Piriformis Syndrome

Assessment presentation
II.2
 Introduction
Piriformis syndrome is neuromuscular
disorder that occurs when the piriformis
muscle compresses or irritates the sciatic
nerve-the largest nerve in the body.
Compression of the sciatic nerve causes
pain-frequently described as tingling or
numbness-in the buttocks and along the
nerve, often down to the leg.

The pain may worsen as a result of sitting for

a long period of time, climbing stairs,
walking, or running

Important to remember!!
* This syndrome remains controversial because, in most cases, the diagnosis is clinical,
and no confirmatory tests exist to support the clinical findings
 Incidence and etiology
• 6:1 prevalent in females than in males could be to the anatomic
variation of the female pelvis Likewise, women tend to have a greater Q
angle.

•no dominant etiological factors have been reported

• minor trauma to the buttocks or pelvis The trauma is thought to

precipitate a spasm of the piriformis muscle, which subsequently inflames
the adjoining sciatic nerve
 Piriformis anatomy
The piriformis muscle is flat,
pyramid-shaped, and oblique.
This muscle originates to the
anterior of the S2-S4 vertebrae,
the sacrotuberous ligament, and
the upper margin of the greater
sciatic foramen.
This muscle passes through the
greater sciatic notch and inserts
on the superior surface of the
greater trochanter of the femur.
With the hip extended, the
piriformis muscle is the primary
external rotator; however, with the
hip flexed, the piriformis muscle
itself becomes a hip abductor.
This muscle is innervated by
branches from L5, S1, and S2.
The drawing shows the important anatomy of the PS,and how a certain leg
positions pull the PM up against the sciatic nerve causing buttocks pain and
radiating leg pain
 Causes
Trauma to the buttocks or gluteal region
is the most common cause 50% of all
cases

Bleeding in and around the piriformis muscle forms a hematoma

The piriformis muscle begins to swell and put pressure on the
sciatic nerve
 Causes
•The piriformis muscle become tight or get in to spasm
•Bilateral piriformis syndrome due to prolonged sitting during
an extended neurosurgical procedure
•Bad posture
•lumbar lordosis and hip flexor tightness predisposes one to
increased compression of the sciatic nerve against the sciatic
notch by a shortened piriformis
•Muscle anomalies with hypertrophy can be cause by
asymmetry of the muscle, Muscle spasm may change the
shape and hardness of a muscle.
•Scarring in the region of the ischial tuberosity, a pelvic mass
like Endometriosis near the greater sciatic notch, aneurysm of
the superior or inferior gluteal artery, or anatomical variations
of these vessels can all compress the nerve and lead to the
syndrome.

Axial T1-weighted MR image showing asymmetry in the size of

the piriformis muscles. This may reflect either hypertrophy on
the right or atrophy and spasm on the left. Muscle spasm may
change the shape and hardness of a muscle.
 Symptoms
• shooting pain from the buttock along the
posterior part of the thigh to the lateral part
of foot
• symptoms seem to get worse during
prolonged sitting, car driving, and going up
inclines
• Palpation in the buttock region shows
tenderness
 Predisposing Factors
• Morton’s foot may be a factor for piriformis
tightness as it will change the gait pattern
• 15 % of the population has the sciatic
nerve passing through the piriformis
muscle making them prone for PS
 Case study
A 32 years old single female presented
to the clinic complaining of left hip and buttock pain.

2 months ago, the patient fell down the stairs (10 stairs) on her buttock

Complained on localized left buttock pain that radiated

to her left hip and at times, midway down her left thigh.

After sitting for 1 hour or more, the pain was worse and
occasionally she noted numbness in the left lateral thigh with
paresthesia down the posterior aspect of the calf.

Next page physical examination of the patient

 Differential diagnoses
 Lumbar disc herniation
 Sacroiliac joint dysfunction
 Hamstring syndrome
 Coxofemoral pain
 physical examination

•Palpation of buttocks
•ROM inspection of the trunk and lumbar spine
•Resistence test in abduction and lateral rotation of the hip
•Slump test
•Straight leg raising
• left buttock pain was elicited upon left hip flexion and internal rotation
of left hip
•Freiberg’s sign: Pain with passive medial rotation of the extended hip causes a
stretch of the piriformis muscle
•Piriformis test
•Relaxed hands run over the skin around the sciatic nerve distribution indicating
alteration of sensation
•In disc herniation the Achilles tendon reflex is weak or absent
 Outcomes of Assessment
• Full range of motion, flexion, and extension of the trunk
and lumbar spine
• Palpation of buttocks painful and tense
• Weakness in abduction and lateral rotation of the hip
• Slump test negative
• Left buttock pain was elicited upon left hip flexion and
internal rotation of left hip
• Positive Lasèque’s sign (the medial rotated and
adducted hip the straight leg is raised, than foot
dorsiflexed, followed by lifting up the chin) with pain in
the leg
• Piriformis test positive
• Achilles Tendon reflex ???
 …rule out diff.diagnoses
• Stressing the sacrospinous and sacrotuberous
ligaments is pain free
• The SIPS move equal during nutation/ counter-
nutation
• Slump test, sneezing, coughing causes no pain
• Usually referred pain from coxofemoral
conditions do not go below the knee joint and
the ROM of the hip would be decreased
 Treatment Goals

• Relax muscle spasm

• Decrease pain
• Rest
• Ice
• Physiotherapy (Electrotherapy, stretching)
• Medication
• Injections
Piriformis Stretching
 CONCLUSION
• Controversy about piriformis syndrome
and its actual existence
• Estimated at 6 % to 8% of low back pain
• We could not find enough evidence in an
article that states an established pathology
to validate the existence of piriformis
syndrome. Therefore we believe that more
research has to be done in order to justify
this percentage.