1. Piriformis Syndrome Presented by Dr. Emily Kliethermes August 8, 2005

2. Tips for Successful Credit Case History Chief Complaint Worksheet Physical & spinal Exam Problem Management Treatment Plan Differential Diagnosis Worksheet

3. PIRIFORMIS SYNDROME – Sciatica like pain caused by compression of the sciatic nerve by the piriformis muscle, which 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. (Merck Manual 17 th edition)

4. Piriformis Posted by mrich@u.washington.edu, 6/2/00 at 12:24:02 PM. mrich@u.washington.edu Origin Anterior surface of lateral process of sacrum and gluteal surface of ilium at the margin of the greater sciatic notch Insertio n Superior border of greater trochanter Action Lateral rotator of the hip joint; also helps abduct the hip if it is flexed Innervat ion Piriformis nerve (L5, S1, S2) Arterial Supply Superior and inferior gluteal and internal pudendal arteries The medical illustrations contained in this online atlas are copyrighted © 1997 by the University of Washington. They may not be utilized, reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, or by any information storage or retrieval system, without permission in writing from the University of Washington.

6. Patient Information Twenty-two year old male caucasian History – Family history was not contributory – Patient had been treated previously by chiropractic in California for similar symptoms that improved but did not remit. – The patient moved from California to Texas following a change in relationship status

7. Patient Information History (cont.) – Patient experienced an acute exacerbation of symptoms following the move. – Patient attributes exacerbation to caring two 150 lbs bags, one over each shoulder, through the airport.

8. Chief Complaint Low back pain that radiates down the right leg below the knee to the lateral foot. Experiences burning type pain in foot and “tightness or pressure in the muscles of the low back and outside aspect of the thigh”. Pain is constant, however, worse in morning.

9. Chief Complaint Patient states that moist heat over low back and hip area decreases the pain. Cold (including weather) increases his pain. Standing and sitting for prolonged periods increase the pain.

10. Physical Exam Abnormal Thoracolumbar ROM – Flexion 75 degrees with pain in right low back (norm 90 deg.). – Extension 45 degrees with pain (norm 35 deg.). – Right lateral flexion 35 degrees (norm 40 deg.). – Right rotation 28 degrees (norm 35 deg.).

11. Physical Exam Positive/Clinically Relevant Orthopedic Tests – Supported Adam’s Test (dec pain with support) – SLR on Right at 8 degrees (pain decreases with external rotation of the hip) – Braggard’s – Patrick Fabere (dec sciatic symptoms) – SOTO decrease pain

12. Physical Exam Postural Analysis – Left head tilt – Left high shoulder – Left high hip – External rotation of right foot

13. Physical Exam Palpation – Restriction throughout spine – Hypertonicity in lumbar musculature – Trigger points in belly of Piriformis Muscle

14. X-ray Findings Mild left curvature involving the T9-L5 levels Lateral lumbar reveals a uniform reduction of the posterior body height of L5 (probable congenital variation in anatomical presentation of L5 body).

15. DDX: Sciatica Piriformis Syndrome Disc Herniation

16. Diagnosis: Condition: Piriformis Syndrome (pseudosciatica) Secondary to: Sacroiliac segmental dysfunction With associated: myospasm

17. Treatment CMT 3 x / week for 2 weeks CMT 2 x / week for 3 weeks Then Re-evaluate Adjunctive procedures were performed as listed PRN – Myofascial release of piriformis, TFL, and QL muscles – PIR stretch of piriformis and psoas muscles

18. Treatment Adjunctive procedures (cont.) – Percussor (lower extremities) – Aqua massage Treatment Goals: – Decrease trigger points, spasm and pain – Increase ROM

19. Treatment Nutrition – Calcium / Magnesium complex – Increase Water intake Home stretches were given for piriformis and psoas muscles to be performed bid