Physical Medicine and Rehabilitation for Piriformis Syndrome-1
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Transcript of Physical Medicine and Rehabilitation for Piriformis Syndrome-1
11/25/11 Physical Medicine and Rehabilitation for Piriformis Syndrome
1/5emedicine.medscape.com/article/308798-overview#showall
Physical Medicine and Rehabilitation for PiriformisSyndrome
Author: Milton J Klein, DO, MBA; Chief Editor: Consuelo T Lorenzo, MD more...
Updated: Mar 31, 2010
Background
Piriformis syndrome has been a controversial diagnosis since its initial description in 1928.[1] The condition, whichcan mimic a diskogenic sciatica, usually is caused by a neuritis of the proximal sciatic nerve. The piriformismuscle can either irritate or compress the proximal sciatic nerve due to spasm and/or contracture. Piriformissyndrome is also referred to as pseudosciatica, wallet sciatica, and hip socket neuropathy.
Pathophysiology
The piriformis muscle is flat, pyramid-shaped, and oblique. This muscle originates to the anterior of the S2-S4vertebrae, the sacrotuberous ligament, and the upper margin of the greater sciatic foramen. Passing through thegreater sciatic notch, the muscle inserts on the superior surface of the greater trochanter of the femur. With thehip extended, the piriformis muscle is the primary external rotator; however, with the hip flexed, the musclebecomes a hip abductor. The piriformis muscle is innervated by branches from L5, S1, and S2, as demonstrated inthe image below.
Nerve irritation in the herniated disk occurs at the root (sciatic radiculitis). In piriformis syndrome, the irritation extends to the full thickness
of the nerve (sciatic neuritis).
A lower lumbar radiculopathy may cause secondary irritation of the piriformis muscle, which may complicatediagnosis and hinder patient progress.
Many developmental variations of the relationship between the sciatic nerve in the pelvis and piriformis muscle
have been observed.[2, 3, 4] In approximately 20% of the population, the muscle belly is split, with 1 or more partsof the sciatic nerve dividing the muscle belly itself. In 10% of the population, the tibial/peroneal divisions are notenclosed in a common sheath. Usually, the peroneal portion splits the piriformis muscle belly, although in rarecases, the tibial division does so.
In a study of 200 pairs of sacral roots (100 patients, none of whom had piriformis syndrome) by Russell et al, T1-weighted magnetic resonance imaging (MRI) scans revealed that 199 of the S1 nerve roots (99.5%) werepositioned above the piriformis muscle, while 150 of the S2 nerve roots (75%) traversed the muscle and 50 of them(25%) were located above it. The images also showed that 194 S3 nerve roots (97%) traversed the muscle andthat 190 S4 nerve roots (95%) were below it. The piriformis muscles had an average size of 1.9 cm; in 19% of the
study's patients, the muscle was asymmetrical by more than 3 mm.[5]
11/25/11 Physical Medicine and Rehabilitation for Piriformis Syndrome
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Involvement of the superior gluteal nerve usually is not seen in cases of piriformis syndrome. This nerve leaves thesciatic nerve trunk and passes through the canal above the piriformis muscle.
Blunt injury may cause hematoma formation and subsequent scarring between the sciatic nerve and short externalrotators. Nerve injury can occur with prolonged pressure on the nerve or vasa nervorum.
The etiology of piriformis syndrome can be divided into the following categories:
HyperlordosisMuscle anomalies with hypertrophyFibrosis (due to trauma)Partial or total nerve anatomical abnormalities
Other causes can include the following:
Pseudoaneurysms of the inferior gluteal artery adjacent to the piriformis syndromeBilateral piriformis syndrome due to prolonged sitting during an extended neurosurgical procedureCerebral palsyTotal hip arthroplastyFibrodysplasia ossificans progressiva (myositis ossificans)Vigorous physical activity
Piriformis syndrome remains controversial because, in most cases, the diagnosis is clinical, and no confirmatorytests exist to support the clinical findings.
Papadopoulos and colleagues proposed the following classifications for piriformis syndrome[6] :
Primary piriformis syndrome - This designation would apply to piriformis syndrome resulting from intrinsicpathology of the piriformis muscle itself, such as myofascial pain, anatomic variations, and myositisossificans.Secondary piriformis syndrome (pelvic outlet syndrome) - This classification would encompass all otheretiologies of piriformis syndrome, with the exclusion of lumbar spinal pathology.
Epidemiology
Frequency
United States
Given the lack of agreement on exactly how to diagnose piriformis syndrome, estimates of the frequency ofsciatica caused by piriformis syndrome vary from rare to approximately 6% of sciatica cases seen in a general
family practice.[7] Approximately 90% of adults have had at least 1 episode of disabling low back pain (LBP) intheir lifetime.
Mortality/Morbidity
Piriformis syndrome is not life-threatening, but it can have significant associated morbidity. The total cost of lowback pain and sciatica is significant, exceeding $16 billion in direct and indirect costs.
Sex
Some reports suggest a 6:1 female-to-male ratio for piriformis syndrome.
Contributor Information and DisclosuresAuthorMilton J Klein, DO, MBA Consulting Physiatrist, Heritage Valley Health System-Sewickley Hospital and OhioValley General Hospital
Milton J Klein, DO, MBA is a member of the following medical societies: American Academy of DisabilityEvaluating Physicians, American Academy of Medical Acupuncture, American Academy of Osteopathy,American Academy of Physical Medicine and Rehabilitation, American Medical Association, AmericanOsteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, American
11/25/11 Physical Medicine and Rehabilitation for Piriformis Syndrome
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Pain Society, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.
Specialty Editor BoardRajesh R Yadav, MD Associate Professor, Section of Physical Medicine and Rehabilitation, MD AndersonCancer Center, University of Texas at Houston
Rajesh R Yadav, MD is a member of the following medical societies: American Academy of Physical Medicineand Rehabilitation
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment
Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine andRehabilitation, Michigan State University College of Osteopathic Medicine
Michael T Andary, MD, MS is a member of the following medical societies: American Academy of PhysicalMedicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine,American Medical Association, and Association of Academic Physiatrists
Disclosure: allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching
Kelly L Allen, MD Medical Director, Medevals
Disclosure: Nothing to disclose.
Chief EditorConsuelo T Lorenzo, MD Consulting Staff, Department of Physical Medicine and Rehabilitation, AlegentHealth, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of PhysicalMedicine and Rehabilitation
Disclosure: Nothing to disclose.
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