particularly promising for patients who suffer from piriformis syndrome.

In severe cases of illness, acupuncture can also be performed by applying local heat (so-called Moxibustion) get supported. With this method, special acupuncture points are placed over the needle or directly with smoldering moxa herb (Synonym: mugwort) heated. Even after the first acupuncture session, most of the affected patients describe a significant reduction in pain and an improvement in mobility.

Taping

Taping can provide acute relief in patients with piriformis syndrome. The advantage of taping for muscular and / or nervous complaints in the area of the sciatic nerve is the fact that the treated region is only partially immobilized by the tape bandage. In this way, the mobility is not completely restricted but only prevents overloading. For this reason one speaks of a so-called "functional bandage" when taping.

The effect of taping is based on the fact that the plaster strips stuck on the skin transfer the forces that hit the body region to the skin and in this way support deeper structures (for example muscles or the capsule-ligament apparatus of a joint). In addition, the swelling of the treated area of the body is effectively prevented by taping and the resulting compression.

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Tape bandage

Osteopathy

Osteopathy is a special area of alternative medicine. A variety of diseases and complaints can be effectively treated through the various treatment methods of osteopathy. One of the basic assumptions of osteopathy is the opinion that the body represents a functional unit and is basically capable of self-regulation.

The healing of various diseases is therefore only possible through the promotion of self-healing powers. In patients suffering from piriformis syndrome, the so-called fascia techniques in particular should often lead to effective relief from the symptoms. This treatment method from the field of osteopathy includes special connective tissue massages, which are intended to help relieve tension in the muscles.
Basically, it is a manual stimulation therapy that primarily targets the connective tissue under the skin. The effect of this treatment method from the field of osteopathy is mediated by the activation of various muscle reflex arcs during the massage.
In this way, normal muscle tone, which is often disturbed in the presence of piriformis syndrome, can be restored. In addition, tensions that are directly in the connective tissue can be effectively released in this way. Patients affected by Piriformis Syndrome usually report that they were able to notice significant relief of the symptoms after just a few applications.

Medicines for piriformis syndrome

In addition to trigger point treatment, stretching exercises and massages, drug-based pain therapy plays an important role in the treatment of piriformis syndrome.
First and foremost, pain relievers (analgesic) and anti-inflammatory (anti-inflammatory) active drugs such as diclofenac, ibuprofen and coxibs (for example celecoxib) used. They belong to the group of drugs called NSAIDs (non-steroidal anti-inflammatory drugs). In combination with physical rest, they can quickly lead to freedom from pain. Although they are over-the-counter, NSAIDs should be used with caution, as excessive or long-term use can lead to stomach upset, among other things.

If the effect of these drugs is insufficient, the local injection of a local anesthetic, possibly in combination with a cortisone, can help. This can achieve pain reduction or even freedom from pain for weeks or even months. The prerequisite for this, however, is the easy accessibility of the piriformis muscle. The success of the injection also depends heavily on the skills of the doctor performing the injection.

Read about this:

Therapy of piriformis syndrome

Healing the Piriformis Syndrome

Treating piriformis syndrome is usually very difficult and takes a long time. Patients often turn to a doctor late with their complaints so that the correct diagnosis is made late. A delayed start of treatment makes healing much more difficult and delays the success of the treatment. But even after starting treatment immediately, the goal of freedom from pain is often only achieved after a period of weeks to months.

After healing in the sense of freedom from pain, there is usually an increased susceptibility to a recurrence of the piriformis syndrome.
The consistent implementation of the stretching exercises mentioned and targeted muscle training are therefore important preventive measures.
With the help of this, a relapse (Relapse) can often be prevented well.

How can I prevent piriformis syndrome?

The most common cause of piriformis syndrome is prolonged, bent over, or sitting posture. Therefore, people who work at their desks all day are particularly affected by the disease.

Heavy lifting can also trigger piriformis syndrome. Exercise helps counter these risk factors in two ways. On the one hand, the sitting posture can be interrupted by standing up regularly; on the other hand, the piriformis muscle is trained during movement.

Which doctor should I see if I have piriformis syndrome?

The piriformis syndrome is a disease that has to do with the movement and holding apparatus of our body. The piriformis muscle is particularly affected. It also causes problems in other muscles, ligaments and joints. Therefore, the piriformis syndrome is a case for the orthopedic surgeon.

If necessary, the doctor can arrange for imaging, which is usually carried out by a radiologist.

Summary

The piriformis syndrome has a wide variety of causes, in which external pressure or the working piriformis muscle causes irritation of the sciatic nerve running in the immediate vicinity over a longer period of time.
The symptoms are pain radiating from the buttocks into the leg, but also into the lumbar spine, similar to those of a herniated disc.
For treatment, physical rest is important, as are pain and anti-inflammatory drugs, as well as stretching of shortened or hardened muscles.
Local "anesthetic injections" can help effectively for a short time, but the lengthy healing process requires above all patience with the aforementioned treatment options.