Piriformis Syndrome & Coccygodynia

Question 1

What are the primary and secondary etiology (causes) of Peiriformis syndrome

Answer 1

Primary = An entrapment neuropathy (of the sciatic nerve) or neurovascular entrapment due to the location of the piriformis muscle in relationship to the nerve and other vessels. This is associated with anatomic variation in the piriformis muscle, sciatic nerve or anomalous pat of the sciatic nerve

Secondary = trauma of pelvis/buttocks (macro, micro, repetitive)

Question 2

Where is the sciatic nerve relative to the piriformis?

Answer 2

Sometimes the nerve enters over the muscle,
Sometimes below the muscle
Sometimes through the belly of the muscle.

Question 3

What is the primary action of the Piriformis. What else can it do?

Answer 3

Hip external rotator.

With hip flexion > 90 degrees, it is also a hip abductor

Question 4

What is the common symptom profile of a patient with Piriformis syndrome?

Answer 4

• Pain in the buttock/sacroiliac joint region that may radiate to hip and backside of thigh, all the way down to the KNEE, but not inferior to the knee.
• Paresthesia down the course of the sciatic nerve
• vascular symptoms are much less common, but possible.

Question 5

A patient is presented sitting down with the hip externally rotated. You attempt a straight leg raise test and note pain with passive lower extremity elevation. What is this a sign of?

Answer 5

Piriformis syndrome

Question 6

A hypertonic piriformis will create what type of torsion with the axis? Where is the rotation created?

Answer 6

Forward torsion w/ rotation created opposite to the side of the tight piriformis.

Question 7

In a pifiromis syndrome, What direction will L5 rotate to the torsion? Give an example.

Answer 7

L5 will rotate opposite to the torsion.

Example, for a Left on Left, L5 will rotate right.

Question 8

What percentage of individuals with piriformis syndrome are due to anatomic variation (a primary cause)?

Answer 8

15%

Question 9

What are some secondary causes of piriformis syndrome?

Answer 9

Running (repetitive)
Soccer (truck forcibly rotate while food is firmly planted on the ground).
Driving
Sacral/Pelvic somatic dysfunctions
Strucural causes (masses, fibrosis, scarring, hematomas)

Question 10

How do you diagnosis piriformis syndrome?

Answer 10

• Prone testing of piriformis Lenth
• Seated piriformis test w/ (+) piriformis sign
• Straight leg raise test
• Muscle strengtht testing reflexes
• EMG testing

Question 11

What is an EMG test and what is a positive EMG result?

Answer 11

EMG test tests electrical activity in the muscles. Altered electrical activity is present if a nerve is compressed.

In piriformis syndrome, altered electrical activity will be present DISTAL to the compression, while muscles proximal to compression will show normal electrical activity.

Question 12

Which muscles would show altered electrical activity in a piriformis EMG test? Which muscles would show a normal EMG?

Answer 12

Abnormal/altered = hamstrings
Normal = gluteus medius and erector spinae

Question 13

What is the cause of Lumbar Radiculopathy? How does this EMG test results differ to a piriformis syndrome test?

Answer 13

Lumbar Radiculopathy is caused by a nerve compressed by a herniated disc/lesion.

On the EMG, all muscles distal to the compression will exhibit altered electrical activity. Therefore, the erector spinae may show altered electrical activity.

Question 14

What is the treatment protocol for piriformis syndrome?

Answer 14

1. Remove cause
2. OMT
   - Address underlying functional/structural pathology
   - Treat with: Strain/Counterstrain, Myofascial release, Muscle energy, Spray and stretch,
3. Therapeutic Exercise
4. Muscle relaxants/NSAIDs
5. Injection of tender points

Question 15

What is an easy way to self-treat piriformis syndrome?

Answer 15

Exercise and Home Stretching via piriformis stretching and muscle pump

Question 16

For myofascial release, do you treat perpendicular to muscle fibers or parallel to muscle fibers?

Answer 16

Both??

Question 17

What does the muscle energy treatment for the piriformis look like?

Answer 17

Because the Piriformis is an external rotator of the femur, a contracted piriformis restricts internal rotation.

In treatment, the physician sits at the side of the leg with restriction. Leg is bent 90 degrees at the knee while the patient is supine. Operator leans leg into internal rotation and patient pushes into external rotation.

Question 18

For counterstrain treatment of the piriformis, where are the three tenderpoints and what position should the patient be?

Answer 18

• mid-pole: near origin of the piriformis
• In the belly of the piriformis
• High flare out sacroiliac (associated with coccygodynia)

Patient should be placed in piroette position = abduct thigh, externally rotate leg, flex patient’s knee.

Question 19

Where is the origin of the piriformis?

Answer 19

Pelvic surface of the lateral part of the sacrum at the second through fourth sacral segmental levels, and the sacrotuberous ligament

Question 20

What is the spray and stretch method of treating the piriformis?

Answer 20

Spray and Stretch = Spray of ethyl chloride or fluorimethane over buttocks in direction of Piriformis fibers

Follow up with Piriformis trigger point injection of
Lidocaine into piriformis trigger point or in the second trigger point point near trochanteric
insertion of muscle.

Question 21

What are other pharmacologic treatments for piriformis syndrome?

Answer 21

BOTOX, NSAIDs, Corticosteroids, and surgery (last resort)

Question 22

What is Coccygodynia?

Answer 22

pain in the coccyx

Question 23

Anteriorly, the coccyx is concave or convex?

Answer 23

concave

Question 24

What is the etiology of coccygodynia?

Answer 24

idiopathic (disease related) or tumor

Question 25

What are the basic symptoms of coccygodynia

Answer 25

• Pinpoint pain at coccyx
• Inability to sit, or to sit in backwards leaning position (thus often sit forward or shift weight to the side)
• Pain may worsen during bowel movements or sex
• Possible muscle pain in coccygeus or levator ani

Question 26

What are possible differential diagnosis for coccygodynia?

Answer 26

• Sacral somatic dysfunction
• Lumbar somatic dysfunction
• Lumbar degenerative disk disease
• Lumbar facet arthropathy/spondylosis
• Lumbar spondylolysis and spondylolisthesis
• Piriformis syndrome

Question 27

What is the OMT treatment for coccydynia?

Answer 27

Extra rectal (if possible)
Intra rectal (if necessary)

w/ or without lidocaine

….??? this slide made no sense to me

Question 28

What else besides OMT can be used to treat coccydynia?

Answer 28

• Medicaiton (NSAIDs, oral corticosteroids)
• Ganglion sympathetic block
• Epidural injection
• Surgical intervention (though high rate of post surgical complications)