Piriformis Syndrome
Ankle Injuries
July 24, 2020
Hit the Ground Running
July 24, 2020Piriformis Syndrome
Piriformis Syndrome
Piriformis syndrome- what an absolute pain in the butt!!! Piriformis syndrome is an umbrella term for pain in the back of the hip and occasionally into the leg caused by piriformis spasm or overactivity. This piriformis is a muscle deep in the back of the hip which attaches from the front of your tailbone (sacrum) extending out onto the greater trochanter of the hip (hard bit on the outside of your hip). The sciatic nerve literally passes through the piriformis in 15- 20% of people which may make them more susceptible to neurological symptoms and referred pain related to piriformis spasm/tension. Personally, I feel the diagnosis of piriformis syndrome – as is the case with many ‘syndromes’- is weak and offers very little insight as to the why and how we’re going to address the problem. So when someone pops in to the clinic for an initial assessment for their weird and wacky hip/ low back/pelvic pain what is it that our practitioners at City Physio are looking for?
First of all, getting to the bottom of any injury requires a detailed history to identify potential past incidents or ongoing behaviours which may predispose you to altered loading patterns through the area of injury. A physical assessment will then help to correlate the information you have provided with posture, movement strategies, muscle length and muscle strength before some palpation – or more colloquially ‘poking and prodding’- will give us a complete picture of joint position which can be either the cause or result of your problem. Unfortunately, people come to see us when they’re in pain so attaining a ‘normative’ baseline on initial assessment of back pain is difficult but as acute flares of pain start to settle and we start to tick some boxes with regards to muscle strength and function we can ascertain what your bodies go-to movement strategies may be. This allows for a targeted approach which will consist of postural cueing which facilitates activation of little stabiliser muscles, stretching and self-release techniques for unloading of painful structures, strength training with a focus on form which will progress into specific goal-oriented tasks, whether they be sport- specific drills or strategies for the sedentary desk bound office worker. Treatment outcomes are totally based around what you want to get out of your body!
Now for the why… and I’ll preface this by saying pain is a multifactorial experience and there are certainly often emotional, psychological and environmental contributors which should be recognised and considered BUT as physio’s these things are more in our backyard than our house and if they’re primary drivers then referral onwards and multidisciplinary care should be encouraged. What we know from a primary hip and pelvic injury is it is influenced by force closure (muscles and fascia), form closure (ligaments, bones and joint) and motor control (neural sequencing).
Generally speaking, without a history of significant trauma, i.e. motor vehicle accident, high impact fall from a height, or complications in pregnancy; form closure or structural contributors to pelvic dysfunction are less likely. So, the primary musculoskeletal contributor to pelvic dysfunction and in this context, piriformis syndrome, is force closure and motor control. These two things are entirely related and without decent neural input and optimal muscle activation and sequencing to stabilise a joint, even the strongest and bulkiest muscle isn’t going to perform well.
Think back to earlier where we talked about your history formulating a picture regarding pathology. Now if there was ‘trauma’ or a noted incident, i.e. tweaked back during a heavy deadlift (definitely one of the more common stories we hear!), we’re thinking technique may have gone amiss leading to compression or distraction of structures in the lumbar spine which may create a guarding repose (spasm) and an acute inflammatory event. Trauma CAN but DOES NOT have to involve tissue damage as this instance indicates, however in some cases there may be a discogenic component which involves a tear of the hard outer surface of a disc with some protrusion of the soft inner outwards towards potentially affecting a nerve root. In any case, an acute inflammatory event perpetuates pain and dysfunction which almost always settles within a matter of weeks so if you’re in the midst of an acute flare you need not worry this will likely settle soon! Those with issues arising without trauma likely have a behavioural predisposition which creates an overload on structure sin the back creating a similar form of spasm or guarding. Think desk workers with postural inadequacies, hypermobile people, predominantly unilateral sport players (soccer and tennis for example), sudden changes in lifestyle to name a few.
Importantly, the difference between getting on top of chronic back pain for longer periods and just managing symptoms as they come up is the quality of rehabilitation and your willingness to engage in it. Pain will resolve however dysfunction will remain unless addressed – unfortunately symptoms represent a very small part of a problem! There are over 600 muscles in the human body and most of them lay deep and act to stabilise the skeleton. There are probably only ~30 muscles which you can see when looking in a mirror- most of these ones are bigger and contribute towards producing movement and power. During a pain event there is inhibition of the smaller stabiliser muscles, e.g. there is cross-sectional wasting of the lumbar multifidus (segmental stabiliser) muscle within 24 hours of a pain event. I often use the analogy of a light dimmer. Pain starts turning the dial backwards so that the light grows dimmer in the stabiliser muscles while inversely turning the dial up in some of the bigger surface muscles which creates significant muscle spasm and general compression symptoms. Gluteus maximus activation has also been shown to be delayed on the side of low back/ pelvic (SIJ) dysfunction with ramifications to pelvic stability during load transfer, as well as altering hip motion. Piriformis runs parallel to the gluteus maximus and is generally the muscle whose dial is turned up to compensate for altered hip and pelvic biomechanics due to glute inhibition.
In summary- piriformis syndrome is the result of altered lower back and pelvic stability. The piriformis acts as a guard in the case of gluteus maximus inhibition. Gluteus maximus is a large powerful muscle so these are some pretty big shoes to fill. Is it any wonder it hurts when someone sticks an elbow into your butt when you’re back has been sore on and off for weeks, months, or years? If you think you have ‘piriformis syndrome’ pop in and see us at City Physio in Martin Place and let’s forego the band-aid approach and aim for a more permanent solution focusing on strength and resilience.
Matthew Hagerty
NOTE: if you have significant neurological symptoms (pins and needles, numbness, weakness), change in bladder or bowel function, significant trauma, unremitting night pain or recent surgery (particularly abdominal) please contact and see your health professional IMMEDIATELY. For the rest of you – rest where possible, short bouts of gentle movement regularly are encouraged and see your physio ASAP to help with pain management and transition into a rehabilitation program focused on long term self-management.
At City Physio we are very patient-focused. We listen to your goals and we want you to achieve them in the safest way. Contact us Now!
