Conservative Management of

Piriformis Syndrome

Douglas R. Keskula, MS, PT, ATCMichael Tamburello, MS, PT

ABSTRACT:Piriformissyndrome isaques-tionable clinical entity that has been citedas a cause of buttock pain and sciatica.The intimate relationship between thepiriformis and the sciatic nerve has beensuspected as being the source ofthe signsand symptoms that often appearfollowingminor trauma to the pelvic or buttock re-gion. Muscle function is an importantconsideration in the evaluation and treat-mentoftheathletewithsuspectedpiriformissyndrome. The action of the piriformismuscle on the hip varies as the hip movesfrom a neutral to aflexedposition. While inaflexed position, the piriformis internaltyrotates and abducts the hip; however, in aneutral position, the piriformis acts as anexternal rotator of the hip. A comprehen-sive evaluation provides the informationnecessary to design a treatment plan spe-cific to the involvedstructures, while meet-ing the functional needs of the individualathlete. Thispaper describes the anatomy,pathomechanics,physicalexamination, andtreatmentoptions relevant to thepiriformissyndrome. Treatment protocols stressingexercises that promote strength, flexibil-ity, andfunctional activities are believed tobe essential in restoring the athlete's abil-ity to return to pain-free competition.

r he piriformis syndrome has been im-plicated as a potential source ofpain

and dysfunction, not only in the generalpopulation, but in athletes as well (2,8,11).While there is disparity in the literature asto whether this syndrome actually exists(1,8,12), some suggestthatitismore preva-lent than citations in the literature would

Douglas Keskula is a doctoral candi-date at the University of Virginia inCharlottesville, VA.

Michael Tamburello is a commanderin the United States Navy and a doctoralcandidate at the University of Virginia.

indicate (1). Whether or not one embracesthis as a clinical entity, our purpose is toprovide the reader with an understandingof piriformis syndrome by reviewing therelevant anatomy and the proposedpathomechanics of this syndrome. More-over, practical and systematic strategiesfor evaluating and managing the athletewith suspected piriformis syndrome willbe offered.

Incidence/EtiologyThe incidence ofpiriformis syndrome

has been reported to be six times moreprevalent infemalesthanmales (11). Whileno dominant etiological factors have beenreported, piriformis syndrome often oc-curs following a minor trauma to the but-tocks or pelvis (1,2,12). The trauma isthought to precipitate a spasm of thepiriformis muscle, which subsequently in-flames the adjoining sciatic nerve (2).Piriformis syndrome has typically beencharacterizedby symptoms consistentwithirritation of the sciatic nerve. Isolating thedysfunction to this region usually followsexclusion of the more common causes ofbuttock pain and sciatica. More specifi-cally, complaints of buttock pain with dis-tal referral of symptoms are not unique topiriformis syndrome. Similar symptomsare prevalent with the more clinically evi-dentlowerbackpain syndromes and pelvicdysfunctions. Thus, a thorough evaluationof these regions must be performed toexclude underlying pathology.

AnatomyThe key elements of the piriformis

syndrome are the anatomical relationshipsofthepiriformismuscletothesciaticnerve.The piriformis muscle arises from the pel-vic surface of the sacrum, the greater sci-atic notch, and the sacrotuberous ligament.The lower attachment is the superior bor-der of the greater trochanter of the femur.The pirifonnis muscle passes over the sci-atic nerve in the majority of cases. How-

ever, variations in this arrangement havebeenreportedwiththenervecrossing aboveor through the muscle belly itself (3,4).The typical relationship ofthe sciatic nerveand the piriformis is presented in Fig 1.

Fig 1.-Posterior view of the pelvis and rightproximal lower extremity, illustrating the ana-tomical relationship between the piriformismuscle and the sciatc nerve

Some tiink tfiat the piriformis canbecome hypertrophied or can spasm, re-sulting incompression ofthe nerve againstthe ischium, or, more specifically, againstthe bony edge of the sciatic notch (3). Italso has been suggested that an accentu-ated lumbar lordosis and hip flexor tight-ness predisposes one to increased com-pression of the sciatic nerve against thesciatic notch by a shortened piriformis (7).Although differences in the anatomical re-lationships are helpful to facilitate under-standing the mechanism of dysfunction,these differences do not affect conserva-tive treatmnent strategies.

The pirifonmis muscle primarily is in-nervated by the S1 and S2 spinal nervesegments viathe sacral plexus. The sciaticnerve is derived from the same spinal seg-ments with contributions from theL4, L5,

102 Volume 27 * Number 2 * 1992 * Joumal ofAthletic Training

and S3 segments (4). Thus, one can appre-ciatetheconstellation ofneurological signsand symptoms that could emanate locallyor be referred distally to the lower extrem-ity as a result of this syndrome.

The piriformis is an external rotator ofthe hip and functions in conjunction withthe quadratus femoris, obturator externus,obturator internus, and the gemellus supe-rior and inferior. The rotary component ofthis muscle group has been reported todecrease with flexion ofthe hip (9). At 900hip flexion, this group of muscles has asignificant abductor component. Somereport that the piriformis functions as aninternal rotator in hip flexion (5,15). Thefunction of the piriformis at varying jointangles is animportantconsideration fortheclinician who is evaluating and treatingpiriformis syndrome.

EvaluationThe diagnosis ofpiriformis syndrome

is primarily a clinical determination; there-fore, a thorough history mustbe taken, anda careful, comprehensive physical exammustbe performed. Establishing a system-atic routine of evaluation not only facili-tates gathering objective informationfromthe examination, but it ensures that signifi-cantfactors arenot overlooked. The evalu-ation of the spinal neuromusculoskeletalsystem is summarized in the Table.

Subjective EvaluationObtaining a thorough medical history

from the athlete is an integral componentof the evaluation. It serves to enhance thephysical assessment process by providing

insight for the clinician to use to betterfocus on the relevant signs and symptoms.The subjective evaluation should be di-rected toward determining causative fac-tors, such as ahistory ofarecent trauma, orchanges in training regimen or lifestyle.Information regarding the location, inten-sity, behavior, and frequency of pain willassist in directing the clinician during theevaluation. Generally, individuals withpiriformis syndrome will report deep painthat is localized to the posterior aspect ofthe hip and is accentuated with standing oractivity. This discomfort often lessenswhen the patient is lying down. Also, flex-ion of the knees may further moderate thesymptoms. Pain, numbness, andparesthesiaradiating distally into thelowerextremity may be encountered; however,thesesymptoms frequently arepresentwithlumbo-pelvic dysfunctions as well. There-fore, it is crucial that you extend the examto these regions to rule out associated lum-bar or sacroiliac dysfunction.

Objective EvaluationThe objective evaluationmustencom-

pass an assessment of active and passiverange of motion of the spine and lowerextremities, as well as muscle strength andposture. Palpation of the area is necessaryto delineate the specific tissues involved.Several provocation tests have been sug-gested to differentiate piriformis syndromefrom other types ofdysfunction and will bediscussed later. In addition, aneurovascularassessment is necessary to rule out moresevere spinal pathology. The evaluationalso should include assessment of func-

tional and sport specific abilities to allowthe clinician to clearly defime the athlete'sfunctional limitations.

Range of MotionQualitative and quantitative assess-

mentofthemobility ofthepiriformismuscleis an important component of the evalua-tion. Passive intemal rotation of the hipwhile in 00 flexion may be painful, withlimitation ofmotion secondary to pain andspasm. Passive extemal rotation and ad-ductionwhile thehip isflexed to 900 wouldalso be expected to be limited and painful.Saunders (14) suggests a clarifying testforassessing sciatic nerve entrapment by thepiriformis. He advocates that when astraight leg raising test is positive for but-tockpain, you shouldthenextemallyrotatethe extremity to see ifthesymptoms dimin-ish. A lessening of symptoms is purportedtobeconfimationthatthepirifoimismuscleis impinging on the sciatic nerve.

StrengthThe conventional manual muscle test

for the external rotators, including thepirifonnis, is carried out while the patientis sitting (6). The test position is repre-sented in Fig 2. However, testing hip

Evaluaton of the Spinal Neuromusculoskeletal System

1. Observe the athlete's gait, stance, and sitting posture/position.2. Take a thorough history of the sequence and nature of the problem.3. Examine the structure and posture.4. Assess the range of motion and muscle length, qualitatively and

quantitatively.5. Assess strength, qualitatively and quantitatively.6. Palpate to determine the tension, texture, and temperature of the tissue.7. Perform neurogical assessment: deep tendon reflexes, myotome

screening, sensation, and special tests.8. Assess fuctonal ability and sport-specific activity.9. Examine X-rays, CT scans, and reports.10. Define problem areas.11. Establish short- and long-term goals.12. Develop treatment strategies to meet goals.13. Reassess to determine effectiveness of the treatment program.

Fig 2.-Conventional manual muscle test posi-tion t assess the external rotators of the hipincluding the piriformis muscle (Adapted fromKendall (6))

rotation in this position may provide mis-leading information about the status of thepiriformis and other intemal rotators (9),because, in hip flexion, the piriformis actsas an internal rotator. The correct manualmuscle test for the piriformis with the hipflexed to 900 would be resisted intenalrotation. Also, test the piriformis as anexternalrotatorwith the hip inO0 flexion asthe patient lies on his or her side or is prone

104 Volume 27 * Number 2 * 1992 * Joumal of Athletic Training

(Fig 3). Testing hiprotation inboth neutraland flexed positions provides you with amore comprehensive clinical picture ofmuscle performance.

difficult to palpate because of the depth ofthe muscle and the often large mass ofoverlying muscle and soft tissues. How-ever, you can locate the piriformis muscle

A B

Fig 3.-Alternative manual musde testing positions to assess the piriformis musde while the hip isinaneutral position. Theathletemaybe evaluated inA, the prone position, or B, the sidelying position.

pain in this area. This region is normallytender to palpation, and you must compareit with the uninvolved side to verify find-ings of painful areas. Furthermore, thisregion is the site of referred pain for lowerback disorders and may develop triggerareasthatcouldbeconfused withpirifornmissyndrome.

Functional AbilitiesThe athlete with piriformis syndrome

may exhibit functional limitations; how-ever, it is the pain that restricts activity orlimits normal function. Difficulty may beencountered when moving the leg outsidea car to stand up, moving laterally while ina sitting position, and maintaining balanceon a movable surface. Sport-specific limi-tations may be present and must be evalu-ated to further enhance the clinical deci-sion-making process.

Manual muscle testing applied to hiprotation may elicit contractions that arestrong, but painful. Because many func-tional activities are performed while stand-ing, testing in a neutral hip position mayprovide you with a more functionally ap-plicable strength test.

The pirifonrnis is an abductor of thehip in a flexed position. Carter (2) de-scribed an abductionprovocation testwherethe athlete is seated over the edge of thetable and asked to push his or her legs apartagainstmaximal manual resistance (Fig 4).The test is positive for a piriformis syn-drome if pain is localized directly over thepiriformis muscle.

Fig 4.- Manual musde test for hip abductionwith the athlete sitting

PalpationCareful palpation about the lumbo-

pelvic region not only provides you withinformation about tissue turgor, but willadequately locate hyperirritable regions inthe soft tissues. The piriformis can be

intheprone athleteusing deeppalpation. Ifa line were drawn from the posterior supe-rior iliac spine (PSIS) to the greater tro-chanter, and an intersecting line weredrawnfromthe anteriorsuperior iliac spine (ASIS)to the ischial tuberosity, the piriformismuscle would lie where the lines cross (Fig5) (10).

Fig 5.-Anatomical references used to locatethe piriformis musde

Others (2,12) advocate placing theathlete on his or her side with the involvedhip flexed, and palpating at the midpointbetween the ischial tuberosity and greatertrochanter. This position seems to displacethe gluteus maximus superiorly to partiallyuncover the sciatic notch for palpation ofthe piriformis and sciatic nerve. In addi-tion to assessing tenderness with palpa-tion, you should note evidence ofmuscularspasm. When using deep palpation tolocate suspected trigger areas, be carefulwhen interpreting the athlete's report of

TreatmentTreatment options for piriformis syn-

drome focus around the subjective andobjective findings of the assessment. Inmostcircumstancesofpiriformissyndrome,an inflammatory response is suspected inthe muscle and/or sciatic nerve. Therefore,the treatment goals are directed initiallytoward decreasing inflammation, associ-ated pain, and spasm, ifpresent. Treatmentoptions may include rest, cryotherapy,gentle pain-free stretching exercises, andelectrical modalities. Heating modalitiesoften are useful later in the rehabilitationprocess, when more vigorous stretchingexercises are necessary. These modalitiesare beneficial because soft tissue elonga-tion seems to be facilitated by the applica-tion of heat (18).

Exercise is perhaps the optimal meansof managing this disorder. Active exer-cise, passive stretching, soft tissue mobili-zation, and proprioceptive neuromuscularfacilitation (PNF) techniques are particu-larly effective inmoderating the symptomsand restoring range of motion. Fig 6 illus-trates specific exercise techniques thatpro-mote lengthening and relaxation of thepiriformis muscle, facilitating the restora-tion of pain-free range of motion. Theexercises are easily adapted for use in theclinic or as a component of the home exer-cise program. When incorporating thesetechniques into a plan, the clinician mustremember the internal rotation and abduc-tion function of the piriformis in the flexedhip. Therefore, the direction to stretch the

106 Volume 27 * Number 2 * 1992 * Joumal of Athletic Training

A B

C D

Fig 6.-Suggestions for exercises directed at lengthening the piriformis muscle. When the hip isflexed, the athlete applies pressure into adduction, as in A and B, or external rotation, as in C andD, to stretch the piriformis.

muscle should be opposite to thatused withthe hip in a neutral position.

The intensity, frequency, anddurationofthe exercise regimens aredetenninedbythe tolerance of the athlete. Initially, apractical guideline for active exercise in-cludes few repetitions (ie, five to ten) per-formed in three sets, two to three timesdaily. Once a base level of exercise toler-ance is established, the exercise program isprogressed as tolerated. More aggressivestretching methods, including contract-re-lax PNF techniques, can be employed inthe sub-acute phase.

Soft tissue mobilization may be inte-grated into the treatment plan to furtherenhance soft tissue extensibility. The ath-lete is positioned in a prone position with apillow under the abdomen. Apply gentlepressure to the piriformis muscle with theheel of your hand in a medial, superiordirection. You may flex the athlete's kneeto 900 and passively internally and exter-nally rotate the hip at a slow speed. Thistechnique may be contraindicated in ath-letes withkneepathology because itplacesincreased stress on the knee joint duringrotation of the hip.

You also may use modalities to facili-

tate relief from exercise-induced sorenessand may begin additional exercises tostretch othershortenedmuscle groups (suchas the hip flexors) at this point. Strengthdeficits in the piriformis and surroundingpelvic musculature also must be addressedin the rehabilitation program. Usually aprogressive strengthening program for thepiriformis may be initiated early in therehabilitation plan. Strengthening of thepiriformis should be carried out with the

hip in a flexed position, emphasizing ab-duction and internal rotation, as well as inaneutral position addressing external rota-tion. Resistance may be provided manu-ally with cuff weights, or using rubbertubing. Entry-level exercises designed tostrengthen the piriformis are presented inFig 7.

Tofacilitatestrengthgainswhilemini-mizing adverse symptoms, the strengthprogram should begin with few repetitionsand little resistance. The athlete shouldprogressbasedonhis orhertolerance to theexercise. Strength training also might in-clude the use of PNF diagonal patterns,specifically D2 flexion and D2 extensionpatterns (13,17).

Functional activities are an integralcomponent of the rehabilitation program.Proprioceptive, balance, and coordinationactivities are introduced when the neces-sary mobility and strength elements be-comeevident. Progressingfromcontrolledmobility activities (distal componentfixed)to skill activities (distal component free)provides the clinician with a myriad oftreatment options tomeetthe specific goalsoftheathlete. Consultthework of Sullivan,et al (16) to expand your knowledge of thestages of motor control and its applicationto therehabilitation ofpiriformis syndrome.As basic activities are tolerated, sport-spe-cific skills may be introduced.

A home exercise program is an inte-gral component of the overall rehabilita-tion program. Consider independence andcompliance with the program in planningshort-term objectives. Providing the ath-lete with clear and concise illustrated in-structions should promote independenceand compliance with the exerciseregimen.

Additional treatment options may

A B

Fig 7.-Suggestions for exercises directed at strengthening the piriformis muscle. When the hip isflexed, theathlete abducts the lower extremity, as in A. When the hip is ina neutral position, the athleteexternally rotates the thigh, as in B. External resistance may be applied with rubber tubing to eitherexercise as illustrated in B.

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include education with respect to bodymechanics andpostr activitymodification,and use of foot orthotic devices. In caseswhere consenivemvmeasufrfal,injectionofthe piLifmis muscle with a steroid has beenadvocated, with surgical resection being re-sevedforthemostrecalcitantcases (1,Z21 1).

SummaryPiriformis syndrome is both a diag-

nostic enigma and a questionable clinicalentity touted as a cause of buttock andlower extremity pain. While piriformissyndrome is not frequently encountered inthe sports medicine setting, a basic under-standing of the relevant anatomical rela-tionships, evaluative techniques, and treat-ment options is necessary to effectivelymanagethe athletewhopresents withsymp-toms suggestive of piriformis syndrome.

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12. PapadopoulosKM,McGillicuddyJE,A1bersJW. Un-usual cause of pirifomnis muscle syndrome. ArchNeurol. 1990; 47: 1144-1146.

13. Prentice WM. Rehabilitation Techniques in SportsMedicine. St Louis,Mo: TimesMirror/Mosby, 1990:73-85.

14. Saunders HD. Evaluation,TreatmentandPreventionofMusculoskektal Disorders. Eden Pmiric, Minn:Educational Opportunities; 1985: 155-156.

15. SteindlerA. Kinesiology of theHuman Body. 4thed.Springfield, 1l: Charles C. Thomas Publisher, 1976:296.

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