RICE & MICE: What a pain in the butt! Piriformis syndrome

Piriformis syndrome is one of the causes of sciatica, or irritation of the sciatic nerve. The piriformis is a deep muscle of the buttocks that lays beneath the gluteal muscles. It runs from the sacrum, the fused vertebrae at the bottom of the spine to the femur, or thigh bone. In most people, the sciatic nerve lays underneath the piriformis, but in up to 25 percent of people, the sciatic nerve will actually pass through the muscle.

The function of the piriformis is external rotation or rotation of the leg out as well as assist in abduction, or bringing the leg outward and away from the other leg. Of course, the piriformis isn’t a lone player in these movements and there are other muscles that work to rotate and abduct the leg.

When ice skating, the hip is slightly externally rotated so the toes point outward as the leg pushes off. The piriformis helps maintain efficient walking, running and skating strides. More females are affected by piriformis syndrome than males.

Symptoms of piriformis syndrome include pain in the buttock, decreased mobility and tightness of the hip, low back pain and pain radiating or shooting down the back of the leg. Because there is radiating pain, called radicular pain, it is important to differentiate simple sciatica from more serious problems such as herniated or ruptured vertebral disks, however piriformis syndrome usually does not cause numbness or tingling in the affected leg.  The sciatic pain from piriformis syndrome usually worsens with sitting or squatting. In some women, piriformis syndrome can cause pain in the vulva area and pain with intercourse. Likewise, men may complain of scrotal pain.

The pain of piriformis syndrome can be reproduced by palpation or pushing on the gluteal area (mid-buttock), pain with elongation or stretching the piriformis by adduction of the hip or by flexion at the hip. The most common cause of piriformis syndrome is trauma to the buttock, through a fall or by blunt force, but other causes include overuse or anatomic variations where the sciatic nerve passes through the muscle. When the piriformis muscle suffers trauma, it begins to swell and put pressure on the sciatic nerve. Sometimes the muscle will go into spasms to help protect itself from further trauma and restrict motion in the pelvis.

Overuse of the muscle may include overtraining or training after a period of inactivity or a period of sudden activity increase like weekend tournaments. The athlete may be well-trained and well-conditioned; however the sudden increase in stress can cause the muscle to go into spasm. Sports that focus on explosive speed and quick acceleration may have a higher incidence of strain of the piriformis, such as a football running backs or hockey players.

Pregnant women are also prone to this because a hormone, relaxin, is released to help relax the ligaments and joints of the pelvis to accommodate a growing baby and childbirth. The widening of the pelvis can put an increased strain on the sacrum at the bottom of the spine where the piriformis attaches.

Piriformis syndrome is largely a diagnoses of exclusion, which means that other possibly diagnoses are explored and ruled out before the diagnosis of piriformis syndrome is made.

Once the diagnosis is made, treatment and rehabilitation can begin. Of course, the best treatment is prevention, including maintaining flexibility of the groin and hip through stretching, however physical therapy will help to ease muscle spasm and pain, and increase strength and flexibility. Heat is usually used in the form of warm whirlpool, hot packs and/or ultrasound heat. Other methods utilized at therapy include tissue mobilization, stretching, and eventually muscular strengthening.

Other methods of treatment include cortisone injection to reduce inflammation around the sciatic nerve, muscle injection with lidocaine to temporarily relax the muscle, or injection of botulism toxin, similar to botox, to actually paralyze the piriformis muscle. Botulism toxin is temporary and only lasts a couple of months, but sometimes if the muscle is paralyzed it is easier to manipulate and stretch

Surgical treatment is used as a last resort only and involves releasing or cutting the tendon of the piriformis where it attaches to the thigh bone or actually cutting a portion of the muscle to ease pressure on the sciatic nerve.

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