Piriformis syndrome Optimum rehab ?

Suggestions please for the most effective approach to piriformis syndrome rehab, my pt. a competitive triathlete, c/o deep aching pain with occasional 'sciatica' type twinge during exertion (pushing high gear in cycling) very non specific pain but reproduced on exercise only, any idreas welcome

Thanks.

[Physiobase]

Check bike setup first. Perhaps put some EMG (electromyography) pads on the quads etc and have them ride on rollers. Then measure what's happening where as you change things like stem height, seat position and height and distance from seat to stem.

All these have influences on what happens to the leg during cranking and therefore the potential overuse of one side, including the piriformis. You must check out the amount of internal hip rotation in flexion. Note this is lessened by an increase in stem height.

It might sound like a lot to consider but it really works. please let us know how you get on.

Hi all,
i think, u may check mobilization of the sacrum bec smthimes it locked and makes pain. I always use priformis streching and sacrum mobilization. I hope it will work.

[alophysio]

Hi!

Similar to the above posts...

Why is the piriformis overactive on that side? Is it a joint dysfunction, compensation strategy or muscle injury?

The non-specific nature and low irritability of the condition seems to say to me that the problem is probably postural - why does he only have the pain now - how long has he been cycling for and how long has the pain been there for?

Good luck!

Thanks for the comments,

the pain was first noticed on a training ride, 60+ miles, insidious onset, and only evident when seated and pushing a high gear, i.e. demanding effort ++ on downstroke, and eases as soon as effort is reduced,
following initiation of pain, pt. is left with a feeling of 'weakness' in adductors (though when tested, none evident) although lat. rotn. m/strength may be slightly reduced.

palpn reveals deep adhesions to piriformis and surrounding tissues, which have reduced with rx.

I have tried deep sstm and piriformis stretches which seem to have relieved symptoms to a degree and have introduced theraband exercises to address rotator weakness.
I think part of the pt.s problem may be psychological ? imagined rather than real injury perhaps ?

thanks for all your advice, any more much appreciated.

[alophysio]

Hi Bikerphys.

Have you considered his joints? You probably have but you do not mention them, only his muscles.

Adductor Longus has fascial attachments to the contralateral external oblique (EO). Overactive EO can cause pain and overactivity in the adductors. I had one lady who had >6 month progressively declining ROM in her right hip which another physio couldn't help. In the end, it was an overactive EO that was the culprit and simple oblique cruches improved her ROM (by teaching EO to become phasic again). Maybe the same is happening to your guy.

What about his pubic symphysis? Is it symmetrical? Does his Active SLR test show one leg heavy? If so, he has a load transfer problem and it is probably the cause of the overactive piriformis which is trying to stabilise the pelvis. The same would go for the L/S and SIJ. I only add these since you did not mention them, only muscles...

Lastly, please don't write your patients off with psychosoial problems unless there are clear yellow flags. I feel that too many physios go down this route when they can't get their patients better - better to blame the patient than improve their own knowledge. I am not saying that you are doing this. It is just a pet hate of mine! A good yellow flag screening can be found on the NSW Workcover Site, Appendix 1. It also has the Orebero Questionnaire in it. It is publication Number 4402 and the link is www.workcover.nsw.gov.au/...ctprog.htm

I find the FACTORWEB acronym helpful and the list is in a particular order.

In summary, I believe that this guy - based on such limited information and not actually seeing him - has a load transfer problem through his pelvis or L/S and it is shown up through harder work. If untreated, i would expect it will begin to take less strenuous training to bring on the pain. In my experience, triathletes are not wimps and don't fake things to get out of training - I find it hard to stop them overtraining!

Hope this helps!

Dear alophysio,

thanks v. much for your input, much appreciated something there for me to look at, although his joints are all clear and he has full active symmetrical ROM in both hips and his Lx and pelvis are unrestricted and also symettrical, the idea of EO involvement has flicked a switch though !
I agree with your comments about triathletes psyche and wasn't seriously suggesting my pt is a wimp ! (I wouldn't dare, he's bigger than me !!:eek )

Thanks for the reply.
Much appreciated.

[MrPhysio+]

Hi
I think Alophysio is very wise. The problem does sound like loading, with resultant irritation and tethering. Have you checked leg length? Either real or apparent leg length discrepancy can cause excessive loading through one side of the seat. Apparent leg length discrepancy will be caused by tighter muscles of the erector spinae group on that side, hitching the hip. A weakness on one side will also cause more effort on that side when pushing, with a postural list onto the seat, increasing pressure onto the sciatic nerve. This in turn causes inflammation, tethering, and a greater focus for pressure, leading to potential weakness, perpetuating the cycle ( sorry about that pun).

If there is a leg shortening, address the muscles of the low back via appropriate stretching, and if a real leg length problem have the shoe or cleat / crank adjusted to compensate. Sometimes a number of areas need to be addressed to sort out the various compensatory mechanisms that have developed.

Very deep tissue massage through the Glut Max to piriformis and the tethering are necessary. Trigger point dry needling (if available), can be of assistance. Postural stretching for the shortened side is imperative, as are stretches for the hamstrings and gluteals, but only after deep massage (friction type - to the point of bruising).

Another option is to identify the pressure area and make up a temporary pressure relieving pad for the bike nicks or seat.

Good luck. Let me know the relevance of the above - and any outcome.

Last resort is a cortisone injection - avoid if possible.

hey guys

truly interesting stuff you are mentioning here

Did you know all this after graduating? or experience?

[Physiobase]

post Grad. I was a triathlete and am a qualified triathlon and swimming coach and was doing this prior to and after physio. Also a great EMG course run by Jenny McConnell and Craig Allingham (mainly on throwing) is an excellent post grad course if it comes yuor way.

Bike set up is all important to relate the machine to the individual riding it. Do some google searches and you'll find some good material on it. 8o

[alophysio]

I agree - post grad.

I "wasted" my first 2 years as a physio and couldn't even justify why you would do even a mobilisation. The treatment I was giving people was "right" because I was told what I was doing was "right" by my seniors but I couldn't understand why nor could I get a decent explanation about things.

I then started doing courses - the turning point was a Manual Concepts course "Certificate of Spinal Manual Therapy" - see www.manualconcepts.com - which set me on the path to learning.

From there, it was Barb Hungerford courses which led me to Diane Lee and LJ Lee, Trish Wisbey Roth,Peter O'Sullivan, the work of Paul Hodges et al, etc...

Until then, I was a typical Sydney-Educated physio who comes out thinking that we know it all in Sydney!

Find someone to help guide you in your learning is the best...

I grad one yr ago, and know what you mean Alophysio, sometimes im doing something, and ask myself but why, so i go back to books to read read and read, took 1 post grad course which was pretty amazing, and looking forward to my next one in April. Want to do more, but unfortnately masters is drinking my money right now, and working on the Canadian licence exam is not cheap!!

So have to be patient....

>:

[alophysio]

Does that mean you are currently doing your masters?

If so, good on you...

ANyway, you are in Canada - you have Diane Lee and LJ Lee and Stu McGill in your own back yard - try to get on some courses - when the money is there!

Enjoy learning - it should be for life.

yep doing masters, but dont like it as only research based
i emailed u few days ago on manip masters in autsralia, as I believed the masters here would help me become a better physio, but its only research oriented, so pretty disappointed...

Yep, Diana Lee is great, but shes giving courses bit far away for now....so need to win the lottery to get some money

take care

[sdkashif]

Piriformis syndrome is characterized by pain and instability. The location of the pain is often imprecise, but it is often present in the hip, coccyx, buttock, groin, or distal part of the leg. The piriformis muscle can either irritate or compress the proximal sciatic nerve due to spasm and/or contracture, and this problem can mimic diskogenic sciatica (pseudosciatica). This condition is identical in clinical presentation to LBP with associated L5, S1 radiculopathy due to diskogenic and/or lower lumbar facet arthropathy with foraminal narrowing.

Aetiology:

The different causes of the piriformis syndrome can be categorized as under:

Trauma to the buttocks or gluteal region is the most common cause. Skiers, truck drivers, tennis players, and long-distance bikers are at high risk. Blunt injury may cause hematoma formation and subsequent scarring between the sciatic nerve and short external rotators

In Morton foot, the prominent head of the second metatarsal causes foot instability and a reactive contraction of the external rotators of the hip during gait.

Spinal stenosis can lead to bilateral piriformis tenderness.

Anatomic variations of the divisions of the sciatic nerve above, below, and through the belly of the piriformis muscle may be causative factors.

Hyperlordosis

Muscle anomalies with hypertrophy

Fibrosis (due to trauma)

Partial or total nerve anatomical abnormalities

Pseudoaneurysms of the inferior gluteal artery adjacent to the piriformis syndrome

Bilateral piriformis syndrome due to prolonged sitting

Total hip arthroplasty

Myositis ossificans

Vigorous physical activity

Functional biomechanical deficits: These may include the tight piriformis muscle,tight hip external rotators and adductors, hip abductor weakness, lower lumbar spine dysfunction, Sacroiliac joint hypomobility. As a result functional adaptations to these deficits include the ambulation with thigh in external rotation, functional limb length shortening, shortened stride length.

Management:

A suitable management programme will be followed as under:

Acute Phase:

Rest & avaoidance of provocative activities:

The patient should be instructed to rest from offending activities. Professions that involve prolonged sitting can worsen symptoms, and patients should avoid sitting for long periods. Patients should be instructed to stand and walk every 20 minutes. Patients should make frequent stops when driving to stand and stretch.

Modalities & Stretching:

Physical therapy modalities often are beneficial forms of treatment when used in conjunction with stretching and manual therapy. The use of moist heat and/or ultrasound treatment (~2 W/cm2 for 5-10 min) often is recommended prior to stretching of the piriformis muscle. Prior to performing piriformis stretches, the hip joint capsule should be mobilized anteriorly and posteriorly to allow for more effective stretching. Soft tissue therapies of the piriformis muscle can be helpful, including longitudinal gliding with passive internal hip rotation, as well as transverse gliding and sustained longitudinal release with the patient lying on his/her side. The piriformis muscle is stretched with flexion, adduction, and internal rotation of the hip adductors and the knee while the patient lies supine. This stretching is performed by bringing the foot of the affected side across and over the knee of the other leg. To enhance the stretch of the piriformis muscle, the physical therapist may perform a muscle-energy technique. This is completed by having the patient abduct the limb against light resistance provided by the therapist for 5-7 seconds, and then is repeated 5-7 times. In addition to stretching the piriformis, the patient also should be instructed to stretch the iliopsoas, tensor fascia latae, hamstrings, and gluteal muscles. Cold packs and, occasionally, electrical stimulation are applied after exercise or manual therapy. Cold modalities help to decrease pain and inflammation that may have been further triggered by stretching or massage. Remember to stress to patients the importance of light and gradual stretching techniques for the piriformis muscle to avoid overstretching and possible further irritation to the sciatic nerve.

Myofascial Therapies:

The Spray and Stretch myofascial treatment and ultrasound modality can be used to restore the original length of the muscle. In addition ischemic compression, lewit technique can also be used

Soft Tissue Massage:

Soft tissue massage to the gluteal and lumbosacral regions may help to decrease tightness of the affected musculature and reduce irritation of the sciatic nerve. Some physical therapists may be trained in performing myofascial release techniques for the piriformis muscle as well. Friction massage as described by James Cyriax can be used effectively.

Manipulation:

The patient is placed in a lateral recumbent position on the unaffected side. The therapist faces the patient and rotates the patient’s upper body away by laterally pulling on the lower arm. The therapist places his or her cephalad hand most superiorly on the paravertebral muscles. The patient’s top leg is brought over the edge of the table. The therapist places her caudal hand over the patient's hip in the line of the lowered leg. Force is applied in the direction of the lowered leg but perpendicular to the muscle fibers. When tension is reduced, a thrust (high-velocity low-amplitude) technique can be applied.

Addressing sacroiliac joint and low back dysfunction also is important.

Homes Activities Modifications:

(1)Before arising from bed, roll side to side and flex and extend the knees while lying on each side. This exercise can be repeated for a total of 5 minutes.

(2) Rotate side to side while standing with the arms relaxed for 1 minute every few hours.

(3) Take a warm bath with the full body (to the shoulders) immersed; the buoyancy effect is effective.

(4) Lie flat on the back and pedal the legs as if riding a bicycle by raising the hips with the hands.

(5) Perform knee bends, with as many as 6 repetitions every few hours. A countertop can be used for hand support.


Recovery Phase:

Modalities:

Therapeutic modalities are continued through this phase to enhance the benefits of rehabilitation.

Strengthening and Resumption of Activities:

The patient may begin gradual strengthening activities for the piriformis and gluteal muscles.. As the patient becomes asymptomatic, he or she may initiate light sport-specific activities and functional training.

Addressing posture and faulty pelvic mechanics is important when resuming activity. Some athletes may need to change their footwear or undergo an orthotic consultation to correct their pelvic alignment and avoid further stress on the piriformis muscle.

Maintenance Phase:

During the maintenance phase of rehabilitation, the patient should continue performing a home exercise program for increasing flexibility and strength. Athletes may gradually increase their training volume as tolerated. Runners should be cautious when resuming speed training and hill running, doing so in a gradual fashion with proper warm-up and cool-down periods. Compliance to a daily stretching program is crucial to avoid recurrence of this syndrome. Return to play is dependent on many factors (eg, severity of condition, how soon treatment was initiated, level of patient compliance to program).