Piriformis syndrome

[proud]

Diane,

I had a patient today whom I think fits the bill for this syndrome. I searched the site and came up with some fantastic stuff. However I would love to know how you might treat this syndrome?

You mentioned that it was in the manual in one of the threads but I would love to have a description like the one I read regarding the pudendal nerve.

Is that possible?

[Diane]

Yes, but I have to go to work shortly, so please be patient.
:)

[proud]

I'm coming to you for info.....no rush!:thumbs_up

[Diane]

OK, for proud: piriformis syndrome.

First, let's gather the resources: Here is the thread here about it, based on the Tunnel Syndromes book, called Piriformis Muscle Syndrome (http://www.somasimple.com/forums/showthread.php?t=2809). It covers the anatomy, etiology, clinical signs, pictures, all that stuff. It's worth noting that in medicalese, the word "syndrome" usually translates as "don't have a clue."

Excerpt:Besides the direct compression of the nerve, compression of the vessels supplying the nerve can lead to the piriformis syndrome.2 A branch of the inferior gluteal artery (ateria commitans nervi ischiadici) and its corresponding veins join the nerve as it crosses the inferior margin of the piriformis. Constant or repeated muscle spasm can compress the vessels and lead to vascular congestion or ischemia in the sheath. These changes can produce pain along the nerve. Maybe just constant and repeated USE of the muscle, or tonic use of it, would do the same thing.

Any tonic contraction of the butt and it's muscles can affect any of the nerves in the butt by the same mechanism, I'm sure. Here's post #3 (http://www.somasimple.com/forums/showpost.php?p=22763&postcount=3) about other nerves that live in there.

Anyway, please familiarize yourself with the entire old thread. You're quite right - treatment for this never made it into the first draft of the manual. It's coming in the long awaited update (which at this rate won't be anytime soon).

So, details.

Presentation:
The patient with a pain in the backside can be anybody of any age. He or she will have come to you with a pain in their buttock of greater or lesser intensity, but which they cannot seem to stretch out or get rid of, and have had for months or years or even decades. They will likely have had to curtail some activity they like doing. Often they've been active people as opposed to sedentary. They will likely have been provisionally Dxed with "sciatica," will likely already have had treatment according to protocols for sciatica, including for spinal joints. They will likely have been given lots of exercises. Nothing seems to quite do the trick, and they are now in your office.

On visual examination/assessment nothing seems remarkable. They probably have full range in hips and low back, or might seem mildly restricted at end range but the joints seem fine.

On palpatory exam they have diffuse tenderness to pressure in distinct spots in the buttock. You can safely hypothesize that these are places where nerves have to bend around structures or where tunnels are narrowed.

Treatment Set-up
1. Patient can wear a light layer of clothing, or shorts - it's good if the leg itself can be bare.
2. Patient is prone.
3. Practitioner sits down at the affected side. Ensure your own comfort and have the bed at a height perfect for the patient to drop his or her knee off the bed and onto your lap.
4. The patient's leg is in about 60 degrees of hip flexion, about 45 degrees of abduction. Rotation remains relatively neutral.
5. Find the cranky spot with the more proximal hand. The other hand will be controlling the patient's foot.
6. When you find it, stay on it to monitor. Use your own leg (upon which is resting the patient's knee) to maneuver his or her thigh into the position of greatest ease in the buttock zone/sore spot. It will still be sore at this point, so you need to determine softening yourself for now. When you have their leg in the right position, the real treatment part can commence.
7. The knee is flexed to about 70-90 degrees or thereabouts, and is resting on your leg. It will remain fixed. Your controlling hand goes over the heel. You can determine and control knee flexion from there. Get a good skin grip on that heel without digging into it. Tuck the lateral border of the patient's foot against your other knee.

Treatment
8. Slowly pull the patient's heel toward you. You will immediately sense softening in the buttock through your other hand. This is exactly what you are seeking. As soon as you feel the spot soften, stay there at that amount of heel torque - don't add more, because it isn't necessary. Wait for the patient's system to relax in that position with that amount of torque.
9. Once the softening has occurred and the spot is no longer tender to your provocation, just stay there still for a few minutes, holding your applied tension up through the whole leg. The leg didn't move, but all the neural structures certainly did relative to their containers.
10. When relaxation seems to have made its way throughout the patient, slowly ease them out of the heel torque and the position. Tell them, "Stay relaxed. Let me lift your leg back up onto the bed." It will be hard for them to let you do this, so go slow. Slowly straighten out their foot. Slowly bring it back up onto your knee. Slowly lift their leg back up on the bed. Once the leg is back up, retest the spot. It should be history.
.........................................


Now you can ask them to get up and move around, see if there is still any discomfort. Usually there won't be, provided you made the right diagnosis in the first place. And it's not hard to decide to hypothesize/try this, since nothing else seems to have "worked." When it works it works very very well. One session only and the patient is good to go. They really do not have to do much homework. Possibly some reinforcement as per the pudendal nerve thread homework. But usually there is a very definite sense of feeling "better" immediately, and very little chance of recurrence.

While I'm in that position with a patient I usually repeat the business with their foot going the other way, out into eversion, their foot's medial border against my knee, their heel pushed down instead of pulled up. I hypothesize that this:
1. Feeds whatever might be going on on the other "side" of the neural tunnel
2. Might get other portions of it
3. Might get other branches.

A finesse move, if you can't quite get the spot to soften, is to twist the skin on the heel around the heel (either clockwise or counterclockwise - you'll have to figure out in the moment which way works the best for your particular patient). It adds just a wee bit more glide into the cutaneous nerves that embed into the skin over the heel - sural and saphenous branches mostly.

On the resting points on my own body I like to put small chunks of yoga mat between me and the patient's body. They provide "grippage,"(which is a madeup word) and anytime you can get better grippage and consequent skin traction, the more info the patient's brain will get, plus (a big plus) the less hard you'll have to work to maintain their position. The more relaxed you are the more their system will let go of itself.

Let me know if you have any questions.
:)

[proud]

Thank you Diane. I have dyslexia and often have difficulty visualizing positions through text( pictures work better for me). Fortunately, I have turned dyslexia into a positive because when I learn a concept....I REALLY have to learn it....none of this memorization without application stuff.:)

I will set this up on a collegue of mine and if I have any questions I will post it.

On another note. This patient fit the presentation you described perfectly.

Have you ever looked at the "road kill position" on these patients?( Prone/lateral malleolus on the left UNDER tibial plateau on the right.....so hip EXT with LR). Then compare the distance of ASIS to the plinth between the right and left. I often note a decent assymmetry( at least 3 cm). Just something I have noted...curious about your thoughts on possible reasons for this.

Also...do you perform acupuncture? Many PT's where I work swear by G30( big horse needle into the buttocks.....).

Thanks again Diane...big help.

[Diane]

Also...do you perform acupuncture? Many PT's where I work swear by G30( big horse needle into the buttocks.....). Never have, never will.

Have you ever looked at the "road kill position" on these patients?I'm like you, need pictures usually.. not sure what you mean - totally flattened? :D
Just kidding - I can see it. No, I haven't checked that.

I've attached a few drawings I made of this (destined ultimately and long overdue for the manual, spurred on by your request) of this technique, based on a photo taken (by Eric) at a workshop. They will help maybe.

[proud]

Yep, pictures helped.

I'm not a fan of acupuncture myself. However this one makes some sense to me. If the piriformis is in some sort of hypertonic state resulting in vascular congestion or ischemia....would poking right into the muscle potentially "release" the muscle?

Is that possible?

[Diane]

If the piriformis is in some sort of hypertonic state resulting in vascular congestion or ischemia....would poking right into the muscle potentially "release" the muscle? That's a hypothesis, probably not the right one. And how would the muscle let go by being poked? Only after the message has travelled through the nervous system and the nervous system has decided to let go of it, will it "let go." If it's a "tight muscle" in the first place.

Why use noxious stimuli? Why not just figure out how to "feed" the hypothetically oxygen-starved neurons, by moving the nerve/neural tunnel interface slightly, and let the brain of the patient do all its own work or reorganizing itself/its output?

Things that feel "tight" are defense, not defect. They don't need more assault, they need updated information output from the brain, once it can read that the "threat" (i.e. hypoxia) is reduced.

Is that possible? See above.
I doubt it. I think needling is a bunch of BS, highly overrated and underwhelming. I don't doubt that something might happen but I don't think it's usually what we want to see happen.

[proud]

I'd agree with that picture of acupuncture Diane. I once read an article about WHO would actually benefit from acupuncture. The answer was.....anyone who reported a benefit from it in the past...

I think acupuncture is largely placebo( which is a treatment if the result is +ve). So if poking someone with a needle results in the patients perception that you are doing "something" positive, could that not by itself "feed" the hypothetically oxygen-starved neurons by allowing the brain to do it's work?

[Diane]

So if poking someone with a needle results in the patients perception that you are doing "something" positive, could that not by itself "feed" the hypothetically oxygen-starved neurons by allowing the brain to do it's work?
I don't think so. I think there is definitely neuromodulation with needling, but because so much of the skin is bypassed it can't help provide input up through the neurons that are the fast A myelinated fibers. So it's not "dermo" - it probably works by a DNIC mechanism that is less precise for the brain getting its maps re-edged, and de-insula-ated. My new made-up words.

If there is actual hypoxia in the peripheral branches, I just don't think acupuncture can stimulate them to "feed" themselves the same way neurodynamics can and does. So eventually the pain would return - maybe in a new place.