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British Journal of Sports Medicine
The "piriformis syndrome"- myth or reality? Link
M T F Read
7 Waterden Road, Guildford, Surrey GU24 0LX, UK
Keywords: piriformis syndrome; sciatic nerve; buttock; hamstring
NOTE: I am not a Doctor, Please speak to your doctor regarding any nerve condition.
In the above editorial,1 I noted the desire to package these rather indeterminate
pains in the buttock, around the trochanter, and which can radiate to the groin
or knee, as a deep gluteal syndrome. The piriformis syndrome and the hamstring
syndrome, I believe exist, but in my admittedly very small experience, as they
are rare, they do have a major clinical finding that differs from pain induced by
the hip stabilizers. Because the sciatic nerve is involved, the straight leg raises,
Laseque and Bowstring signs, which produce neural stress peripheral to the lesion,
are positive, but the slump test, which moves the dura and is proximal to the lesion,
is negative. Most patients diagnosed as having "piriformis syndrome" do not have
these clinical findings, and their problem better fits the classification of deep
gluteal syndrome. Perhaps, in fact, the deep gluteal syndrome diagnosis should be
used as well as, and not inclusive of, the piriformis and hamstring syndromes. I
feel the gluteals are often not involved and perhaps an even broader term such as
hip stabilizer syndrome should be considered.
February 3, 2005 -- New News: In, "The Journal of Neurosurgery Spine", from
studies of UCLA and Cedars Sinai Medical Center in Los Angeles, CA. --
Dr. Aaron Filler, M.D.
Study of Piriformis Syndrome -- Proper Diagnosis now Available:
Institute for Nerve Medicine
Internet:
sjackson@nervemed.com
http://www.nervemed.com
Company Information:
Institute for Nerve Medicine
2716 Ocean Park Blvd.
Suite 3082
Santa Monica, CA 90405
USA
Ph. 310-314-6410
Fx. 310-314-2414
Media Contacts:
Shirlee B. Jackson
Executive Director
310.314.6410
VIDEO AND PHOTOS AVAILABLE: Cedars Sinai Medical Center, UCLA and the Institute for
Nerve Medicine: Breakthrough Medical Findings Provide Answers To Back Pain Sufferers
Revolutionary Medical Report published in the February issue of The Journal of
Neurosurgery: Spine - Findings In A Revolutionary Medical Report From Doctors At UCLA,
Cedars-Sinai Medical Center And The Institute For Nerve Medicine Reveal That New
Technology Better Diagnoses And Treats Back Pain Sufferers With Sciatica
For Immediate Release
LOS ANGELES, Calif./EWORLDWIRE/Feb. 3, 2005 --- In a report that may revolutionize
the treatment of more than a million cases of sciatica (radiating leg pain) each year,
investigators from Cedars Sinai Medical Center, UCLA and the Institute for Nerve Medicine
in Los Angeles, California report today in the Journal of Neurosurgery - Spine that new
technology can accomplish the reliable effective diagnosis and treatment of piriformis
syndrome and other causes of sciatica that do not involve a herniated lumbar disc.
The paper, entitled: "Sciatica of Non-Disc Origin & Piriformis Syndrome: Diagnosis by MR
Neurography and Interventional MRI with Outcome Study of Resulting Treatment" addresses
the current problem of a nearly 80% failure rate for diagnosis using standard methods.
The study involved 240 patients followed for up to seven years.
The most common cause for sciatica in the study proved to be a diagnosis called "piriformis
syndrome" - one of several disorders the investigators report on that arise due to entrapment
of the sciatic nerve in the area of the hip. Currently, the report says, when a patient
experiences painful persistent sciatica - pain radiating down the leg - physicians often
look only for a herniated lumbar disk relying upon lumbar MRI scanning. Surgery for the
disk herniation is often carried out to treat the sciatica.
Most spine specialist consider piriformis syndrome to be extremely rare. However, the
authors conclude that although it is rarely diagnosed, it is actually a common cause of
sciatica - possibly as common as the well known herniated disk syndromes.
Although 1.5 million lumbar MRI scans are carried out each year for sciatica (at a cost of
about $1.5 billion), only about 300,000 (20%) reveal a herniated disk amenable to surgery.
About 1/3rd of the surgeries fail to relieve the sciatica. As a consequence, about 1.2
million (80%) receive no clear diagnosis and 100,000 have spine surgery that fails.
The new report includes a diagnostic efficacy study showing that MR Neurography (a new
method for imaging the sciatic nerve) has a 93% specificity for identifying piriformis
syndrome. Treatments involved new technology employing Open MRI real time image guidance
for injection therapy as well as a new minimal access outpatient surgery technique. Good
and excellent outcomes were over 80% in a group of patients that typically have extremely
poor outcomes.
For a copy of this breakthrough report, media can e-mail afiller@nervemed.com.
Media interested in interviewing Dr. Aaron Filler, M.D. can call Charles Barrett, The
Barrett Company Communications, in Los Angeles at 310-471-5764 or by cell at 323-595-5941.
HTML: http://newsroom.eworldwire.com/wr/020305/11339.htm
PDF: http://newsroom.eworldwire.com/pdf/020305/11339.pdf
ONLINE NEWSROOM: http://newsroom.eworldwire.com/2290.htm
LOGO: http://newsroom.eworldwire.com/2290.htm
CONTACT:
Charles Barrett
The Barrett Company
12021 Wilshire Blvd. #600
Los Angeles, CA 90025
PHONE. 310-471-5764
FAX. 310-471-5215
EMAIL: barcorpr@earthlink.net
http://www.barrettco.com
Kelli Hanley
Cedars-Sinai Medical Center
8700 Beverly Blvd.
Room 2429A
Los Angeles, CA 90048-1865
PHONE. 310-423-4767
FAX. 310-423-0435
EMAIL: kelli.hanley@cshs.org
http://www.csmc.edu
KEYWORDS: Medicine, Technology, Patents, Neurosurgery, Imaging, Sciatica, Back Pain,
UCLA, Medical Advance
SOURCE: Publicist, Cedars Sinai Medical Center
AVAILABLE MEDIA:
Photo: Sciatica Neurography (size: 271.9 k)
Sciatica Neurography
http://newsroom.eworldwire.com/media_uploads/2290_998081_1107384865.jpg
Click for full-size
Photo: Piriformis Injection (size: 295.6 k)
Open MR Guided Injection
http://newsroom.eworldwire.com/media_uploads/2290_649103_1107384903.jpg
Click for full-size
Video Clip: Press Release Highlights (size: 3.0 k)
Report Findings Published
http://newsroom.eworldwire.com/media_uploads/institute4nervemed_020205.wmv
This is the personal web page of Paul Dean, Piriformis Syndrome Sufferer:
disclaimer: I am not a doctor and do not claim anything except that there
are many problems people have in getting the proper treatment for Piriformis
Syndrome.
The below information to bring about more awareness of Piriformis Syndrome
with description and links as well as Paul Dean's diagnosis and treatment in
trying to recover from this rare condition which many doctors have overlooked
in Paul Dean's recovery process. You will find many conflicting Doctors
recovery plans because every Doctor has their own research and their own
ideas on what Piriformis Syndrome is and how to treat it.
Terms:
The Disk: Dense tissue between the vertebrae that acts as a shock absorber
and prevents damage to nerves and blood vessels along the spine.
Electromyography: A medical test in which a nerve's ability to conduct
an impulse is measured.
Lumbosacral: Referring to the lower part of the backbone or spine.
Myelography: A medical test in which a special dye is injected into a nerve
to make it visible on an x ray.
Piriformis: A muscle in the pelvic girdle that is closely associated with
the sciatic nerve.
Radiculopathy: A condition in which the spinal nerve root of a nerve has been
injured or damaged.
Spasm: Involuntary contraction of a muscle.
Vertebrae: The component bones of the spine.
Where is the Piriformis Muscle?
In non medical terms, it would be the middle of the buttocks cheek, and very deep.
Piriformis Syndrome: Sciatica, and Back Pain.
Located deep in the hip underneath the Glutes are the 'Deep Six' lateral rotators
of the leg; Gemellus Superior and Inferior, Obturator Internus and Externus, Quadratus
Femoris, and last but not least, the (Piriformis). The Deep Six not only rotate and
stabilize the legs, they also play an important role in pelvic balance. If one hip
is tight then the pelvis will be pulled to the side and rotated causing an imbalance
in the lower back. If both hips are tight then pelvic movement becomes restricted and
the lower back has to contend with the torsion created. Trigger points in the Deep Six
can refer pain into the legs and pelvis and can contribute to other dysfunction such
as 'Restless Leg Syndrome'. One leg or both will usually be rotated outwards and the
joint compressed contributing significantly to arthritic hip joints as well as problems
with the knees and ankles.
There are many medical ideas on what Piriformis Syndrome is and how to fix it,
and it is an ongoing problem in diagnosis and agreement of treatment as you
will see below. Every body is different and there can be many different
variations of the problem in piriformis syndrome so treatment will have to
vary per the individual case by case study.
Where is the pain?
If it lies deep in the buttock and follows down the leg then you may have
sciatica, from a Piriformis Syndrome Condition. Link
Sciatica
The largest nerve in your body has a very devious twist--and when you have a pain
in that nerve, it can really get around.
Sciatica, pain in the sciatic nerve, can radiate from the buttocks down the back
of the leg to the knee, even as far as the big toe. "People with sciatica often say
their back pain is bad but their leg pain is worse," says Loren M. Fishman, M.D., a
physiatrist and rehabilitation medicine specialist at Flushing Hospital Medical Center
in New York City. Often the hip pain is far more severe on one side than the other.
When you've got pain like that, you'll need a hands-on diagnosis before anything else,
Dr. Fishman says. Once the doctor has ruled out a disk problem or fracture, he may be
able to find out whether tight buttocks muscles are causing your pain by compressing
the sciatic nerve.
If you do have sciatica, the doctor will probably recommend a program of supervised
exercises.
Rashad Net University
Post traumatic piriformis syndrome Link
It is postulated by several investigators that sciatica may be secondary to an
aberrant relationship between the piriformis muscle and the sciatic nerve. Pace
and Nagle describe a diagnostic maneuver that is now referred to as Pace's sign-pain
and weakness in association with resisted abduction and external rotation of the
affected thigh.
gluteal atrophy, depending on the duration of the condition. The piriformis syndrome
is thought to occur after blunt trauma to the buttocks. A hematoma forms and scarring
occurs between the sciatic nerve and the short external rotators. Patients who have a
history of this type of trauma and typical findings on physical examination, and
intractable pain after conservative treatment will benefit from release of the piriformis
tendon and sciatic neurolysis.
The authors report the operative treatment and outcome in fifteen cases of piriformis
syndrome (in 14 patients) all patients had blunt trauma to the buttocks. They all
underwent operative release of the piriformis tendon and sciatic neurolysis. The
patients had an average delay of 32 months from the time of injury to the surgery.
Intraoperative findings revealed adhesions between the piriformis muscle, the sciatic
nerve, and the roof of the greater sciatic notch. At twenty-four months all patients
had excellent and four good results from the surgery. All had returned to work.
If conservative treatment has failed a nerve conduction test and referral to an
experience hip surgeon who is familiar with the syndrome is necessary. Note: In the
case of myself, and my occurrence of piriformis syndrome I sought the help of a
Neurosurgeon.
============================================================================
Piriformis Muscle and Blunt Injury Adhesions Link
============================================================================
As mentioned earlier, the sciatic is not the only nerve that may get compressed
in this region. Pressure may be placed on the superior gluteal nerve between
the piriformis muscle and the greater sciatic notch. The piriformis muscle
may also compress the inferior gluteal nerve, either with fibrous bands in
the muscle or with pressure against the sacrospinous ligament.
The pressure on nerves in piriformis syndrome is usually from a hypertonic
piriformis muscle, but it may also occur from external pressure, such as sitting
on a wallet. There are also reports of piriformis syndrome occurring from a
direct blow to the buttock area, (fall injury trauma). As a result of
the blunt trauma, adhesions may develop between the piriformis muscle, the
sciatic nerve and the roof of the greater sciatic notch.
Myofascial trigger points in the piriformis or other gluteal muscles may play
an important role in piriformis syndrome. Piriformis trigger points will often
perpetuate muscle tightness, leading directly to nerve compression. Trigger
points in the gluteus minimus are known to reproduce "sciatica-like pain.
Furthermore, sacroiliac joint dysfunction may perpetuate trigger pointymptoms
and may easily be confused with nerve entrapment by the piriformis muss in
the piriformis muscle and increase the likelihood of nerve compression. A
sudden load placed on the sacroiliac region or the piriformis muscle - from
a fall on the stairs, for example - is often the initial cause of perpetual
trigger-point problems. The constant hypertonicity may then lead to nerve
compression.
"trigger points perpetuate muscle tightness, forcing nerve compression"
============================================================================
The Journal of Bone & Joint Surgery
Excellence Through Peer Review
Sciatica
Sciatica is a condition involving impaired movement and/or sensation in the leg,
caused by damage to the sciatic nerve.
Piriformis syndrome is estimated to cause 6-8% of sciatica, but is more common
in the general population because it has been under diagnosed and under treated.
Information about Sciatica
Sciatica is a form of peripheral neuropathy. It occurs when there is damage to
the sciatic nerve, located in the back of the leg. This nerve controls the muscles
of the back of the knee and lower leg and provides sensation to the back of the
thigh, part of the lower leg and the sole of the foot. Incomplete damage to the
sciatic nerve may appear identical to damage to one of the branches of the sciatic
nerve (tibial nerve dysfunction or common peroneal nerve dysfunction).
A problem in a single nerve group, such as the sciatic nerve, is classified as a
mononeuropathy. The usual causes are direct trauma (often due to an injection into
the buttocks), prolonged external pressure on the nerve, and pressure on the nerve
from nearby body structures. It can also be caused by entrapment -- pressure on the
nerve where it passes through a narrow structure. The damage slows or prevents
conduction of impulses through the nerve.
The sciatic nerve is commonly injured by fractures of the pelvis, gunshot wounds,
or other trauma to the buttocks or thigh. Prolonged sitting or lying with pressure
on the buttocks may also injure it. Systemic diseases, such as diabetes, can
typically damage many different nerves, including the sciatic nerve. The sciatic
nerve may also be harmed by pressure from masses such as a tumor or abscess, or
by bleeding in the pelvis.
In many cases, no cause can be identified.
Note: A ruptured lumbar disk in the spine may cause symptoms that simulate the
symptoms of sciatic nerve dysfunction.
Symptoms
Chronic pain may arise from more than just compression on the nerve. According
to some pain researchers, physical damage to a nerve is only half of the equation.
A developing theory proposes that some nerve injuries result in a release of
neurotransmitters and immune system chemicals that enhance and sustain a pain
message. Even after the injury has healed, or the damage has been repaired, the
pain continues. Control of this abnormal type of pain is difficult. Link
Diagnosis of Sciatica
Before treating sciatic pain, as much information as possible is collected. The
individual is asked to recount the location and nature of the pain, how long it
has continued, and any accidents or unusual activities prior to its onset. This
information provides clues that may point to back strain or injury to a specific
location. Back pain from disk disease, piriformis syndrome, and back strain must
be differentiated from more serious conditions such as cancer or infection. Lumbar
stenosis, an overgrowth of the covering layers of the vertebrae that narrows the
spinal canal, must also be considered. The possibility that a difference in leg
lengths is causing the pain should be evaluated; the problem can be easily be
treated with a foot orthotic or built-up shoe.
Often, a straight-leg-raising test is done, in which the person lies face upward
and the health- care provider raises the affected leg to various heights. This
test pinpoints the location of the pain and may reveal whether it is caused by
a disk problem. Other tests, such as having the individual rotate the hip joint,
assess the hip muscles. Any pain caused by these movements may provide information
about involvement of the piriformis muscle, and piriformis weakness is tested with
additional leg-strength maneuvers.
Further tests may be done depending on the results of the physical examination
and initial pain treatment. Such tests might include magnetic resonance imaging
(MRI) and computed tomography scans (CT scans). Other tests examine the conduction
of electricity through nerve tissues, and include studies of the electrical activity
generated as muscles contract (electromyography), nerve conduction velocity, and
evoked potential testing. A more invasive test involves injecting a contrast substance
into the space between the vertebrae and making x-ray images of the spinal cord
(myelography), but this procedure is usually done only if surgery is being considered.
All of these tests can reveal problems with the vertebrae, the disk, or the nerve
itself.
If the pain is chronic and conservative treatment fails, surgery to repair a herniated
disk or cut out part or all of the piriformis muscle may be suggested, particularly
if there is neurological evidence of nerve or nerve-root damage.
Sciatica Following a Fall 1
continued Link
It is thought that acute or chronic injury causes swelling of the piriformis
muscle and irritates the sciatic nerve, resulting in sciatica. Patients with
an aberrant course of the nerve through the muscle are particularly predisposed
to this condition.
Answer: Piriformis syndrome secondary to myositis ossificans of the
piriformis muscle.
Discussion
Piriformis syndrome is usually a diagnosis of exclusion once the more common
causes of sciatica have been ruled out2. Yoeman3 is credited as being the first
author to have described entrapment of the sciatic nerve by the piriformis muscle.
Freiberg and Vinke4,5 further defined the condition and described what is known
as the Freiberg sign (pain caused by passive internal rotation of the extended
thigh). Beaton and Anson6 described four anatomical variations in the relationship
between the piriformis muscle and the sciatic nerve and implicated these variations
as a cause of compression and inflammation of the sciatic nerve.
The diagnosis often can be made on the basis of a careful clinical evaluation2,
7-10. Physical findings that suggest compression of the sciatic nerve by the
piriformis muscle include tenderness over the sciatic notch, isolated atrophy
of the gluteus maximus, dysesthesia of the posterior aspect of the thigh, and
tenderness of the rectal wall with or without a sausage-shaped mass that is
felt laterally during a rectal examination11. Additional findings that are
indicative of such compression include the Freiberg sign4,5
============================================================================
The Piriformis Syndrome Link
By September Nelson
--------------------------------------------------------------------------------
Introduction. Not all low back, hip, and gluteal (buttock) pain are manifestations
of back injury. Pain in any of these areas may indicate injury or irritation of
any one of a number of muscles and nerves surrounding the low back and hip. Injury
to any of these structures can result in pain and loss of function. A specific
muscle that is susceptible to injury and inflammation is the piriformis muscle.
Due to the location of this muscle, the sciatic nerve is often involved with
piriformis problems. Pain and dysfunction resulting from piriformis injury is
referred to as piriformis syndrome. The symptoms of this disorder sometimes mimic
those of a bulging lumbar disc, or similar low back injury. Therefore, diagnosis
of pain in the low back, gluteal, or hip region should include an evaluation of
the piriformis muscle (PM), other hip musculature, and surrounding nerves.
Anatomy and Function. The piriformis muscle is located deep in the gluteal region.
This muscle attaches to the sacrum and the lateral portion of the upper part of the
femur. It is one part of a group of muscles whose actions include abduction (moving
the thigh away from the midline) and external rotation of the thigh (turning the
knee and toes outward). These muscles are important in maintaining stability of
the hip in all weight bearing activities.
References.
(1) Julsrud, M. E. (1989). Piriformis syndrome. Journal of the American
Podiatric Medical Association, 79, 128-131.
(2) Chen, W. S. (1992). Sciatica due to piriformis pyomyositis. The Journal
of Bone and Joint Surgery, 74-A, 1546-1548.
(3) Vandertop, W. P., and Bosma, N. J. (1991). The piriformis syndrome. The
Journal of Bone and Joint Surgery, 73-A, 1095-1097.
(4) Keskula, D. R. and Tamburello, M. (1992). Conservative management of
piriformis syndrome. Journal of Athletic Training, 27, 102-108.
(5) Barton, P. (1991). Piriformis syndrome: a rational approach to management.
Pain, 47, 345-352.
============================================================================
Acupuncture Today
May, 2002, Volume 03, Issue 05
Treatment of Piriformis Syndrome Pain: Acupuncture Link
=============================================================================
Dr. Katz's Corner
Alejandro J. Katz, MD, OMD, LAC, QME
Treatment of Piriformis Syndrome Pain
Some of the cases termed "lower back pain" are in reality piriformis syndrome.
In piriformis syndrome, the piriformis muscle gets tight (due to overstretching,
trauma, prolonged bad posture, etc.) and compresses the sciatic nerve, producing
numbness and pain going down the thigh and calf (UB channel). If the compression
is on the inferior gluteal nerve (a branch of the sciatic nerve), the pain will
be in the buttock (local symptoms).
Piriformis Trigger Points /Acupuncture
When the initial examination takes place, it is very common to see the patient
leaning toward the other side (when sitting or standing) in order to reduce the
compression of the sciatic nerve. The great majority of these patients are taking
medications - for example, 800 milligrams of ibuprofen (Motrin) three times a
day, or 500 milligrams of naproxen two times a day - with little or no improvement.
The examination of the affected area begins with moderate digital palpation of
GB 30 and moves toward the midline. A series of trigger points will be discovered
that, when palpated, will produce local and/or referred pain (referred pain/
tingling toward the buttock and/or leg [UB channel]).
Technique used: Chinese acupuncture needles (gauge #36), 1.5-2 inches long.
Micro-current device: Acutron Mentor, biphasic milliamp pads, with milliamp
stimulation for 20 minutes (milliamp stimulation is maintained as a noticeable,
mild tingling sensation). A second stage follows: a cooling period of five minutes
(micro amp stimulation, biphasic, 75-100 micro-amps).
Treatment points: GB 30 is connected to 2-4 trigger areas on top of the piriformis
muscle.
The treatment frequency is 1-3 times a week (depending on the pain level) for 4-6
weeks. The acupuncture needles are inserted with the stimulation pads on top of
the needles (the pads used are Zimmer, single use).
Within 6-8 treatments, the patient is able to feel improvement: pain/burning and
tingling is reduced; the range of motion of the hip is increased; and pain medication
reduced or discontinued.
As in almost all muscle disorders, the indication of the appropriate stretching
exercises for the muscles involved will assist in a speedy recovery. A course
of daily stretching exercises is recommended (part of the protocol) to patients
to assist in recovery of the muscles and tendons. Targeting the piriformis is
done with a single knee to the chest with painful side cross-over. The stretching
exercises are performed three times a day, five times each time, maintaining the
stretch between 5-10 seconds. It is convenient to apply heat for 15 to 20 minutes
before the stretching exercises are done in order to increase the elasticity of
the muscle, and ice for five minutes afterward in order to reduce the inflammation
produced by the stretching exercises.
Other treatments: Posture training is another pillar of patient rehabilitation.
In some cases, a cortisone injection is administered locally to reduce the inflammation
and edema of the muscle. Surgery is another resource (although rarely used): it
"cleans up" the fibrotic muscle.
If you have any questions about the treatment described in this article, please
contact me at the address below.
Alejandro J. Katz, MD, OMD, LAc, QME
Los Angeles, California
tvstardr@aol.com
www.drkatz.org
============================================================================
Description of Problem:
----------
1: Pain. 1991 Dec;47(3):345-52. Related Articles, Link
Piriformis syndrome: a rational approach to management.
Barton PM.
Department of Physical Medicine and Rehabilitation, University of Western Ontario,
London, Canada.
Although rarely recognized, the piriformis syndrome appears to be a common cause of
buttock and leg pain as a result of injury to the piriformis muscle. Four cases
representing a broad spectrum of presentations are described here. The major findings
include buttock tenderness extending from the sacrum to the greater trochanter and
piriformis tenderness on rectal or pelvic examination. Symptoms are aggravated by
prolonged hip flexion, adduction, and internal rotation, in the absence of low back
or hip findings. Minor findings may include leg length discrepancy, weak hip abductors,
and pain on resisted hip abduction in the sitting position. Myofascial involvement of
related muscles and lumbar facet syndromes may occur concurrently. The diagnosis is
primarily clinical as no investigations have proved definitive. The role of MRI of the
piriformis muscle is assessed and other investigative tools are discussed. A rational
management schema is demonstrated: (1) underlying biomechanical factors and associated
conditions should be corrected; (2) the patient is instructed in a home program of
prolonged piriformis muscle stretching which may be augmented in physical therapy by
preceding ultrasound or Fluori-Methane (dichlorodifluoromethane and trichloromono
fluoromethane spray); (3) a trial of up to three steroid injections is attempted;
and (4) if all these measures fail, consideration should be given to surgical sciatic
nerve exploration and piriformis release.
Piriformis Muscle Injection: LinkLidocaine is usually used
The piriformis muscle is a relatively small structure located as far as eight
inches below the surface of the buttock. If a blind injection misses the muscle,
the injection test is meaningless. Immediately deep to the piriformis muscle is
the sciatic nerve and the colon so misplacement of the needle may lead to significant
complications. The use of Open MRI image guidance makes this a safe reliable and
accurate procedure. In these images, the physician's finger is seen indicating
the angle of approach in the first image. In subsequent views, local anaesthetic
is injected in the skin and then a titanium Lufkin needle is introduced and
advanced into the piriformis muscle. An injection of Marcaine (10 cc of 0.5%
solution of this long acting local anesthetic) and Celestone (1cc of this
steroid medication) is then seen darkening the interior of the muscle in the
last two image frames. These flash MRI images each take about 12 seconds to
complete. In about 20% of cases the injection is therapeutic and the piriformis
syndrome resolves completely and permanently. In others, the injection needs to
repeated in a few months, and in still others, it last only a few days. In this
category, surgery may be required to maintain the pain relief. Piriformis surgery
is now a small procedure which can be carried out under local anesthetic as an
outpatient.
----------
What is Piriformis Syndrome?
Piriformis syndrome is a rare neuromuscular disorder that occurs when the piriformis
muscle compresses or irritates the sciatic nerve-the largest nerve in the body. The
piriformis muscle is a narrow muscle located in the buttocks. Compression of the
sciatic nerve causes pain-frequently described as tingling or numbness-in the buttocks
and along the nerve, often down to the leg. The pain may worsen as a result of sitting
for a long period of time, climbing stairs, walking, or running.
Piriformis syndrome can develop when the piriformis muscle becomes tight or spasms
and places pressure on the sciatic nerve that runs beneath it. The pressure on the
sciatic nerve can cause low back pain and/or pain that radiates to the rear and
down the leg (similar to sciatica pain). From a technical standpoint, piriformis
syndrome does not cause true sciatica (as sciatica is usually defined as a
radiculopathy, or compression of a nerve root as it exits the spine). However, just
like sciatica, piriformis syndrome can cause pain, numbness and tingling along the
sciatic nerve, which runs down the back of the leg and into the foot.
Piriformis Syndrome is caused by an entrapment (pinching)
of the sciatic nerve as
it exits the Greater Sciatic notch in the gluteal region.
History: Piriformis syndrome often is not recognized as a cause of LBP and
associated sciatica. This clinical syndrome is due to a compression of the
sciatic nerve by the piriformis muscle. The patient with an unrelenting
sciatica may be suffering with a piriformis syndrome.
This syndrome is considered an entrapment
neuropathy caused by pressure on
the sciatic nerve by an enlarged or inflamed piriformis muscle. The sciatic
nerve can be compressed between the swollen muscle fibers and the bony pelvis.
Causes: Approximately 50%
of patients with piriformis syndrome have a history
of trauma, with either a direct buttock contusion or hip/lower back torsional
injury. The remaining 50% of cases are of spontaneous onset, so the treating
physician must have a high index of suspicion for this problem, lest it be overlooked.
Dr. Stephen M. Pribut's Sport Pages
Sports Medicine
December 11, 2004
Piriformis Syndrome: The Big Mystery or A Pain In The Behind
by Stephen M. Pribut, DPM and Amelia Perri-Pribut, B.S., R.N., M.B.A.
Superior and Inferior Gluteal Region
"...The existence of piriformis syndrome has been doubted for years."
Piriformis syndrome may overlap with a variety of other problems including what
McCrory et. al. have called a "deep buttock" syndrome. This includes pain in the
buttock region, possibly pain in the hamstrings, occasionally pain in the back
of the leg that is difficult to locate. Link
These symptoms of the piriformis muscle dysfunction may be caused by other
clinical entities that include gluteus medius dysfunction, herniated or bulging
disks, "sciatica" and other musculoskeletal problems in this area. Scant information
is available on the piriformis syndrome in lay publications, and only a little
more in scientific publications. The functioning of the muscle has not been clearly
defined and examined in the literature. The location of the muscle does not allow
for surface EMG (electromyographical) study. It is quite difficult, if not impossible
to place a deep electrode in the muscle for study purposes also.
Anatomically, the piriformis muscle lies deep to the gluteal muscles. It originates
from the sacral spine and attaches to the greater trochanter of the femur, which is
the big, bony "bump" on the outside top of the thigh. The sciatic nerve usually passes
underneath the piriformis muscle, but in approximately 15% of the population, it
travels through the muscle. It is thought that acute or chronic injury causes swelling
of the muscle and irritates the sciatic nerve, resulting in sciatica. Patients with
an aberrant course of the nerve through the muscle are particularly predisposed to
this condition.
The piriformis syndrome is diagnosed primarily on the basis of symptoms and on the
physical exam. There are no tests that accurately confirm the diagnosis, but X-rays,
MRI, and nerve conduction tests may be necessary to exclude other diseases. Some of
the other causes of sciatica include disease in the lumbar spine (e.g. disc herniation)
chronic hamstring tendonitis, and fibrous adhesions of other muscles around the
sciatic nerve.
Once properly diagnosed, treatment is undertaken in a stepwise approach. Initially,
progressive piriformis stretching is employed, starting with 5 seconds of sustained
stretch and gradually working up to 60 seconds. This is repeated several times
throughout the day. It is important that any abnormal biomechanical problems, such
as overpronation of the foot or other coexisting conditions, are treated. This
stretching can be combined with physical therapy modalities such as ultrasound.
If these fail, then injections of a corticosteroid into the piriformis muscle may
be tried. Finally, surgical exploration may be undertaken as a last resort.
-----------------------------------------------------------------------------------
Piriformis Stretch
The gentle Piriformis Stretch:
Place the right knee on the ground roughly in line with your
left shoulder The right foot should be just in front of the
left knee Press your hips towards the ground so that your
bodyweight is on your right leg. As you move down the right
knee comes closer to the left shoulder.
You should feel a gentle pull deep in the right hip / buttocks.
-----------------------------------------------------------------------------------
A good sports medicine physician with experience in caring for athletes with the
piriformis syndrome can help direct appropriate management. With proper diagnosis
and treatment, there is no reason for this syndrome to be dreaded. Good luck and
good training.
last update - 2/97
Diagnosis:
The symptoms most often reported are pain when running or walking in the gluteal
region. Pain may go down the back of the leg. Dyspareunia is sometimes noted.
Having the patient lie down, flex the knee to 10 - 20 degrees and then have the
patient attempt to externally rotate the leg against resistance. Pain may occur
with piriformis tendonitis. Direct tenderness will be found in the region of the
piriformis tendon over the buttock region.
If there is a positive test to the straight leg lift (causing sciatica like pain),
externally rotate the leg to see if this lessens the pain. This could indicate
compression of the sciatic nerve by the piriformis.
Be certain to examine the sacroiliac joint also.
Treatment:
Rest is usually recommended. A two to three week break from the sports and activities
that cause pain can be very helpful. Relative rest, meaning less intense workouts,
and fewer miles is also helpful, and should be used during your return to activity.
Like Achilles tendonitis and iliopsoas tendonitis this is a very difficult problem
to eliminate.
The piriformis syndrome is a condition in which the piriformis muscle irritates
the sciatic nerve, causing pain in the buttocks and referring pain along the course
of the sciatic nerve. This referred pain, called "sciatica", often goes down the
back of the thigh and/or into the lower back. Patients generally complain of pain
deep in the buttocks, which is made worse by sitting, climbing stairs, or performing
squats.
The anatomical position of the muscle leads one to conclude that it functions in
some ways similar to that of the gluteus medius. The major portion of origin of the
piriformis is the anterior lateral portion of the sacrum and the insertion is on the
upper portion of the femur.
It can be seen that the sciatic nerve passes immediately below the piriformis muscle.
The first places the sciatic nerve inferior (below) to the Piriformis muscle and
superior (above) the gemellus muscle. Entrapment in this area is likely due to a
myospasm or contracture (tightening or shortening respectively) of either of these
two muscles. The athlete's cause is primarily due to improper stretching and warm-up
exercises as well as overuse during activity. In this case it is most likely that
the piriformis muscle is irritated and usually in spasm.
This particular syndrome can often mimic its more notorious counterpart known as
sciatica, and that being the case, it is often misdiagnosed as sciatica. The main
difference between sciatica and piriformis syndrome is in the cause. Sciatica is
directly due to a lumbar disc pressing on the sciatic nerve as it exits the intervertebral
foramen in the lumbar spine. What both of these complaints have in common is that
both can produce pain, numbness and tingling below the knee and into the foot.
Link to below article:
In the United States each year, 1.5 million people have lumbar MRI scans to look
for the cause of the buttock and leg pain called 'sciatica'. More than 1.2 million
of those scans fail to find the cause in the spine. Three hundred thousand of the
scans are sufficiently positive that the patient has lumbar spine surgery. Of the
300,000 surgeries, as many as 25% fail to relieve the pain - in many cases this
is because the diagnosis of a spinal cause for the sciatica was incorrect.
October 13, 2004
Piriformis Syndrome: The Big Mystery or A Pain In The Behind
by Stephen M. Pribut, DPM and
Amelia Perri-Pribut, B.S., R.N., M.B.A.
Piriformis syndrome is difficult to diagnose and resistant to therapy. The existence
of piriformis syndrome has been doubted for years. In many instances it is not even
considered as a diagnosis, in others it is ruled out, and in others yet the symptoms
are ascribed to "sciatica" or some other cause, even if the piriformis is considered
as a possible cause. Often the patient has considered the possibility before the
physicians, trainers, therapists and others have.
"...The existence of piriformis syndrome has been doubted for years."
Piriformis syndrome may overlap with a variety of other problems including what McCrory
et. al. has called a "deep buttock" syndrome. This includes pain in the buttock region,
possibly pain in the hamstrings, occasionally pain in the back of the leg that is
difficult to locate.
These symptoms of the piriformis muscle dysfunction may be caused by other clinical
entities that include gluteus medius dysfunction, herniated or bulging disks, "sciatica"
and other musculoskeletal problems in this area. Scant information is available on the
piriformis syndrome in lay publications
The piriformis syndrome
------
Balanced Concepts
in Health
Piriformis Syndrome
by Christine M. Booras, B.A., LMT, CPFT
"What a pain in the _ _ _ _ !
No, I'm not talking about a fellow co-worker. What I am talking about is Piriformis
syndrome...
How can one muscle cause so much discomfort? Link The problem is its
relation to the sciatic nerve (shown below in yellow, running just under the
piriformis muscle), the largest nerve in the body. As the sciatic nerve runs from
the lower back and down the body to supply all of the nervous functions to the leg,
it just happens to pass underneath the piriformis muscle. Both the piriformis
muscle and sciatic nerve pass together through a small hole, or foramen, of the
pelvis.
If the piriformis muscle gets irritated due to excessive sitting, walking or
squatting it will be come inflamed and compress the sciatic nerve against the
bone. The result: radiating, excruciating pain. Because the gluteal muscles
are tight and contracted, "trigger points" and spasms may also develop due
to the lack of adequate blood and oxygen reaching the tissues. Now you have
a true "pain in the butt!"
Before the serious decision of a surgery you have the following options:
So, now what? There is hope and it doesn't have to involve surgery. Research
has proven that a combination of stretching, massage therapy, proper posture
and utilizing anti-inflammatory can produce a significant reduction or
elimination of pain.
Seeing as how it can possibly be a purely muscular condition, stretching should
be your first approach. Several stretches specifically designed to treat
piriformis conditions are described in a companion article. They should be
performed daily.
STRETCHING:
STRETCHES FOR THE PIRIFORMIS AND RELATED MUSCLES
It is always best to warm-up the muscles for about 3-4 minutes before stretching.
You can do this by jogging in place, jumping jacks, etc. Just to get the body
warmed up.
These stretches should be performed on both sides of the body one to two times
daily for treatment and then once each day after you have started getting some
relief.
Hold the stretch for 2-3 seconds and repeat a second time on the same side. Go
to other side and repeat what you did on the first side. Repeat whole sequence
3-5 times. Remember: NEVER BOUNCE!
We are stretching not only the piriformis but also other muscles that it affects
or is affected by. This will enhance the lengthening and softening of all
muscles involved.
MASSAGE THERAPY:
Massage Therapy can be very effective in re-nourishing the muscles with blood
and oxygen, thus helping to eliminate the spasms and "trigger points" that may
be present. On your own, you can do "self massage", use a tennis ball or
Lacrosse Ball for deeper penetration and have a partner help you out, which
can be fun.
You can also make an appointment with a Licensed Massage Therapist (LMT) who
knows how to treat "all the right spots" in order to expedite the healing process.
As always, follow the recommendations of your physician. In closing, utilizing
proper biomechanics, stretching, massage and anti-inflammatory can bring you
back to your normal self in no time, though you may have to deal with the other
"pains" at work with some other creative alternative!
Christine M. Booras, B.A., LMT, CPFT
================================================================================
Assess & Address
Piriformis Syndrome
by Whitney Lowe
Link
Radiating neurological pain that goes down the back of the leg is often diagnosed
as originating from disc hernias in the lumbar spine; however, there are numerous
sites where nerve irritation may produce similar symptoms. One of the most common
is in the gluteal region, where the sciatic nerve may get compressed by the
piriformis muscle, creating a condition known as piriformis syndrome.
Neurological pain may also be produced in this region by entrapment of other nerves,
such as the superior and inferior gluteal nerves. This entrapment is sometimes
referred to as piriformis syndrome, as well.
--------------------------------------------------------------------------------
The piriformis syndrome is a condition in which the piriformis muscle irritates
the sciatic nerve, causing pain in the buttocks and referring pain along the course
of the sciatic nerve. This referred pain, called "sciatica", often goes down the
back of the thigh and/or into the lower back. Patients generally complain of pain
deep in the buttocks, which is made worse by sitting, climbing stairs, or performing
squats. The piriformis muscle assists in abducting and laterally rotating the thigh.
In other words, while balancing on the left foot, move the right leg directly sideways
away from the body and rotate the right leg so that the toes point towards the ceiling.
This is the action of the right piriformis muscle.
It is thought that acute or chronic injury causes swelling of the muscle and irritates
the sciatic nerve, resulting in sciatica. Patients with an aberrant course of the nerve
through the muscle are particularly predisposed to this condition.
The piriformis syndrome is diagnosed primarily on the basis of symptoms and on the
physical exam. There are no tests that accurately confirm the diagnosis, but X-rays,
MRI, and nerve conduction tests may be necessary to exclude other diseases. Some of the
other causes of sciatica include disease in the lumbar spine (e.g. disc herniation),
chronic hamstring tendonitis, and fibrous adhesions of other muscles around the sciatic
nerve.
Piriformis syndrome also causes sciatica. Its treatment is much less invasive and
severe than the treatment of herniated lumbar disks. However, many doctors never
consider piriformis syndrome as a possible diagnosis. Many physicians who are
aware of it are uncertain how to properly diagnose and treat it. A course of
daily stretching exercises is recommended (part of the protocol) to patients
to assist in recovery of the muscles and tendons.
Stretching can be combined with physical therapy modalities such as ultrasound.
If these fail, then injections of a corticosteroid into the piriformis muscle
may be tried. Finally, surgical exploration may be undertaken as a last resort.
The advent of MR Neurography and Open MR injection techniques together with new
large scale outcome studies are now leading to the successful diagnosis and treatment
of many more sciatica sufferers. Surgery is another resource for pain reduction
(although rarely used): it "cleans up" the fibrotic muscle scar tissue.
====================================================================================
This Publication Is Searchable
The Merck Manual of Diagnosis and Therapy
Section 5. Musculoskeletal And Connective Tissue Disorders Link
Chapter 62. Common Sports Injuries
Piriformis Syndrome
Sciatic pain can be caused by compression of the sciatic nerve by the piriformis
muscle. The piriformis muscle extends from the pelvic surface of the sacrum to the
upper border of the greater trochanter of the femur and, during running or sitting,
can squeeze the sciatic nerve at the site where the nerve emerges from under the
piriformis to over the gemellus and obturator internus muscles.
Symptoms and Signs
A chronic nagging ache, pain, tingling, or numbness starts in the buttocks but
can extend along the course of the sciatic nerve, down the entire back of the
femur and tibia, and in front of the tibia. Pain is usually chronic and worsens
when the piriformis is pressed against the sciatic nerve (eg, while sitting on
a toilet, a car seat, or a narrow bicycle seat or while running). Unlike piriformis
pain, disk compression of the sciatic nerve is usually associated with lumbar pain,
particularly during lumbar extension.
Diagnosis
Thorough physical examination is essential for diagnosis: Freiberg's maneuver
(forceful internal rotation of the extended thigh) stretches the piriformis muscle,
causing pain. Pace's maneuver (abducting the affected leg) elicits pain in a sitting
patient. For Beatty's maneuver, the patient lies on a table on the side of the
no affected leg. The affected leg is placed behind the non affected leg with the
bent knee on the table. Raising the knee several inches off the table causes pain
in the buttocks. For the Mirkin test, the patient should stand, keeping the knees
straight, and slowly bend toward the floor. The examiner should press into the
buttocks where the sciatic nerve crosses the piriformis muscle, causing pain that
starts at the point of contact and that extends down the back of the leg. Pain can
also occur with pelvic or rectal examination.
Treatment
The patient should stop running, bicycling, or performing any activity that elicits
pain. A patient whose pain is aggravated by sitting should stand up immediately or,
if unable to do so, change positions to raise the painful area from the seat.
Stretching exercises, although often recommended, are rarely beneficial, and any
movement that raises the knee forcibly often aggravates symptoms. A corticosteroid
injection into the site near where the piriformis muscle crosses the sciatic nerve
often helps, presumably by reducing fat around the muscle, making it less likely
to press on the nerve.
====================================================================================
Medical Operative Report For Paul Dean
Sciatica, Piriformis Syndrome, Piriformis Release, Piriformis Surgery for
buttock injury occurring on April 4, 2001 from a fall injury at construction
site at job.
Doctors Report Provided Below.
TUSTIN HOSPITAL AND MEDICAL CENTER
14662 Newport Avenue, Tustin, California 92780
SURGEON: Israel P. Chambi, M.D.
ASSISTANT SURGEON: Edward Boseker, M.D.
DATE OF SERVICE: 06/09/04
DIAGNOSIS
1. Piriformis syndrome.
2. Residual sciatic nerve root irritation, status post lumbar
laminectomy/discectomy.
3. Lumber discogenic disease, L5-S1.
OPERATION:
1. Decompression of the right sciatic, posterior cutaneous, and inferior
gluteal nerves, and the operative microscope was used.
2. Mapping of the nerves in the gluteal area using electrical stimulation.
ESTIMATED BLOOD LOSS: 10 cc.
INDICATIONS: The patient is a 39-year-old, right-handed male who comes
with a history being involved in an industrial injury on 04/02/2001. The
patient presents with intense pain in the right buttocks with radiation to
the right leg. The patient also has experienced weakness in the hamstring
muscles with sensory deficit in the right S1 and L5 nerve root distribution.
The patient has a positive Tinel sign in the region of the right sciatic
notch as well as pain in the distribution of the piriformis muscle. The
patient had received extensive medical treatment. Initially, the patient
improved with piriformis injections. However, over last recent months, the
patient has substantial recurrence of the pain that clearly increases with
sitting and is relieved by rest. Pain medications have provided minimal
relief of the patient's pain. Based on the lack of improvement with
intensive medical treatment, the patient was recommended to have an operation
to decompress mainly the sciatic nerve as well as the inferior gluteal and
the posterior cutaneous nerve. The patient understands the risks of
operation including infection, bleeding, the possibly of nerve damage,
as well as the potential possibility that the operation may not improve,
and after the implications of operation, the patient signed the consent.
PROCEDURE IN DETAIL: After obtaining general endotracheal anesthesia, the
patient was placed in the prone position on a Wilson frame. The right buttock
was prepped and draped in the sterile fashion. A small curvilinear incision
was made. The incision was carried down through the subcutaneous tissue. The
gluteus maximus muscle was split parallel to its fibers. We took an oblique
approach to direct our view to the piriformis muscle. The gluteus maximus
was extremely taken; we have problems in applying the appropriate retraction.
Immediately, we were able to identify the inferior gluteal nerve, which was
substantially displaced medially and the inferior gluteal nerve was displaced
inferiorly. We came to find a very prominent fibrosis involving --
Page 1
OPERATIVE REPORT
Patient Name: PAUL DEAN
MR NO:
Physician: ISRAEL P. Chambi, M.D.
----------------------------------------------------------------------------------
Page 2
OPERATIVE REPORT
TUSTIN HOSPITAL AND MEDICAL CENTER
14662 Newport Avenue, Tustin, California 92780
-- almost the entire piriformis muscle and this was causing the substantial
displacement of the sciatic nerve as well as the posterior cutaneous and inferior
displacement of the inferior gluteal nerves. Using the microscope, a portion of
the muscle that is still attached to this fibrous tissue that looks like very
thick fibrous bands were cauterized with bipolar electrocoagulaton and then
sectioned with Metzenbaum scissors. Once this was sectioned, there was a
substantial decompression of the sciatic nerve and we were able to place a #3
Penfield into the pelvis through the sciatic notch. Further stimulation of the
inferior gluteal nerve demonstrated that the nerve was working well and this
was not affected during our dissection. The fatty tissue that was there
in the vessel was replaced to cover the sciatic nerve. Then fibrin glue
was applied. After obtaining excellent hemostatis, the fascia of the gluteus
maximus muscle was approximated with interrupted 2-0 Vicryl sutures as well as
the subcutaneous tissue and the skin with 5-0% to reduce the incision pain.
The patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: 10 cc.
NEEDLE AND SPONGE COUNT: Correct.
FINDINGS: We found a very thick fibrosis involving most of the piriformis
muscle replacing and displacing the sciatic nerve medially. Following the
operation, there was substantial relaxation of the sciatic nerve. There were
no complications:
___________________________
ISRAEL P. Chambi, M.D.
IMC/MWSM
D: 06/09/2004 09:41
T: 06/09/2004 22:44
JOB: 161795
Page 2
OPERATIVE REPORT
Patient Name: PAUL DEAN
MR NO:
Physician: ISRAEL P. Chambi, M.D.
--------------------------------------------------------------------------------
DISABILITY STATUS
This patient will continue on temporary total disability. Good or bad,
to be declared permanent and stationary after sufficiently recovered.
DISCLOSURE STATMENT
I declare under penalty of perjury that I, the signing physician, have
actually performed this examination and the time spent in performing this
evaluation is in compliance with the IMC Guidelines
(Section 5307.1 and 4507.6).
I declare under perjury that I have devoted at least 1/3 of my total
practice to providing medical treatment.
ISRAEL P. Chambi, M.D.
----------------------------------------------------------------------------
Stock Photo
Israel P. Chambi-Venero, MD
Neurosurgeons
Israel P. Chambi, M.D., FACS
801 N. Tustin Ave., Suite 406
Santa Ana, CA 92705
714 973 0810
FAX 714 973 0840
drisraelchambi@yahoo.com
Diplomat American Board of Neurological Surgery Brachial-Plexus & Peripheral
Nerve Institute
micro neural surgeon
- Santa Ana, California (CA) 92705
PRESCRIPTION
ISRAEL P. CHAMBI, M.D., FACS
Diplomat American Board of Neurological Surgery
Adult & Pediatric Neurosurgery
Brachial Plexus & Peripheral Nerve Surgery
Address:
XXX XXXXX
XXX XXXXX Santa ANA, CA 92705
Paul Dean 39
_______________________________________________
Name (Print) Age
XXXX Riverside, CA 6/29/2004
_______________________________________________
Address City Date
Rx
Hydrocodone/Apap 5/500 - Tab Every 4 hours
Mobic #15 - Once A Day
Post Piriformis Syndrome
Right - Center
Physical Therapy 3 times a week for 6 weeks
Ultrasound
Right Massage
Heat
No Weights
No Stretching
Thank you.
_______________________________________________
Israel P. Chambi, M.D. Calif. Lic. # XXXXXXXXXX
------------------------------------------------------------------------
My questions to Dr. Chambi at first post surgery visit. I already
had a back surgery (L5 S1 Discectomy) a year and a half earlier.
POST-OP RT. PIRIFORMIS RELEASE FIRST VISIT TO DR. CHAMBI AFTER SURGERY
WHY DO I STILL HAVE PAIN AFTER THE SURGERY...
June 29, 2004
QUESTIONS FOR DR. CHAMBI FROM PAUL DEAN, PATIENT:
1. Why do I still have intense pain when sitting, lifting,
standing long periods, or moving around after the Piriformis
Surgery?
DR CHAMBI: You are having pain because your sciatic nerve
in the Piriformis Region has shrunk and lost elasticity.
Over the next 6 months the body will bring some of that
elasticity back and then the nerve will be able take stretching
and lifting which take a longer length of elasticity than
you have at this time.
DR CHAMBI:
You have been scarred down completely by your Piriformis Muscle
and your nerve has been impinged for so long that it will take
some time for the sciatic nerve to heal.
2. What can I do in the meantime to help the healing, so that
I can get back to lifting and sitting and doing what I was
able to do in the past?
DR. CHAMBI: Do not stretch the sciatic nerve and do not lift
any weights. This damages the sciatic nerve. You can do light
walking and massage as well as ultra sound and heat can be
applied to the region affected region. Use Vicodin for pain,
and Mobic to help circulation and nerve healing.
3. What exactly was done in the surgery?
DR. CHAMBI: The Piriformis muscle was separated
and several inches of scarring that
was attached to the sciatic nerve was
removed.
4. Did you remove any of my Piriformis Muscle?
DR. CHAMBI: It was cut, but none was removed.
5. How much Piriformis Muscle did you cut through?
DR. CHAMBI: About two-thirds of the Piriformis
was cut through.
6. How much scarring did you remove?
DR. CHAMBI: Several inches of scar tissue was
removed because it had adhered to
the sciatic nerve making it impossible
for the nerve to move, giving you pain.
7. Will the scarring come back and a later time?
DR. CHAMBI: No it will not. We use a Fibrin Glue
which stops scar tissue.
8. Will my pain get better?
DR. CHAMBI: Some elasticity in the sciatic nerve
will come back, reducing your pain.
9. Will I be 100%?
DR. CHAMBI: You should get quite a bit better now
that your sciatic nerve is no longer
trapped. However, the nerve has been
entrapped for three years and has been
compressed extremely and will need to
heal. All sciatic nerve healing is slow
and we will have to wait and see what
the final outcome of healing will be.
You will be in physical therapy for quite
some time before we know how well you
have healed up.
10. Does waiting a long time before the surgery become a
problem for the healing of a sciatic nerve?, in my case
it has been three years since my injury first occurred.
DR. CHAMBI: Yes, when the sciatic nerve is compressed for a
very long time, it is less likely that it will regain its
elasticity and full functioning.
11. If I exercise my muscles or body will that help the healing
process of my sciatic nerve?
DR. CHAMBI: No. The sciatic nerve does not do well when stretched
or exercised a lot. Soft message and gentle walking and are recommended,
but do not stretch the sciatic nerve and do not lift weights as this
hurts the injured sciatic nerve. You do not have a muscle problem,
but a nerve problem which needs very gentle care. Stretching and
strengthening does not help a damaged nerve, and you do not want to
inflame the area.
12. I know that 8 out of 10 patients were helped by the Piriformis
Release and I am glad I did the operation because the intensity of
my pain has been reduced from it maximum pain levels, and I was
wondering why 2 patients had a failure of an outcome?
DR. CHAMBI: Both patients waited to long before having the piriformis
release surgery. The first patient waited 8 years and the second
patient waited 10 years, and they never regained elasticity of their
nerve and there was permanent damage because the sciatic nerve was
compressed for two long.
13. Have you treated any Professional Sports Figures lately, and
how is there recovery?
DR. CHAMBI: We just did a Piriformis Release on a Professional
Baseball player who hurt his sciatic nerve in the Piriformis Region
a year ago while pitching a fastball. We gave him the release and
he is still recovering at this time.
14. Why did I have to see four Doctors before you and none knew
that I had piriformis syndrome, but you figured it out right away.
These other doctors were well known in their Orthopedic field and
Neurological fields. It was quite upsetting that nobody could tell
me the real reason I was in pain. I feel like this is the most
misunderstood injury there could possibly be. It has the sciatic
pain that goes down to the foot and every doctor assumes that you
have a bad disc, or a failed back surgery. Why is there such a
misunderstanding about this injury?
DR. CHAMBI: Most Doctors never see this type of injury in their practice
because it is quite rare in most practices, however, I see this type
of injury quite often because I deal so much with professional
athletes. You have to fall in an unusual manner to get this type
of trauma. The fall must be sideways and backwards which occurs often
in football lineman and other high contact type of sports.
DR. CHAMBI:
The Doctor must rule out disk problems in the back by looking at the
MRI and determining that the disk in the back is not affecting the pain
after a back surgery because the nerve in the back is freed up from that
surgery. Also the symptoms are different for Piriformis Syndrome than
in the back patient. There is buttock pain in the Piriformis region
that is quite specific and the piriformis muscle is in spasm in many
cases. The pain is mostly in the outlaying areas and not in the
lower back region specifically. Lidocaine Injections usually help
calm down the Piriformis Muscle which helps the pain go away and this
is a positive sign that you have Piriformis Syndrome. However, if
your sciatic nerve has been scarred down, that scarring needs to
be removed so that you can have full range of motion without pain.
The sciatic nerve needs to have full elasticity and movement and cannot
be compressed by the spasm or displaced Piriformis Muscle.
15. I still cannot sit, lift or stretch or be active without a lot
of pain. Do you think this will all change for the better?
DR. CHAMBI: Yes, but it will take some time for the sciatic nerve to heal,
and it cannot be rushed. You will be doing a lot better in time but
you need to take it easy for right now.
Thank you Dr. Chambi, I will be going into physical therapy three times
a week for six weeks and am looking forward to my next visit with you.
I am glad I did the surgery and feel I now have an opportunity to heal,
and I was not able to heal before now because my nerve was way to impacted
and scarred down in the past to heal on my own. At least now I have a
chance to get better. It is a shame that no other Doctor could diagnose
this problem, and that I had to wait so long. Every day my nerve
is impacted the chances of full recovery are that much worse as permanent
damage can be caused.
Click below for the photos of the operation for the following:
Piriformis Release Surgery
Dr. Israel Chambi, Neurosurgeon: Training and Civil life:
Dr. Israel Chambi finished his undergraduate training at the National University
of Arequipa, Peru, and his medical training at the University of Mexico in 1974.
He came to California for his internship at the University of California at both
the Irvine and Los Angeles campuses, and later moved to Toronto, Canada, where
he obtained a fellowship in stereotactic neurosurgery. He held a teaching and
research post at the University of California at Irvine and founded the Brachial
Plexus and Peripheral Nerve Institute in Santa Ana. At the present time he is chair
of the division of neurosurgery at Western Medical Center in Santa Ana.
Besides his contribution to the scientific world, Dr. Israel Chambi is an exemplary
contributor to civic and church life. He excels in the field of neurosurgery, not
only in his clinical skills, but also as a teacher, mentor, publisher, and national
and international speaker. He has been a supporter of La Sierra University's Stahl
Center for World Service. His ethnic roots motivated him to participate in various
projects, which bring north and south together. His cross-cultural vision motivated
him to pioneer "Radio Adventista" in the Peruvian Andes and to promote medical
conferences in Arequipa, Peru.
The Chambi Venero brothers are part of the history of rural education in Peru.
Evenezer Chambi owns a clinic in Beverly Hills, California and his brother
Dr. Israel Chambi is a renowned neurologist who also lives in the United States
of America.
Chambi Father and head of Family:
The head of the family is Pastor Pedro Chambi, learned to read at age 22.
As a leader in his local congregation, Dr. Chambi has a lasting impact in fostering
inclusiveness and interdependence in the multi-ethnic Santa Ana Seventh-day Adventist
Church. He is married to Rosalba Chambi, who is a nurse, and has three children:
Ruth, Moses, and Israel Jr.
NEWS: La Sierra University
Donors: Dr. Israel and Mrs. Rosalba Chambi - half million-dollar gift for the Science
Complex at Los Sierra University, 4700 PIERCE ST , RIVERSIDE , CA - 92515
Dr. Israel Chambi, Neuro-Surgeon
Wife: Rosalba Chambi - Nurse
Dr. Israel Chambi is a neurosurgeon in Orange County. He and his wife, Rosalba Chambi
are exemplary contributors to civic and church life. Born and raised in Peru and Mexico,
the Chambi's international roots and cross-cultural vision motivate participation in
projects that foster inclusiveness in both North and South America such as the founding
of Radio Adventist in the Peruvian Andes and this their most recent gift to La Sierra
University for the new Science Complex.
Professional Reports:
Chambi, Israel P. "The Piriformis Syndrome Manifesting As Lumbar Disc Syndrome: Report
of 19 Cases" The Western Neurosurgical Society, Annual Meeting, Boson, MA., August 18, 1994
Chambi, Israel P. "The Piriformis Syndrome Manifesting As Lumbar Disc Syndrome: Report
of 19 Cases" The Western Neurosurgical Society, Annual Meeting, Gleneden Beach, Oregon.
September 9-12, 1995.
Neuroscience Conference
02.20.92 Annual Scientific Program
UCI Neurosurgery and SNSOC
"Does Piriformis Syndrome Exist?"
State-Of-The-Art Microscope Provides Incredible Precision In
Neurosurgery
"The diameter of a human hair, is how Israel P. Chambi, M.D., FACS, a Diplomat of the
American Board of Neurological Surgery and a distinguished Fellow of the American College
of Surgeons, describes the size of a blood vessel in the brain. "A small peripheral nerve
is no larger than a toothpick." This obstacle of scale, present in even the simplest surgeries,
is the reason the sue of a high-powered microscope is an essential part of his neurosurgical
practice at Tustin Medical Center.
Most people understand that high blood pressure can disrupt blood flow to the brain,
causing a stroke. Dr. Chambi explains that, like the brain, the peripheral nervous
system is also vulnerable to pressure. "Many of my patients are athletes who experience
pain from pressure on the peripheral nerves in their arms or legs. The pressure may
be caused by an actual injury or be secondary to inflammation of the nerves caused by
overuse." Dr. Chambi's goal is to correct or minimize the neurological disability
that results from disruption in blood flow caused by pressure from swelling or
bleeding within the nervous system.
Unique in the diversity of his practice, Dr. Chambi is noted for his expertise in
neurovascular surgery. Also, he is one of only a handful of surgeons in the region who
perform specialized surgery to treat disorders of the peripheral nerves, including
nerve gafting procedures. In addition to maintaining his private practice, Dr. Chambi
has been instrumental in the development of the Neurovascular and Peripheral Nerve
service at Western Medical Center, where he is part of a team of qualified neurosurgeons.
NOTE: He is not at Western Medical Center but is instead at Tustin Medical Center at this
time.
Additional information regarding the use of microsurgery for the treatment of
neurovascular or peripheral nerve disorders, such as those listed below, may be
obtained by requesting a referral from your physician or by contacting Dr.
Chambi's staff at 714-973-0810.
* Aneurysm and Arteriovenous Malformation
* Spinal Disorders -- Ruptured Disc, Stenosis
* Traumatic Brain and Spinal Cord Injuries
* Brain Tumors *hydrocephalus
* Breathing Disorders -- Phrenic Nerve Pacemaker
* Peripheral Nerve Disorder Affecting the Arms and Legs
CURRICULUM VITAE
Isreal P. Chambi, M.D.
PERSONAL DATA:
Date of Birth: January 25, 1949 - Chile
Home Address: 112 South M***** ********** ***
Anaheim, CA.
Business Data: Brachial Plexus and Peripheral Nerve Institute
801 N. Tustin Ave Suite 406
Santa Ana, CA 92705
(714)-973-0810
FAX: (714)-973-0840
Citizenship: United States
EDUCATION
1966-68 National University of Peru B.S.
Arequipa, Peru
1968-74 University of Mexico M.D.
Mexico City, Mexico
POSTGRATUATE TRAINING
1978-79 Martin Luther King Internship
Medical Center
Los Angeles, California
1979-81 University of California, Irvine General Surgery
Medical Center Resident
Orange, California
1981-83 University of California, Irvine Neurosurgery
Medical Center Resident
Orange, California
-------------------------------------------------------------------------------
As a side note... Compassion is in the family.
Israel P. Chambi, M.D. has a brother, Ebenezer Chambi, M.D. Link
Ebenezer Chambi, M.D.
Family practice Physician
Chapel Medical Clinic
9739 California Avenue
South Gate, CA 90280
Phone: 323-567-1212
-------------------------------------------------------------------------------
Ebenezer Chambi: Dialogue with an Adventist physician, health educator, and
community leader Link
Ebenezer Chambi MD - Chambi Ebenezer MD
9739 California Ave
South Gate, CA 90280
Phones: (323) 564-2228
by Michael Peabody
Born in Peru, Dr. Ebenezer Chambi developed early in his life a sense of community
and an inclination to service. His family was active in the local church. Throughout
his educational experience, he was guided by a commitment to help others. In 1970,
he completed his pre-medical studies at Union College (now Peru Union University)
located near Lima, the capital. Although he wanted to study medicine in his homeland,
the then prevailing political situation made this virtually impossible. His older
brothers had moved to Mexico to pursue their medical training; so did he.
Completing his medical degree from the Autonomous University of Guadalajara, Mexico,
in 1975, he did his residencies in Puerto Rico and Los Angeles, California. After
completing the latter, Dr. Ebenezer Chambi joined a research team to study epilepsy.
Currently, he is practicing general medicine at the Chapel Medical Clinic in South
Gate, California. In addition to ensuring quality care to his patients, Dr. Ebenezer
Chambi brings his Christian commitment to bear on his profession by continually
promoting preventive care and healthful living. He is involved in his community through
a variety of activities ranging from sponsoring folk music concerts to speaking to
high school students on health. In recognition of his community service, he received
in 1994 the La Sierra University Presidential Citation for Humanitarian Service.
Ebenezer Chambi and his wife, Esther, have three children who are pursuing advanced
studies: Esther Janet, Ebenezer Howard, and Eber Caleb.
Dr. Ebenezer Chambi, what influences have shaped your life?
Perhaps the same four major influences that shape all of us: family, education,
community, and religion. The family teaches us how to care for each other. Parents
care for children, children care for each other and their parents. In a good home,
we learn to love people unconditionally. Education is one of the major ways to learn
about ourselves and develop our talents and intellectual skills. It structures our
personality. Community teaches us that we are not alone-no one is an island. We
depend on other people and they depend on us. Christianity gives us inner strength,
especially when we feel discouraged and don't have energy to keep going. There is a
higher power, God, ready to help us. Religion gives us the powerful tool of confidence.
It brings us strength and hope. It keeps us from giving up on life. At the end of
the journey, it gives us the assurance of a better life.
What type of research did you do in epilepsy?
Epilepsy can be a very debilitating disease, and our team wanted to find its cause
and determine whether it could be successfully treated or even cured. We studied a
diverse population in the Los Angeles area, seeking ways of helping epilepsy victims.
The results were rewarding. Some were cured. Many were able to live relatively normal
lives and return to their vocations.
Currently, what does your practice cover?
I am involved in general practice. Beyond the regular treatment of patients, I focus
on preventive medicine. I want to teach people how to live healthier, happier lives.
In my practice, I see a lot of baby boomers. I'm one of them, so I know what they are
like and how they live. Because they work so many hours and have so many activities,
they often wait until the last possible moment to come to see me, knowing that a visit
to the doctor takes time. They usually don't come in when they have a slight cold or
a stomach ache. They visit my office only when they sense that they are in serious
trouble and need help. We do a complete check-up, including blood and urine tests.
Most of the time we find that they have high cholesterol levels; they are not eating
right and not exercising. Most of the common problems can be prevented, and I emphasize
that.
How do you convince busy people to live healthier lives?
The key is behavior modification. We can give objective explanations of why a person
should exercise more or spend some time relaxing rather than overworking, but it is
challenging to convince people that they need to make fundamental changes in how they
live. At times a physician needs to be quite direct, even blunt, to persuade patients
to radically alter their lifestyle.
A while back, a man, suffering from exhaustion, came to my office. He was working at
two jobs so he could buy a new house every year. His wife told me that he worked too
many hours a day and did not take time to relax and enjoy life. She told me that they
already owned three homes and that he wanted to buy another one. I told her, "Don't
worry. The more he works, the more houses he will leave to you when he dies!" He got
the message and changed his habits.
Do you also utilize the media to educate the public?
When I was doing my residence in Puerto Rico, I started a radio program on health
prevention and promotion. Then here, in the Los Angeles area, I hosted for ten years
a weekly radio forum called El Médico Habla (The Physician Speaks) that was quite
popular. We have also prepared several short video programs on health that I make
available to pastors and TV cable stations.
Does the emphasis on exercise and nutrition in the popular media help in having
people change their lifestyle?
Yes. Ten or 15 years ago, it was more difficult to convince people that they needed
to exercise and eat well. But now, the media's coverage of prevention and health has
made my job easier in terms of education. The problem is that many people who understand
the principles of healthful living aren't putting them into practice. They still eat
too much fast food and stay up too late watching the late shows.
Fortunately, people are beginning to see the light. The city where I practice has a
park where you can see more people running, walking, and doing other exercises than
in any other park in the nearby cities. I like to think this has something to do with
our emphasis on exercise.
The hamburger place that is near our office now also sells vegetarian burgers. I think
that shows some of the positive influence we've had on people who are trying to eat
more healthful foods.
How can people who are not involved in the health-care profession effectively spread
the message of healthful living?
All of us exert an influence and convey a silent message wherever we go. People are
searching for a better life, and they look up to good role models. If we spend time
with people, we can influence them positively by your example. I've found it effective
not to preach at people, but rather to lead by example. We can encourage others to see
that there's a better life.
It's easy to become so focused on our own studies or profession that we forget that
we are part of a larger community outside our walls. How can a person who has become
so insulated begin to interact with the larger community beyond their family or church?
Before I became active in the community, it was easy to be critical of those outside
my circle. But after I became involved, I discovered how much good I could do and how
much I enjoyed it.
Get to know other people, especially those with whom we would not normally associate.
It will help with your social and intellectual development. You will also learn how
your community works and how you can help.
Becoming involved begins with something as simple as the way you greet people. Start
with a solid and sincere, "Good morning. How are you?" Speak words of encouragement.
Learn to listen. Meet with the people who are having problems in your area of expertise
who don't know where to look for help. Focus on relieving their suffering.
A few years ago, an earthquake hit the Los Angeles area. When people asked me why I
left my office to volunteer in the relief efforts, I told them that I was just paying
part of my debt to my community. The community has given me a lot and I want to give
back. It's a two-way street.
And don't forget to have fun! One of the things I do is organize folk-music concerts.
And though lots of people enjoy them, I enjoy them the most!
How do you apply this involvement in your church?
I love my church like a family. I do things not to be recognized or rewarded, but
because I want to do something for Christ and my church. If you start a project with
the goal of being recognized for your efforts, you miss the point. Instead, do the
job because it is important and necessary.
As a successful physician, a health educator, and community leader, what would your
counsel be to people who are just entering their careers?
Learn from successful people by watching how they live, how they get along with
others, and how they maintain their emotional balance. Emulate their good traits.
If I retrace my journey, being active in the church and in the community were the
most important factors that kept me on track. Those of us who have been blessed by
talents and education can do much good. Put yourself where God can use your skills.
Take the initiative to help the community and make people's lives better. That is
a worthwhile goal in life.
Interview by Michael Peabody. Michael Peabody is a third year law student at Pepperdine
University in Malibu, California. E-mail: mdpeabod@pepperdine.edu
Dr. Ebenezer Chambi's address: 9739 California Ave.; South Gate, California 90280; U.S.A.
-------------------------------------------------------------------------------
Orthopedics Link
Information about diagnosis and treatment of piriformis syndrome
What is piriformis syndrome?
Good question! No one really knows exactly what causes piriformis syndrome, or
if it really exists. Some physicians believe that piriformis syndrome is the
name given to hip/buttock pain that cannot be otherwise diagnosed. Others believe
that piriformis syndrome is a very real cause of pain and disability.
What is the piriformis muscle?
The piriformis is a muscle that travels behind the hip joint. The piriformis
muscle is small compared to other muscles around the hip and thigh, and it
aids in external rotation (turning out) of the hip joint. The piriformis muscle
and its tendon have an intimate relationship to the sciatic nerve--the largest
nerve in the body--which supplies the lower extremities with motor and sensory
function. The piriformis tendon and sciatic nerve cross each other behind the
hip joint, in the deep buttock. Both structures are about one centimeter in
diameter.
What do people think happens in piriformis syndrome?
It is thought that the piriformis muscle tendon may be tethering the sciatic
nerve, and causing an irritation to the nerve. While it has not be proven,
the theory supported by some physicians is that when the piriformis muscle
and its tendon are too tight, the sciatic nerve is choked. This may decrease
the blood flow to the nerve and irritate the nerve because of pressure.
What else may be causing this pain?
Sometimes referred to as "deep buttock pain," other causes of this type of
pain include spine problems (including herniated discs, spinal stenosis, etc.),
sciatica, and tendonitis. The diagnosis of piriformis syndrome is often given
when all of these diagnoses are eliminated as possible causes of pain. Other
signs of piriformis syndrome include examination maneuvers that attempt to
isolate the function of this muscle, and the finding of pain directly over
the tendon of the piriformis muscle.
Is there any treatment for piriformis syndrome?
Unfortunately, the treatment of piriformis syndrome is quite general, and
often this is a difficult problem to recover from. Some treatment suggestions are:
1. Physical Therapy - Emphasis on stretching and strengthening the hip rotator
muscles
2. Rest - Avoid the activities that cause symptoms for at least a few weeks
3. Anti-Inflammatory Medication - To decrease inflammation around the tendon
4. Deep Massage - Advocated by some physicians
5. On some occasions, when these treatments fail, patients have surgery to
release, or loosen, the piriformis muscle tendon. This surgery is not a
small procedure, and generally considered the last resort if a lengthy
period of conservative treatment does not solve the problem.
=============================================================================
eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal
Conditions Link
Piriformis Syndrome
Last Updated: June 14, 2004 Rate this Article
Email to a Colleague
Synonyms and related keywords: hip socket neuropathy, pseudosciatica, wallet sciatica,
deep gluteal syndrome, piriformis syndrome
AUTHOR INFORMATION Section 1 of 10
Author Information Introduction Clinical Differentials Workup Treatment Follow-up
Miscellaneous Pictures Bibliography
Author: Milton J Klein, DO, Consulting Staff, Department of Physical Medicine and
Rehabilitation, Sewickley Valley Hospital and Ohio Valley General Hospital
Milton J Klein, DO, is a member of the following medical societies: American Academy
of Disability Evaluating Physicians, American Academy of Osteopathy, American Academy
of Physical Medicine and Rehabilitation, American Association of Electrodiagnostic
Medicine, American Medical Association, American Osteopathic Association, and American
Osteopathic College of Physical Medicine and Rehabilitation
Editor(s): Rajesh R Yadav, MD, Assistant Professor, Section of Physical Medicine
and Rehabilitation, MD Anderson Cancer Center, University of Texas at Houston;
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine;
Michael T Andary, MD, MS, Residency Program Director, Associate Professor,
Department of Physical Medicine and Rehabilitation, Michigan State University
College of Osteopathic Medicine; Kelly L Allen, MD, Consulting Staff, Department
of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center,
Our Lady of Lourdes Medical Center; and Consuelo T Lorenzo, MD, Consulting Staff,
Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel
Rehabilitation Center
INTRODUCTION Section 2 of 10
Author Information Introduction Clinical Differentials Workup Treatment
Follow-up Miscellaneous Pictures Bibliography
Background: Piriformis syndrome has remained a controversial diagnosis since
its initial description in 1928. Piriformis syndrome usually is caused by neuritis
of the proximal sciatic nerve. The piriformis muscle can either irritate or compress
the proximal sciatic nerve due to spasm and/or contracture, and this problem can
mimic discogenic sciatica (pseudosciatica).
Pathophysiology: The piriformis muscle is flat, pyramid-shaped, and oblique.
This muscle originates to the anterior of the S2-S4 vertebrae, the sacrotuberous
ligament, and the upper margin of the greater sciatic foramen (see Image 1).
This muscle passes through the greater sciatic notch and inserts on the superior
surface of the greater trochanter of the femur. With the hip extended, the piriformis
muscle is the primary external rotator; however, with the hip flexed, the piriformis
muscle itself becomes a hip abductor. This muscle is innervated by branches from
L5, S1, and S2. A lower lumbar radiculopathy also may cause secondary irritation
of the piriformis muscle, which may complicate the diagnosis and hinder patient
progress.
Many developmental variations of the relationship between the sciatic nerve in
the pelvis and piriformis muscle have been observed. In approximately 20% of the
population, the muscle belly is split with one or more parts of the sciatica
nerve dividing the muscle belly itself. In 10% of the population, the tibial/peroneal
divisions are not enclosed in a common sheath. Usually, the peroneal portion splits the
piriformis muscle belly; the tibial division rarely splits the muscle belly.
Involvement of the superior gluteal nerve usually is not seen in cases of piriformis
syndrome. This nerve leaves the sciatic 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 external rotators. Nerve injury can occur with prolonged pressure on
the nerve or vasa nervorum.
Etiology can be subdivided into a few categories as follows:
Hyperlordosis
Muscle anomalies with hypertrophy
Fibrosis (due to trauma)
Partial or total nerve anatomical abnormalities
Other causes can include the following:
Pseudo aneurysms of the inferior gluteal artery adjacent to the piriformis syndrome
Bilateral piriformis syndrome due to prolonged sitting during an extended
neurosurgical procedure
Cerebral palsy
Total hip arthroplasty
Myositis ossificans
Vigorous physical activity
This syndrome remains controversial because, in most cases, the diagnosis is clinical,
and no confirmatory tests exist to support the clinical findings.
Frequency:
In the US: Given the lack of agreement on exactly how to diagnose this condition,
estimates of frequency of sciatica caused by piriformis syndrome vary from rare to
approximately 6% of sciatica cases seen in a general family practice.
Approximately 90% of adults have had at least one episode of disabling LBP in their
lifetime.
Mortality/Morbidity: Piriformis syndrome is not life-threatening, but it can have
significant associated morbidity. The total cost of low back pain (LBP) and sciatica is
significant, exceeding $16 billion in both direct and indirect costs.
Sex: Some reports suggest a 6:1 female-to-male predominance. CLINICAL Section
3 of 10 Author Information Introduction Clinical Differentials Workup Treatment
Follow-up Miscellaneous Pictures Bibliography
History: Piriformis syndrome often is not recognized as a cause of LBP and associated
sciatica. This clinical syndrome is due to a compression of the sciatic nerve by the
piriformis muscle. This condition is identical in clinical presentation to LBP with
associated L5, S1 radiculopathy due to discogenic and/or lower lumbar facet arthropathy
with foraminal narrowing. Not uncommonly, patients demonstrate both of these clinical
entities simultaneously. This diagnostic dilemma highlights the need for patients with
LBP and associated radicular pain to undergo a complete history and physical examination,
including a digital rectal examination.
Many cases of refractory trochanteric bursitis are observed to have an underlying occult
piriformis syndrome due to the insertion of the piriformis muscle on the greater
trochanter of the hip. If both the trochanteric bursitis and the piriformis syndrome
are treated inadequately, both conditions remain resistant to medical management.
Physical: Examination findings may include the following:
Piriformis muscle spasm often is detected by careful deep palpation.
Digital rectal examination may reveal tenderness on lateral pelvic wall that
reproduces symptoms.
Reproduction of sciatica type pain with weakness is noted by resisted abduction/external
rotation (Pace test).
The Freiberg test is another diagnostic sign that elicits pain upon forced internal
rotation of the extended thigh.
The Beatty maneuver reproduces buttock pain by selectively contracting the piriformis
muscle. The patient lies on the uninvolved side and abducts the involved thigh upward;
this activates the ipsilateral piriformis muscle, which is both a hip external rotator
and abductor with the hip flexed.
A painful point may be present at the lateral margin of the sacrum.
Shortening of the involved lower extremity may be seen.
The patient may have difficulty sitting due to an intolerance of weight bearing on
the buttock.
The patient may have the tendency to demonstrate a splayed foot on the involved side
when in the supine position.
Piriformis syndrome alone is rarely a cause of a focal neuromuscular impairment; either
a sciatic mononeuropathy or an L5-S1 radiculopathy can mimic both of these conditions,
obscuring diagnosis of piriformis syndrome.
A Morton foot may predispose the patient to developing piriformis syndrome. The
prominent second metatarsal head destabilizes the foot during the push-off phase
of the gait cycle, causing foot pronation and internal rotation of the lower limb.
The piriformis muscle (external hip rotator) reactively contracts repetitively during
each push-off phase of the gait cycle as a compensatory mechanism, leading to piriformis
syndrome.
Causes: Approximately 50% of patients with piriformis syndrome have a history of trauma,
with either a direct buttock contusion or hip/lower back torsional injury. The remaining
50% of cases are of spontaneous onset, so the treating physician must have a high index of
suspicion for this problem, lest it be overlooked.
DIFFERENTIALS Section 4 of 10
Author Information Introduction Clinical Differentials Workup Treatment Follow-up
Miscellaneous Pictures Bibliography
Lumbar Degenerative Disc Disease
Lumbar Facet Arthropathy
Lumbar Spondylolysis and Spondylolisthesis
Myofascial Pain
Trochanteric Bursitis
Other Problems to be Considered:
Lumbosacral radiculopathy
Buttock pain
Ischial tuberosity bursitis
Sciatica
Check the Internet for Related Articles:
Lumbar Degenerative Disc Disease
Lumbar Facet Arthropathy
Lumbar Spondylolysis and Spondylolisthesis
Myofascial Pain
Trochanteric Bursitis
Continuing Education
CME available for this topic. Click here to take this CME.
WORKUP Section 5 of 10
Author Information Introduction Clinical Differentials Workup Treatment Follow-up
Lab Studies:
Laboratory studies generally are not indicated in diagnosing piriformis syndrome.
Imaging Studies:
Diagnostic imaging of the lumbar spine is mandatory to exclude associated discogenic
and/or osteoarthritic contributing pathology.
Reports in the literature on piriformis muscle describe imaging by nuclear
diagnostic studies and MRI of the pelvis, but these tests are neither practical
nor reliable diagnostic approaches to this problem. The history and clinical
diagnostic examination provide the greatest and most specific diagnostic yield
for this problem.
Other Tests:
Results of electrodiagnostic testing for piriformis syndrome usually are normal.
Reports of positional H-reflex abnormalities can be found in the literature;
however, such findings have not been widely accepted or reproduced.
TREATMENT Section 6 of 10
Author Information Introduction Clinical Differentials Workup Treatment Follow-up
Rehabilitation Program:
Physical Therapy: Because a definitive method to accurately diagnose this problem
is not available, treatment regimens are controversial and have not been subjected
to randomized blind clinical trials. Despite this fact, numerous treatment strategies
exist for patients with piriformis syndrome.
Functional biomechanical deficits may include the following:
Tight piriformis muscle
Tight hip external rotators and adductors
Hip abductor weakness
Lower lumbar spine dysfunction
Sacroiliac joint hypomobility
Functional adaptations to these deficits include the following:
Ambulation with thigh in external rotation
Functional limb length shortening
Shortened stride length
Once the diagnosis has been made, these underlying perpetuating biomechanical factors
must be corrected.
Consider the use of ultrasound and other heat modalities prior to physical therapy
sessions. 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. Addressing sacroiliac
joint and low back dysfunction also is important.
A home stretching program should be provided to the patient. These stretches are an
essential component of the treatment program. During the acute phase of treatment,
stretching every 2-3 hours (while awake) is a key to the success of non operative
treatment. Prolonged stretching of the piriformis muscle is accomplished in either
a supine or orthostatic position with the involved hip flexed and passively adducted/
internally rotated.
Medical Issues/Complications: No consensus exists on overall treatment of piriformis
syndrome due to lack of objective clinical trials. Conservative treatment (eg,
stretching, manual techniques, injections, activity modifications, modalities like
heat or ultrasound, natural healing) is successful in most cases.
Injection therapy can be incorporated if the situation is refractory to the
aforementioned treatment program. For effective injection, the piriformis muscle
must be localized manually by digital rectal examination. Then the piriformis muscle
is injected using a 3.5-inch (8.9-cm) spinal needle. Care must be taken to avoid
direct injection of the sciatic nerve.
Surgical Intervention: Surgical management is the treatment of last resort. Surgery
for this condition involves resection of the muscle itself or the muscle tendon
near its insertion at the superior aspect of the greater trochanter of the femur
(as described by Mizuguchi). These surgical procedures are described as effective,
and they do not cause any associated superimposed postoperative disability.
Consultations:
Because of the enigmatic nature of piriformis syndrome, initial consultation obtained
from an orthopedic surgeon or similar specialist usually is nonspecific. This disorder
is considered to be a soft tissue problem that presents as low back or buttock pain
with sciatica. After all differential diagnoses have been excluded, consider piriformis
syndrome. Due to the traumatic etiology of most cases, piriformis syndrome usually is
associated with other more proximal causes of LBP, sciatica, and buttock pain (thereby
further clouding the diagnosis).
Other Treatment (injection, manipulation, etc.):
The Spray N' Stretch myofascial treatment and ultrasound modality preceding physical
therapy sessions are useful.
Manual muscle medicine, including facilitated positional release, may be helpful.
Injections with steroids, local anesthetics, and botulinum toxin have been reported
in the literature for this condition. No single technique is universally accepted.
Localization techniques include manual localization of muscle with fluoroscopic and
electromyographic guidance. The piriformis muscle, after localization with a digital
rectal examination, can be injected with a 3.5-inch (8.9-cm) spinal needle. Care should
be taken to avoid direct injection of the sciatic nerve.
FOLLOW-UP Section 7 of 10
Author Information Introduction Clinical Differentials Workup Treatment
Follow-up Miscellaneous
Further Inpatient Care:
Inpatient care would be necessary only if surgical intervention is warranted.
Surgery is the last resort treatment for severe cases of piriformis syndrome.
Further Outpatient Care:
Piriformis syndrome usually is treated effectively with conservative measures.
Please refer to the Treatment section for a discussion of treatment recommendations.
Deterrence/Prevention:
No method has been demonstrated to prevent piriformis syndrome. The best prevention
is to maintain biomechanical balance by restoration of a more physiologic weight
bearing distribution with a level pelvis/sacral base and equal leg lengths, achieved
by heel lift therapy if necessary. This treatment approach also prevents recurrences
of piriformis syndrome, especially if the underlying etiology is a leg-length discrepancy.
The patient also must engage in a general stretching program that includes bilateral
piriformis muscles.
Complications:
The most significant complication is failure to recognize, diagnose, and treat this
disabling condition. If left untreated, a patient may undergo unsuccessful back
surgery for a disc herniation; however, a coexisting occult piriformis syndrome
can result in a failed back syndrome.
Another complication is inadvertent direct injection of the sciatic nerve, which
usually results in a non disabling and temporary sciatic mononeuropathy.
Prognosis:
The prognosis depends upon early recognition and treatment. As this is a soft
tissue syndrome, it has a tendency to be chronic, usually due to late diagnosis
and treatment and has a less favorable prognosis.
Patient Education:
For conservative measures to be effective, the patient must be educated with an
aggressive home-based stretching program to maintain piriformis muscle flexibility.
He or she must comply with the program even beyond the point of discontinuation of
formal medical treatment.
MISCELLANEOUS Section 8 of 10
Author Information Introduction Clinical Differentials Workup Treatment Follow-up
Miscellaneous Pictures Bibliography
Medical/Legal Pitfalls:
The greatest medical/legal concern is either misdiagnosis or failure to diagnose
piriformis syndrome. In most cases, the diagnosis is one of exclusion. Therefore,
if piriformis syndrome is not in the differential diagnosis list, it may be overlooked.
The patient becomes a chronic pain patient doomed to a lifetime of disability and
chronic management with medication. Because the diagnosis usually is elusive, missing
the diagnosis does not constitute malicious negligence and, therefore, rarely would
be sufficient grounds alone for a medical malpractice lawsuit.
Piriformis syndrome may be a secondary perpetuating factor underlying chronic
posttraumatic intractable LBP. Negligent misdiagnosis or delayed diagnosis of
this condition has caused a significant degree of unnecessary disability and
financial loss.
Special Concerns:
In female patients, piriformis syndrome may be a cause of dyspareunia, but, again,
this connection becomes impossible to prove. Diagnosis of piriformis syndrome requires
a high index of suspicion by either the primary care physician or the obstetric/
gynecologic specialist/surgeon. A bimanual simultaneous vaginal-rectal examination
of female patients to determine this soft tissue diagnosis helps the physician to
prescribe appropriate treatment.
Although it is a misdiagnosed etiology of LBP/sciatica, piriformis syndrome can
be a significant cause of soft tissue pain and disability. This problem requires
a skillful, attentive physician to conduct a thorough history/physical examination
that provides an accurate diagnosis. Once the clinical diagnosis has been made, a
specific treatment can be formulated to provide the best outcome with a minimal degree
of long-term disability.
Author Information Introduction Clinical Differentials Workup Treatment Follow-up
Miscellaneous Pictures Bibliography
Nerve irritation in the herniated disk occurs at the root (sciatic radiculitis).
In the piriformis syndrome, the irritation extends to the full thickness
of the nerve (sciatic neuritis).
BIBLIOGRAPHY Section 10 of 10
Author Information Introduction Clinical Differentials Workup Treatment Follow-up
Barton PM: Piriformis syndrome: a rational approach to management. Pain 1991 Dec; 47(3):
345-52[Medline].
Beatty RA: The piriformis muscle syndrome: a simple diagnostic maneuver. Neurosurgery
1994; 34: 512-514[Medline].
Beauchesne RP, Schutzer SF: Myositis ossificans of the piriformis muscle: an unusual
cause of piriformis syndrome. A case report. J Bone Joint Surg Am 1997 Jun; 79(6):
906-10[Medline].
Brown JA, Braun MA, Namey TC: Piriformis syndrome in a 10-year-old boy as a complication
of operation with the patient in the sitting position. Neurosurgery 1988 Jul; 23(1):
117-9[Medline].
Durrani Z, Winnie AP: Piriformis muscle syndrome: an under diagnosed cause of sciatica.
J Pain Symptom Manage 1991 Aug; 6(6): 374-9[Medline].
Fishman LM, Zybert PA: Electrophysiologic evidence of piriformis syndrome. Arch Phys
Med Rehabil 1992 Apr; 73(4): 359-64[Medline].
Freidberg AH: Sciatic pain and its relief by operation on muscle and fascia. Arch
Surg 1937; 34: 337-349.
Frymoyer JW: Back pain and sciatica. N Engl J Med 1988 Feb 4; 318(5): 291-300[Medline].
Jankiewicz JJ, Hennrikus WL, Houkom JA: The appearance of the piriformis muscle
syndrome in computed tomography and magnetic resonance imaging. A case report and
review of the literature. Clin Orthop 1991 Jan; (262): 205-9[Medline].
Karl RD Jr, Yedinak MA, Hartshorne MF: Scintigraphic appearance of the piriformis
muscle syndrome. Clin Nucl Med 1985 May; 10(5): 361-3[Medline].
Mizuguchi T: Division of the piriformis muscle for the treatment of sciatica.
Postlaminectomy syndrome and osteoarthritis of the spine. Arch Surg 1976 Jun; 111(6):
719-22[Medline].
Noftal F: The Piriformis Syndrome. Can J Surg 1988 Jul; 31(4): 210[Medline].
Pace JB, Nagle D: Piriformis syndrome. West J Med 1976 Jun; 124(6): 435-9[Medline].
Papadopoulos SM, McGillicuddy JE, Albers JW: Unusual cause of "piriformis muscle
syndrome". Arch Neurol 1990 Oct; 47(10): 1144-6[Medline].
Parziale JR, Hudgins TH, Fishman LM: The piriformis syndrome. Am J Orthop 1996
Dec; 25(12): 819-23[Medline].
Rask MR: Superior gluteal nerve entrapment syndrome. Muscle Nerve 1980 Jul-Aug;
3(4): 304-7[Medline].
Retzlaff EW, Berry AH, Haight AS: The piriformis muscle syndrome. J Am Osteopath
Assoc 1974 Jun; 73(10): 799-807[Medline].
Robinson D: Piriformis syndrome in relation to sciatic pain. Am J Surg 1947;
73: 355-358.
Schiowitz S: Facilitated positional release. J Am Osteopath Assoc 1990 Feb;
90(2): 145-6, 151-5[Medline].
Steiner C, Staubs C, Ganon M: Piriformis syndrome: pathogenesis, diagnosis,
and treatment. J Am Osteopath Assoc 1987 Apr; 87(4): 318-23[Medline].
TePoorten BA: The piriformis muscle. J Am Osteopath Assoc 1969 Oct; 69(2):
150-60[Medline].
Thiele GH: Tonic spasm of the levator ani, coccygeus and piriformis muscles.
Trans Am Proct Soc 1936; 37: 145-155.
Uchio Y, Nishikawa U, Ochi M: Bilateral Piriformis Syndrome after Total Hip
Arthroplasty. Arch Orthop Trauma Surg 1988; 117: 177-179.
Yeoman W: The relation of arthritis of the sacroiliac joint to sciatica.
Lancet 1928; ii: 1119-1122.
NOTE:
Medicine is a constantly changing science and not all therapies are clearly
established. New research changes drug and treatment therapies daily. The authors,
editors, and publisher of this journal have used their best efforts to provide
information that is up-to-date and accurate and is generally accepted within medical
standards at the time of publication. However, as medical science is constantly
changing and human error is always possible, the authors, editors, and publisher
or any other party involved with the publication of this article do not warrant
the information in this article is accurate or complete, nor are they responsible
for omissions or errors in the article or for the results of using this information.
The reader should confirm the information in this article from other sources prior
to use. In particular, all drug doses, indications, and contraindications should
be confirmed in the package insert.
FULL DISCLAIMER
Medicine is a constantly changing science and not all therapies are clearly established.
New research changes drug and treatment therapies daily. The authors, editors, and
publisher of this journal have used their best efforts to provide information that
is up-to-date and accurate and is generally accepted within medical standards at the
time of publication. However, as medical science is constantly changing and human
error is always possible, the authors, editors, and publisher or any other party
involved with the publication of this article do not warrant the information in this
article is accurate or complete, nor are they responsible for omissions or errors
in the article or for the results of using this information. The reader should
confirm the information in this article from other sources prior to use. In particular,
all drug doses, indications, and contraindications should be confirmed in the package
insert.
----
: Arch Surg. 1976 Jun;111(6):719-22. Related Articles, Link
Division of the piriformis muscle for the treatment of sciatica. Postlaminectomy
syndrome and osteoarthritis of the spine.
Mizuguchi T.
Division of the piriformis muscle at its tendinous insertion was employed for the
treatment of sciatica in 14 patients with post laminectomy syndrome and osteoarthritis
of the spine. Of these patients, 85% had satisfactory results. It is logical that the
piriformis muscle can play an important role in the production of sciatic associated
with intraspinal lesions. Tension on the sciatic nerve, which passes in close approximation
to the piriformis muscle anteriorly, can be relieved by division of the piriformis
muscle.
----
1: Neurosurgery. 1994 Mar;34(3):512-4; discussion 514. Related Articles, Link
Comment in:
Neurosurgery. 1994 Sep;35(3):545.
The piriformis muscle syndrome: a simple diagnostic maneuver.
Beatty RA.
Department of Neurosurgery, University of Illinois, College of Medicine, Chicago.
Current maneuvers to diagnose the piriformis syndrome are less than ideal. Freiberg's
maneuver of forceful internal rotation of the extended thigh elicits buttock pain by
stretching the piriformis muscle, and Pace's maneuver elicits pain by having the patient
abduct the legs in the seated position, which causes a contraction of the piriformis
muscle. This report describes a maneuver performed by the patient lying with the painful
side up, the painful leg flexed, and the knee resting on the table. Buttock pain is
produced when the patient lifts and holds the knee several inches off the table. The
maneuver produced deep buttock pain in three patients with piriformis syndrome. In 100
consecutive patients with surgically documented herniated lumbar discs, the maneuver
often produced lumbar and leg pain but not deep buttock pain. In 27 patients with
primary hip abnormalities, pain was often produced in the trochanteric area but not
in the buttock.
he maneuver described in this report was helpful in diagnosing the piriformis syndrome.
It relies on contraction of the muscle, rather than stretching, which the author believes
better reproduces the actual syndrome.
Publication Types:
Case Reports
PMID: 8190228 [PubMed - indexed for MEDLINE]
----
Muscle Nerve. 1980 Jul-Aug;3(4):304-7. Related Articles, Link
Superior gluteal nerve entrapment syndrome.
Rask MR.
Entrapment of the superior gluteal nerve can occur as a result of compression by
anterior-superior tendinous fibers of the piriformis muscle and cause aching claudication
-type buttock pain, weakness of abduction of the affected hip with a waddling gait, and
tenderness to palpation in the area of the buttock super lateral to the greater sciatic
notch. Instilling anesthetic into the point of entrapment may relieve the pain completely
but superior gluteal neurolysis may be required to effect a permanent cure.
Publication Types:
Case Reports
PMID: 7412775 [PubMed - indexed for MEDLINE]
-------------------------------------------------------------------------------
1: Clin Nucl Med. 1985 May;10(5):361-3. Related Articles, Link
Scintigraphic appearance of the piriformis muscle syndrome.
Karl RD Jr, Yedinak MA, Hartshorne MF, Cawthon MA, Bauman JM, Howard WH, Bunker SR.
This is the first report in the nuclear medicine literature of the scintigraphic
appearance of the piriformis muscle syndrome. This syndrome previously has been
thought to be a purely clinical diagnosis and imaging modalities have been ignored.
However, its confusing clinical presentation can lead to unnecessary surgical exploration
This case is presented to illustrate the characteristic scintigraphic pattern and
suggest the role of nuclear medicine scanning in establishing the diagnosis.
Publication Types:
Case Reports
PMID: 3160520 [PubMed - indexed for MEDLINE]
-------------------------------------------------------------------------------
1: Arch Surg. 1976 Jun;111(6):719-22. Related Articles, Link
Division of the piriformis muscle for the treatment of sciatica. Post laminectomy
syndrome and osteoarthritis of the spine.
Mizuguchi T.
Division of the piriformis muscle at its tendinous insertion was employed for the
treatment of sciatica in 14 patients with post laminectomy syndrome and osteoarthritis
of the spine. Of these patients, 85% had satisfactory results. It is logical that
the piriformis muscle can play an important role in the production of sciatic
associated with intraspinal lesions. Tension on the sciatic nerve, which passes
in close approximation to the piriformis muscle anteriorly, can be relieved by
division of the piriformis muscle.
PMID: 1275705 [PubMed - indexed for MEDLINE]
---
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What is Piriformis Syndrome?
Piriformis syndrome is a rare neuromuscular disorder that occurs when the piriformis
muscle compresses or irritates the sciatic nerve-the largest nerve in the body. The
piriformis muscle is a narrow muscle located in the buttocks. Compression of the
sciatic nerve causes pain-frequently described as tingling or numbness-in the buttocks
and along the nerve, often down to the leg. The pain may worsen as a result of sitting
for a long period of time, climbing stairs, walking, or running.
Is there any treatment?
Generally, treatment for the disorder begins with stretching exercises and massage.
Anti-inflammatory drugs may be prescribed. Cessation of running, bicycling, or similar
activities may be advised. A corticosteroid injection near where the piriformis muscle
and the sciatic nerve meet may provide temporary relief. In some cases, surgery is
recommended.
What is the prognosis?
The prognosis for most individuals with piriformis syndrome is good. Once symptoms
of the disorder are addressed, individuals can usually resume their normal activities.
In some cases, exercise regimens may need to be modified in order to reduce the likelihood
of recurrence or worsening.
What research is being done?
Within the NINDS research programs, piriformis syndrome is addressed primarily through
studies associated with pain research. NINDS vigorously pursues a research program seeking
new treatments for pain and nerve damage with the ultimate goal of reversing debilitating
conditions such as piriformis syndrome.
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Piriformis Syndrome: Link
New minimal access, outpatient surgery developed at INM greatly improves outcome
and reduces recovery time
Piriformis Surgery Incision
Piriformis surgery is now a small procedure which can be carried out under local
anaesthetic as an outpatient. Traditional piriformis surgery is a large and debilitating
operation but no patient should be having these operations today. There were two types
of traditional piriformis surgery, one involves a large lateral hip incision similar
to the approach used for a hip replacement surgery. The second involves a very large
incision and involves completely detaching all of the gluteal muscles from the iliac
crest. Both of these types of surgery result in weeks of debilitation, walking on
crutches and pain, with only limited success treating the original problem.
The new type of "minimal access surgery" developed at the Institute for Nerve Medicine
by Dr. Aaron Filler involves only a small incision, and in most cases can be performed
on an outpatient basis. Large scale formal outcome trials involving hundreds of patients
with follow-up out to eight years show no detectable effect on normal walking in any
of the patients - this a great change from the traditional surgery that often leaves
permanent problems with gait. Recovery takes only a few days in most patients.
Those patients who have positive physical exam findings, positive MR neurography
findings and a clear positive response to MRI guided piriformis injection have had
a 85% to 90% good to excellent outcome.
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Piriformis Syndrome & Sciatica Link
The nerve-related leg pain of Sciatica is often due to piriformis muscle syndrome.
Unlike the sciatica from a herniated disk, there is often little or no back pain
while buttock pain predominates. The pain is worse when sitting, relieved by standing
or walking, and often extends no farther down the leg than the ankle or mid-foot.
When toes are involved, it usually affects all five toes.
Piriformis Flexion Diagram
This drawing illustrates the important anatomy for piriformis syndrome and shows
how certain leg positions pull the piriformis muscle up against the sciatic nerve
causing buttock pain and radiating leg pain.
Piriformis Syndrome
Anatomy of the piriformis muscle and sciatic nerve
in a T1 weighted axial MRI scan
Piriformis Muscle Open MRI Anatomy Photo Link
This T1 weighted axial MRI scan shows the anatomy used to guide the injection of the piriformis
muscle in an Open MRI scanner.
Link
to MR Images of hypersensitivity to left side of Piriformis Muscle
Piriformis Flexion Exam Manouver
Critical physical exam maneuver for muscle based piriformis syndrome: The patient's
foot is placed lateral to the contra lateral knee. Resisted abduction or adduction
against the examiner's hand may reproduce the symptoms. Straight leg rising is
typically negative. There is often relief obtained by traction on the involved leg,
particularly by pulling upwards at a ten to twenty degree angle and towards the
contra lateral side by a similar amount. The distribution of symptoms typically involves
both L5 (big toe) and S1 (small toe) components because this a pan-sciatic syndrome.
The symptoms often progress no further than the ankle in distinction to sciatica
from a lumbar disk which typically radiates into the toes. Link
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