Piriformis+Syndrome+Diagnosis

__**ANATOMY**__

The piriformis muscle originates from the anterior portion of the sacrum and inserts on the greater trochanter of the femur. Because of its positioning it is an external rotator of the hip when the thigh is extended and an abductor when the thigh is flexed. The piriformis is located so that the sciatic nerve exits just below it (in a small portion of people the sciatic pierces the piriformis) and this can cause complications. The complications are due to the piriformis being shortened and causing the sciatic nerve to be compressed. The shortening can be caused due to overuse of the hip flexors and adductors (runners and bicyclists). This forces the piriformis to have to work harder and causes the tightening over the sciatic nerve, which then produces symptoms of pain, burning, and tingling in the gluteal region and down the leg.

__**SUBJECTIVE**__
 * Symptoms:**
 * pain after sitting for longer than 15 to 20 minutes
 * pain when rising from sitting to standing
 * pain over piriformis
 * muscle spasm or compression of the sciatic nerve,
 * difficulty walking
 * pain with internal rotation of the ipsilateral leg
 * tenderness with palpation over the piriformis muscle,
 * pain that may radiate to the knee
 * external tenderness at greater sciatic notch
 * dysesthesia/hypoesthesia of the posterior aspect of the thigh


 * Signs:**
 * ipsilateral short leg,
 * gluteal and/or piriformis atrophy,
 * limited medial rotation of the ipsilateral lower extremity

__**OBJECTIVE**__ Figure 5 []
 * positive piriformis sign
 * Freiberg sign: pain with passive internal rotation of the hip
 * Pace sign (FAIR): *Placing patients in the FAIR position typically tightens the piriformis muscle and consequently compresses the sciatic nerve fibers and slows NCV- 85%specificit[[image:kumc-ptrs-ebp/PiriformisStSidelying.gif width="198" height="74" align="left"]]y

Figure 7 []
 * Beatty test- The patient is lying on the unaffected side and abducts the painful side upwards. The abduction causes deep buttock pain in those with PS
 * acute exacerbation of pain caused by stooping or lifting
 * Lesegue sign: pain in the vicinity of the greater sciatic notch with extension of the knee with the hip flexed to 90 degrees and tenderness to palpation of the greater sciatic notch also involving pain on voluntary adduction, flexion, and internal rotation
 * pain and weakness in association with resisted abduction and external rotation of the affected thigh
 * electromyography (EMG) may also be beneficial in diagnosing piriformis syndrome

*Keep in mind that there isn't one clear test to diagnosis PS but by doing several tests and eliminating other possible diagnoses you can be pretty certain

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 * Piriformis objective tests** **:**

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__** Medical Tests **__ - The H reflex test is similar to a reflex test but it is performed with an electrical stimulator that stimulates sensory fibers in their innervating nerves
 * Computer tomography (CT) and MRI may show asymmetry
 * Bone scan may demonstrate abnormal uptake in the soft tissues of the pelvis
 * If muscle injury or inflammation is present, increased signal may be seen within the piriformis muscle on T2 or STIR sequence
 * No relation between the sacroiliac joint syndrome and the piriformis syndrome; also consider that the absence of sacroiliac pain is an essential sign for a positive diagnosis
 * H reflex: observed extinction of the H wave, during the painful maneuver of forced adduction & internal rotation of the affected leg
 * New imaging techniques can be ineffective in diagnosing PS. It’s similar to the idea of pain: Some people have abnormal findings on the image but don’t complain of any symptoms; others complain of PS symptoms but nothing shows up on the image.
 * MRI has become essential to rule out any spinal disorders or pelvic disorders as mentioned by Pecina [ [|14] ] who found an MRI abnormality for the piriformis muscle syndrome in 7 out of his 10 patients

__**Can present similar to piriformis syndrome:**__
 * spinal stenosis
 * facet syndrome
 * sacroiliac joint dysfunction
 * trochanter bursitis
 * pelvic tumor
 * endometriosis
 * various conditions that involve irritation of the sciatic nerve

**Clinically speaking...** “We really don't see it that often. We see a lot of piriformis tension and a lot of sciatic nerve involvement - it's just that we rarely see that alone without something else going on.” Piriformis syndrome can come with low back or SI joint pathologies. Usually, these patients are very tender to just simple palpation of the muscle. The therapist might also use a test such as the straight leg raise test to check for nerve involvement.

Women's Health: Pregnant women will complain of pain in the back of their hip - they very commonly have piriformis tension and have sciatic nerve symptoms, however many have a SI joint pathology and a pelvic rotation due to the pregnancy hormones which cause increased joint laxity.

The following would be a good video to have your patients watch. It breaks down sciatica and piriformis syndrome in a way the general public can understand. []

**References: **

Boyajian-O'Neill, L., McClain, R., Coleman, M., & Thomas, P. (2008). Diagnosis and Management of Piriformis Syndrome: An Osteopathic Approach. //Journal of the American Osteopathic Association.// (108):657-664//.//

Cassidy, L., Walters, A., Bubb, K., Shoja, M. M., Shane Tubbs, R., & Loukas, M. (2012). Piriformis syndrome: implications of anatomical variations, diagnostic techniques, and treatment options. //Surgical and radiologic anatomy : SRA//. doi:10.1007/s00276-012-0940-0

Fishman, L.M., Dombi, G.W., Michaelson, C., Ringel, S., Rozbruch, J., Rosner, B., Weber, C. (2002). Piriformis syndrome: Diagnosis, Treatment, and Outcome- a 10 Year Study. //Arch Physical Medicine and Rehabilitation//. (83):295-301.

Hopayian, K., Song, F., Riera, R., & Sambandan, S. (2010). The clinical features of the piriformis syndrome: a systematic review. //European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society//, //19//(12), 2095-109. doi:10.1007/s00586-010-1504-9

Sen A, Rajesh S. Accessory piriformis muscle: An easily identifiable cause of piriformis syndrome on magnetic resonance imaging. Neurol India 2011;59:769-71

Lindsey Cassidy, A. W. (2011). Piriformis syndrome: implications of anatomical variations, diagnostic techniques, and treatment options. //SURGICAL AND RADIOLOGIC ANATOMY//


 * [|Jawish RM], [|Assoum HA], [|Khamis CF]. 2010. Anatomical, clinical and electrical observations in piriformis syndrome .**
 * [|J Orthop Surg Res.] 2010 Jan 21;5:3.**