Piriformis Syndrome

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Introduction

Physical Therapy in Hicksville for Sciatica

 

Welcome to Hicksville Physical Therapy’s patient resource about Piriformis Syndrome and Sciatica.

 

Any pain that begins in the area of the buttocks and proceeds down the leg is often referred to as sciatica. Of all the causes of sciatica, the most common is spinal nerve irritation near the lumbar region of the spine. Occasionally, this irritation of nerves can occur away from the immediate region and instead be down the leg. Another possible cause of sciatica is what’s known as piriformis syndrome. While this syndrome can indeed be painful, seldom does it present any danger and/or require surgical intervention. The good news is that afflicted individuals can ease pain and properly manage their condition with a few easy steps and even physical therapy.

The following information will help you learn:

  • What causes the problem
  • How piriformis syndrome is diagnosed
  • About any available treatment options.

Anatomy

What areas of my body are affected?

The nerves in the lumbar region come out from the spine and come together to create the sciatic nerve. This nerve then travels through the pelvic region through a small opening known as the sciatic notch.

Beginning inside the pelvic region, the piriformis muscle attaches to the sacrum. This connection creates what is known as the sacroiliac joint. The body holds two sacroiliac joints, one on the left side and one on the right side. At the opposite end of the piriformis muscle, the muscle connects, via a tendon, to the greater trochanter.

Now the piriformis muscle is one of the body’s external rotators in both the hip and the leg. This means that the job of the piriformis muscle is to help turn both the foot and the leg in outward directions. The job of the piriformis muscle is what can cause issues of sciatica. As the sciatic nerve travels under, and occasionally though, the piriformis muscle, the muscle can squeeze the sciatic nerve during its normal movement. This, in turn, leads to sciatica.

Related Document: Hicksville Physical Therapy's Guide to Lumbar Spine Anatomy

Causes

What is the cause of this problem?

As previously mentioned, sciatica and any related symptoms result from any form of irritation to the sciatic nerve. While doctors believe that the issue arises when the piriformis muscle begins to spasm and clamp down on or against the sciatic nerve, the truth is that it’s a mystery to medical professionals why this happens in the first place.

The piriformis muscle can also be injured during a fall. When an injury is sustained, bleeding can occur in and around the muscle. This bleeding can lead to a hematoma, a description used to categorize blood that has collected in the region. When this occurs, the piriformis muscle has a tendency to become inflamed and begins to apply pressure to the surrounding areas, including the sciatic nerve. The hematoma will inevitably dissolve, but the piriformis muscle will begin to spasm as this occurs.

This means that the sciatic nerve continues to be irritated. The piriformis muscle will eventually heal, but any damage has the potential to be replaced by scar tissue. As scar tissue does not have the elasticity of normal muscle fibers, this new scar tissue is more rigid and can cause the muscle to become tight. This tightness can, in turn, apply more pressure against the sciatic nerve.

Symptoms

What does piriformis syndrome feel like?

Piriformis syndrome often leads to pain that radiates from the pelvic region one or both legs. This pain can reach as far as the foot, often leading to confusion that the cause may be a herniated disc in the lumbar region. Regardless, while variations in sensation and overall weakness of the leg or foot are uncommon, some individuals have reported a tingling occurring down the afflicted leg.

 

For individuals suffering from piriformis syndrome, sitting can prove difficult with many opting to sit with their affected side tilted up rather than pressed against the chair.

Diagnosis

How can a medical professional diagnose piriformis syndrome?

Your medical provider will take down a thorough medical history as well as perform a physical examination. Upon visiting Hicksville Physical Therapy, our team will ask a series of questions regarding your symptoms and overall pain level. Further questions will include information concerning which positions or activities tend to make you feel better or worse, information regarding any past injuries, and information about additional medical issues that you are suffering from or that are genetic in your family.

After this series of questions has been completed, our physical therapist will perform a physical examination to check your gait, your overall posture, and the location of your pain. Our team will also look at which specific back movements tend to cause any change in your condition. Things such as your muscle strength, your reflexes, and the sensation of your skin will be tested as well.

Occasionally, patients will be referred to a doctor for continued diagnosis. For patients that are not, our team of physical therapists are able to provide you with a wide variety of treatment options to not only assist you in your recovery, but to help you back to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

The vast majority of patients suffering from piriformis syndrome will work with a physical therapist for treatment. During your visit to Hicksville Physical Therapy, a member of our team will evaluate your condition and determine effective treatment options for reducing your pain levels and spasms within your piriformis muscle.

When we at Hicksville Physical Therapy treat a patient with piriformis syndrome, the first course of action is typically the application of heat. Your physical therapist will likely use a hot pack on top of your buttocks muscle in order to help the piriformis muscle relax, therefore helping to relieve your spasming and reduce your pain.

Additionally, we may utilize ultrasound to implement deep heating in and around the buttocks area. During an ultrasound, high frequency sound waves make their way through the skin, producing a deep heating effect. This deep heating stretches out the piriformis muscle and prepares it for other, more hands-on treatment methods.

These hands-on treatment methods often include deep massage or certain methods of soft-tissue mobilization. During your treatment, your physical therapist might also work to position your leg and hip so that the nerve signals leading to the piriformis muscle are more relaxed.

We urge patients suffering from piriformis syndrome to perform recommended exercises, particularly those that stretch the muscle, in an effort to reduce or relieve irritation and pain on the sciatic nerve. Stretching can be even more beneficial when performed after hands-on treatments and heat application. Your physical therapist will demonstrate how you can effectively stretch your piriformis muscle. In addition to your assigned stretches that you perform here in the clinic, you’ll also be shown multiple options for stretching the muscle on your own time. It’s important to perform these stretches every few hours, but be gentle and take care to avoid overexerting yourself.

Once your symptoms begin to decrease, your physical therapist will slowly adjust your program to add exercises such as general conditioning, muscle strengthening, and posture training. The period of recovery and rehabilitation can vary from patient to patient, but typically, physical therapy sessions are attended two or three times per week for a timeline of six to eight weeks.

Post-surgical Rehabilitation

After you undergo surgery for your piriformis syndrome, your surgeon might prescribe physical therapy. Recovery times can vary, but in most cases, patients can expect to undergo physical therapy for four to six weeks. Full recovery typically takes up to three months to be achieved.

Once you’ve completed surgery and begin your physical therapy program, your physical therapist might utilize treatments such as ice or heat, electrical stimulation, ultrasound, or massage to reduce pain and muscle spasms. Afterward, your physical therapist will start teaching you how to safely move around in order to put minimal strain on the area that’s healing.

Throughout your rehabilitation program with Hicksville Physical Therapy, you’ll progress to increasingly more challenging exercises. Our goal for your treatment is to effectively but safety advance your functioning and strength.

As your physical therapy sessions progress, your physical therapist will help you with re-engaging in activities that you enjoy. We will work with you and instruct you on any changes you may need to make in how you perform these activities as well as which activities are acceptable and safe for you to perform. In an ideal situation, you will be more than able to get back to your activities as normal.

When you’re far into your recovery journey, you will no longer have to schedule regular appointments at Hicksville Physical Therapy. We will, of course, continue to be available to you as a helpful resource, but you will take full control of performing your exercises as part of your continuing home program.

Physician Review

If there is a concern that you may have an infection or a form of arthritis that is impacting more than one joint, your physician might order laboratory tests. In this case, it may be necessary for you to have blood drawn and provide a urine sample to submit to the laboratory for these tests.

Radiological Testing

It is typical for X-rays to be ordered for the pelvis and lower back. X-rays allow your physician to determine how much wear your sacroiliac joint has been subject to. X-rays of the hips and the lumbar spine can also be a vital resource for narrowing down the potential problem and eliminating the idea of other sacroiliac joint issues.

Additional radiological tests might also be helpful. An MRI, or Magnetic Resonance Imaging, scan is sometimes issued to see the pelvis and lumbar spine in more detail than what an X-ray can provide. MRIs can also help your doctor rule out other potential problems that could be causing your pain. MRI scans utilize magnetic waves as opposed to X-rays, leading to a more detailed and defined image of the body’s soft tissues.

Neurography is a unique form of MRI scan that is often preferred when looking at the nerves. This scan is performed with a standard MRI scanner; however, the computer settings are altered to focus on irritated areas along the nerve. This distinction can change the way that physicians utilize MRIs to diagnose various nerve problems, including piriformis syndrome, carpal tunnel syndrome, and thoracic outlet syndrome.

A bone scan might be used to determine how your skeleton is reacting to various forms of “stress,” including injuries, inflammation from arthritis, or infections. Your bloodstream will be injected with chemical “tracers,” which will appeal on X-rays specific to the spine. These tracers gather together in regions where your bone tissue is producing a strong reaction to a form of stress, including infection of the sacroiliac joint or arthritis.

Diagnostic Injections

The most effective and accurate way to determine if the cause of your pain is truly the piriformis muscle is to perform a diagnostic injection into said muscle. The piriformis muscle is located far inside the buttock, so the injection must be performed with X-ray guidance using a fluoroscope, an open MRI machine, or a CT scanner. The needle is positioned inside the muscle, then an anesthetic may be injected to paralyze the piriformis muscle. If, after the injection, your pain ceases, your physician can be more confident in stating that your pain is the result of piriformis syndrome.

Medical Treatment

In many cases, doctors begin treating piriformis syndrome by prescribing treatment options that don’t require surgery. Sometimes, doctors will simply keep an eye on the conditions of their patients to see whether there is improvement of symptoms. Anti-inflammatory medicines including naproxen and ibuprofen are typically used to calm the inflammation and pain caused by nerve irritation. Acetaminophen (such as the name brand Tylenol) can help to reduce pain but will have no effect on inflammation. Be sure to speak with your physician and/or pharmacist concerning the utilization of pain or anti-inflammatory medicine.

Injection Therapies

If, after undergoing a physical therapy regimen, you find that you are still in pain, your doctor might recommend injections. The primary use of these injections is to determine whether your pain is the result of piriformis syndrome. A local anesthetic like lidocaine can be injected into the muscle, resulting in temporary relaxation. This injection will help to loosen the muscle and, therefore, reduce the levels of irritation on your sciatic nerve. Additional medications can also be injected into the piriformis muscle.

For instance, cortisone can be combined with the anesthetic in order to reduce the sciatic nerve’s inflammation levels. This anti-inflammatory medication is incredibly potent and is typically used both in pill form and in the form of injections to combat inflammation.

Botox injections, formally referred to as botulism injection therapy, can be utilized in order to paralyze the piriformis muscle. When the muscle is paralyzed, pressure being put upon the sciatic nerve is reduced. Botox injections do not result in a permanent effect; instead, the results typically last just a few months. While the injection is effective, though, it’s recommended to engage in a stretching program to solve the issue. Once the injection wears off, if the patient has been consistently stretching the muscle, it may be stretched to the point where symptoms do not come back.

Surgery

Surgery may be appropriate for those suffering from piriformis syndrome, but often, this treatment method is strictly a last resort. Two procedures may be used. First, the piriformis tendon is cut where it is attached to the greater trochanter (which is the bump located on the side of the hip). Otherwise, the piriformis muscle will be cut through to reduce the pressure on the sciatic nerve.

Each of these methods are typically performed as an outpatient procedure, allowing you to return to your home on the same day of your surgery. Some cases do require patients to remain in the hospital overnight. Both procedures are able to be performed under a general or a spinal version of anesthesia.

Surgery will begin with your surgeon creating a small incision (of around three inches in length) in the buttock. The gluteus maximus, which is the biggest muscle within the buttock, will have its fibers split, allowing the surgeon to look deep inside the buttock and find the piriformis muscle. When both the piriformis muscle and the tendon have been identified, the surgeon will proceed to release, or cut, the tendon in the place where it is connected to the greater trochanter.

If additional room is necessary to relieve the pressure being placed on the nerve, some of the piriformis muscle may be taken out. Typically, this procedure causes no issue with strength since there are multiple muscles that are much stronger that assist the leg in turning outward.

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