1. An Alternative Treatment Approach to Piriformis Syndrome
Korey Pieper, DPT, OCS
Marie Potter, DPT, OCS, ATC
Rick J Rafael, DPT, OCS, CSCS
Jason Tonley, DPT, OCS
Kaiser Permanente West Los Angeles Orthopaedic Residency Program
September 2008

2. Piriformis Syndrome Defined
“Neuritis of the branches of the sciatic nerve, caused by pressure of an injured or irritated piriformis muscle1.”

3. Symptoms
Radiating pain from the low back down over the sacrum into the buttocks and hip region, as well as down the posterior portion of the upper leg to the popliteal region1.
Image from bp1.blogger.com

4. Anatomy
image from

5. Possible Causes of Piriformis Syndrome
Anatomical variation
L/S dysfunction
Muscle tightness and/or spasm
Overuse
Post surgical injury
SIJ dysfunction
Trauma/fall

6. Differential Diagnosis
Differential Diagnosis of Hip pain7,8:
Intra-articular & Extra-articular (Often Managed Operatively) :
Labral Tears
Loose Bodies
Femoroacetabular Impingement (FAI)
Hypermobility
Capsular Laxity
Ligamentum Teres Tear
Chondral Damage
Snapping Hip Syndrome
IT Band Syndrome
Greater Trochanteric Bursitis
Gluteal Tendon Injury

7. Differential Diagnosis
Differential Diagnosis of Hip pain7,8:
Extra-articular Causes (Often Managed Non-Operatively):
Femoral Neck Stress Fracture
Adductor Strain
Piriformis Syndrome
Sacroiliac Joint Syndrome
Tendonitis (hip flexors, abductors, adductors)

8. Differential Diagnosis
Other Competing Diagnosis:
Lumbar Facet Syndrome
Lumbar Disc Herniation
Nerve entrapment
Ischial Tuberosity Bursitis
Lumbar radiculopathy
Spinal stenosis
Spondylolisthesis
Osteoarthritis

9. Common Treatment Options
Injections
L/S stabilization exercises
Mobilization/manipulation L/S
Mobilization/manipulation SI joint
Foot orthotics
Soft tissue mobilization
Strengthening
Stretching
Surgical / arthroscopic release
Ultrasound

10. Common assumption guiding treatment approaches
The piriformis is shortened or in “spasm” and is compressing the sciatic nerve

11. Purpose of study
To create a case series using an alternative treatment approach to piriformis syndrome

12. Inclusion Criteria: Objective Exam
Unilateral pain from lower lumbar/buttock region to the leg
Symptoms not reproduced from lumbar, SI joint, and/or hip joint examinations

13. Inclusion Criteria: Objective Exam
Lumbar Exam
Negative AROM with OP
Negative PA exam
Neurological testing negative for nerve root lesion
SIJ Exam
Negative cluster
Hip Exam
Negative ROM, excluding quadrant

14. Inclusion Criteria: Objective Exam
Reproduction of symptoms with:
Palpation of piriformis muscle
Piriformis stretch test
FAIR Test
Demonstrates movement dysfunction of ADD and/or IR and reproduction of symptoms with step down test
Decreased reproduction of symptoms with corrected movement during step down test

15. Objective Exam Patient to fill out disability questionnaires:
Oswestry Disability Index
Lower Extremity Functional Scale

16. Treatment Approach
Isolated strengthening for hip extensors, abductors, and external rotators
Functional movement re-education for decreasing hip adduction and internal rotation
NO!!!!!
Stretching
Soft tissue massage
Modalities

17. Treatment Approach Examples
Hip strengthening:
Clams
Bridging
Prone hip extension
Quadruped hip extension
Hip abduction

18. Treatment Approach Examples
Movement Re-education:
Postural correction
Sit to stand transitions
Single leg sit to stands
Lunges
Plyometrics if indicated

19. Patient Data 7 Patients Age: mean 56 (range 31 - 69)
Duration of symptoms: 197 days (range 45 – 730)
# of visits: 5 (range 2-8)
Duration of visits: 9 weeks (range 3-16)

20. Average LE Functional Scale
Range: initial (37-70) discharge (54-80)

21. Average VAS (Pain Scale)
Range: initial (6-10/10) discharge (0-4/10)

22. Analysis
Movement assessment allowed proper physical therapy diagnosis and treatment
Patient’s can have multiple positive tests, but movement reproduces primary pain complaint
Ceiling effect of questionnaires affects data analysis

23. Future Research
Prevalence of movement dysfunction in patient’s diagnosed with piriformis syndrome
Most effective treatment modality for movement dysfunction: strength training vs. movement re-education

24. Conclusion
Movement re-education and strengthening can be a successful way to treat piriformis syndrome when a patient presents with a coordination deficit.

25. References
Edwards, F.O.: Piriformis syndrome. Academy of Applied Osteopathy. Yearbook, 1962, pp
Parizale JR, Hudgins TH, Fishman LM: The Piriformis Syndrome. Am J. Orthrop, 1996:25:
Parizale JR, Hudgins TH, Fishman LM: The Piriformis Syndrome A Review. Paper.” The. Am J of Orthop. 2002:25:1-11
Bird JW: Piriformis Syndrome. Oper Tech Sports Med
Mayrand N, Fortin J, Descarreaux M, Normand MC. Diagnosis and management of posttraumatic piriformis syndrome: a case study. J. Manipulative Physiol Ther Jul-Aug;29(6):486-91
Keskula DR, Tamburello M: Conservative Management of Piriformis. Syndrome. J Athl Train. 1992; 27(2):102, 104, , 110
Lisa M Tibor, Jon Sekiya. Differential Diagnosis of Pain Around the Hip Joint. The Journal of Arthroscopic and Related Surgery. 2008;19:1-15
Michael K Shindle, Benjamin G Domb, Bryan T Kelly. Hip and Pelvic Problems in Athletes. Oper Tech Sports Med. 2007; 15: