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Flashcards in Piriformis Syndrome - Lecture Deck (21)
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1

Origin and insertion of piriformis

O = S2-S4 anterolateral borders

I = medial side of upper greater trochanter

2

Actions of piriformis

ER of hip (major)
ABD when flexed (minor)

3

Nerve/vessels SUPERIOR to piriformis

Superior gluteal n/a/v

4

Nerves/vessels INFERIOR to piriformis

Inferior gluteal n/a/v

Pudendal n
Internal pudendal a/v

Post. femoral cutaneous n.

Nerves to obturator internus, superior/inferior gemelli, and quadratus femoris

5

How does the sciatic n relate to piriformis?

Variable - may be over, under, or in the middle

6

Physio of muscle spasm

Position/cause of strain --> rapid lengthening --> reflex contraction --> PAIN-SPASM CYCLE (gamma and alpha fibers of reflex arc activate each other)

7

Secondary/tertiary fibers in the brain for pain sensation

A-delta fibers = to thalamus and sensory cortex (localization/discrimination)

C fibers = other places (behavior modification, memory, etc.)

8

Things that lower pain threshold, increasing likelihood of developing spasm

Sympathetics (NE)
Vasoconstriction

9

What is facilitation? What causes this in the tissue?

Changes in CNS and tissues that lead to LESS stimulus needed for SAME pain response

Release of PGs, bradykinin, histamine, other chemicals that cause lowered nociceptor threshold --> increased input to the CNS

10

How does facilitation affect the sciatic nerve?

How can you tell that these are what the problem is?

The inflammatory agents irritate the NERVI NEURVORUM that supply the sciatic nerve, causing pain in the sciatic nerve distribution

DTRs, strengths, etc. from the sciatic nerve are still in tact

11

This nociception theory behind piriformis syndrome disrupts the balance between ____ and ____

Habituation (lessened response)

Sensitization (heightened response)

12

2 categories of pathologies that can cause piriformis syndrome

Functional

Structural

13

Functional causes of piriformis syndrome

- Planted foot + forcible rotation of trunk
- Sitting in awkward position for long time
- Sacral unleveling (short leg)
- Pelvic instability (SI joint)

14

Structural causes of piriformis syndrome

- Fibrosis/scarring
- Hematoma
- Mass
- Anatomic relationship btwn piriformis and sciatic n. (piercing or not)

15

Presentation of piriformis syndrome

- Low back or butt pain that may radiate down leg
- Tenderness over lateral butt/hip
- Paresthesias along sciatic nerve distribution
- Aggravation by prolonged sitting
- NO DTR or MOTOR DEFICITS

16

PE/Work-Up for piriformis syndrome

- Visualize/observe transverse plane of motion (easy ER, bad IR)
- Palpation (CS, IT band, trigger points)
- Neuro testing
- Special tests
- Radiology/Diagnostics
- Osteopathic exam

17

**Trigger point vs. tender point

Trigger - painful radiation along nerve distribution

Tender - local tenderness

18

4 special tests for piriformis (explain each)

- Lasegue - SLR
- Well Leg Raise - contralateral SLR
- Pace sign - pain/weak abd/ER of hip w/ resistance
- Freiberg sign - pain w/ passive IR of extended thigh

19

DDx for piriformis syndrome

SD
Herniated disc
Foraminal stenosis
Intraspinal lesion
Pelvic mass
Hamstring injury
SI disease (AS, etc.)
Facet syndrome
Diabetic neuropathy

20

Tx for piriformis syndrome (in office)

MFR, ME, CS
NSAIDs
Injections (steroids)
Surgery

21

Tx for piriformis syndrome (self)

Stretching - pigeon posture, figure 4 position, IR, sway

Warm baths