Piriformis syndrome is a condition that is believed to result from a compression of the sciatic nerve around the piriformis muscle. Symptoms may include pain and numbness in the buttocks and in the legs. Often the symptoms worsen by sitting or running.
The causes may include trauma to the gluteal muscle, piriformis muscle spasms, anatomical variations, or excessive injury. Some cases in athletics, however, have been described. Diagnosis is difficult because there is no definitive test. A number of physical exam maneuvers can support. Medical imaging is usually normal. Other conditions that may be present are the same including herniated disks.
Treatment may include avoiding activities that cause symptoms, stretching, physiotherapy, and medications such as NSAIDs. Injection of steroid or steroid toxins can be used in those who do not improve. Surgery is usually not recommended. The frequency of these conditions is unknown, with various groups arguing that this is more or less common.
Video Piriformis syndrome
Signs and symptoms
The signs and symptoms include gluteal pain that may spread down the buttocks and legs, and it is exacerbated in some sitting positions.
Maps Piriformis syndrome
Pathophysiology
When the piriformis muscle shortens or seizures due to trauma or overuse, it can suppress or strangle the sciatic nerve under the muscle. Generally, this type of condition is referred to as a neural trap or as a trap neuropathy; certain conditions known as piriformis syndrome refers to the symptoms of sciatica that are not derived from spinal roots and/or spinal disk compression, but involve the piriformis muscle thereon.
In 17% of the assumed normal population, the sciatic nerve passes through the piriformis muscle, not below it; However, in patients undergoing surgery for suspected piriformis such anomalous syndromes were found only 16.2% of the time that caused doubts about the importance of anomalies as a factor in piriformis syndrome. Some researchers ignore the importance of this relationship in the etiology of the syndrome. Surprisingly, MRI findings have shown that both hypertrophy (unusual abnormalities) and atrophy (very small) of the piriformis muscle correlate with the condition it should be.
It has been theorized that people who regularly exercise by running, cycling, and other activities moving forward may be more prone to develop piriformis syndrome if they do not do lateral stretching and strengthening exercises. When not matched by lateral movement of the foot, forward-forward movement may lead to disproportionate hip abductors and strict adductors. Therefore, weak and disproportionate hip/gluteus medius muscles, combined with very strict adductor muscles, can cause the piriformis muscles to shorten and contract. This means the kidnapper outside can not function properly and the strain is placed on piriformis. However, it is also possible that such people actually experience a small herniation in the spinal disc that then pierces the sciatic nerve and causes the piriformis to become secondary spasm. Evidence for a specific relationship between the strength or weakness of certain pelvic muscles and sciatic nerve pain centered around the piriformis muscle is low. Also, explanations related to this exercise are not useful for understanding piriformis syndrome in those who are not physically active (which often happens).
The result of piriformis muscle spasm may be an outlet not only of the sciatic nerve but also of the pudendal nerve. The pudendal nerve controls the muscles of the intestines and bladder. Symptoms of pudendal nerve trapping include tingling and numbness in the groin and saddle areas, and can cause urinary incontinence and feces.
Piriformis syndrome can also be associated with direct trauma to the piriformis muscle, such as a fall or from a knife wound.
Diagnosis
Piriformis syndrome occurs when sciatic nerve is compressed or pinched by the pelvic piriformis muscle. It usually affects only one hip at a given time, although both hips can produce piriformis syndrome at some point in the patient's lifetime, and after that greatly increases the likelihood that it will recur in one hip or the other at some future point unless the action is taken for prevent it. Indications include sciatica (radiating pain in the buttocks, posterior thighs, and lower legs) and physical examination findings of tenderness in the field of sciatic notch. If the piriformis muscle can be found under other gluteal muscles, this muscle will feel like a rope and will feel pain to compress or massage. This pain is exacerbated by any activity that causes hip flexion including lifting, sitting long, or walking. Diagnosis is largely clinical and is one of the exceptions. During physical examination, attempts can be made to stretch the irritating piriformis and provoke sciatic nerve compression, such as the Freiberg test, Pace test, FABER test (flexion, abduction, external rotation), and FAIR tests (flexion, adduction, internal rotation). Conditions to be ruled out include herniated nucleus pulposus (HNP), facet arthropathy, spinal stenosis, and lumbar muscle strains.
Diagnostic modalities such as CT scan, MRI, ultrasound, and EMG are mostly useful in excluding other conditions. However, magnetic resonance neurons are medical imaging techniques that can indicate the presence of sciatic nerve irritation at a sciatic notch level at which the nerve passes below the piriformis muscle. Magnetic resonance neurography is considered "investigation/not required medically" by some insurance companies. Neurography can determine whether a patient has sciatic split nerve or split piriformis muscle - this may be important in getting good results from injections or surgery. Guided image shots made in open MRI scanners, or other 3D image guides can accurately relax the piriform muscles to test the diagnosis. Other injection methods such as blind injection, fluoroscopic guided injection, ultrasound, or EMG guides may work but are unreliable and have other drawbacks.
Prevention
The most common aetiology of Piriformis syndrome is the result of previous injury-induced trauma. Major injuries include trauma to the buttocks while "micro trauma" results from repeated, recurrent stress attacks on the piriformis muscle itself. To the extent that piriformis syndrome is the result of some kind of trauma and not neuropathy, such secondary causes can be prevented, especially those occurring in daily activities: according to this theory, long sitting periods, especially on hard surfaces, produce little stress. who can be relieved with standing attacks. Individual environments, including lifestyle factors and physical activity, determine vulnerability to trauma of a given type. Although the findings of empirical research on subjects have never been published, many believe that taking reasonable precautions during high-impact sports and while working in physically demanding conditions may lower the risk of having piriformis syndrome, either by preventing injury to the muscle itself or injury the nerve root that causes it to spasm. In this case, proper safety and bearing equipment should be used for protection during any kind of regular and firm contact (ie, American soccer, etc.). At work, individuals are encouraged to make routine assessments of their environment and seek to recognize them in the routine of a person who can produce micro or macro trauma. There is no research that proves the effectiveness of any such routine, however, and participation in one may not do anything but increase the individual's sense of concern over physical things while having no effect in reducing the probability of experiencing or re-experiencing piriformis syndrome.
Other suggestions from some researchers and physical therapists have included prevention strategies including preheating before physical activity, practicing the right form of exercise, stretching, and exercising strength, although this is often recommended to help treat or prevent physical injuries and not piriformis-specific. In their approach As with any type of exercise, it is thought that warming will reduce the risk of injury during flexion or hip rotation. Stretching increases range of motion, while strengthening hip adductors and kidnappers theoretically allowing piriformis to tolerate trauma more easily. However, to the extent that piriformis syndrome is actually linked to spinal sciatic nerve pain, physical "warming" of the hip muscles will have no effect in preventing herniation and subsequent pain experience along the sciatic pathway.
Treatment
Immediately though temporary relief from piriformis syndrome can usually be caused by an injection of local anesthesia into the piriformis muscle. Relieve symptoms of muscle and nerve pain also sometimes can be obtained with nonsteroidal anti-inflammatory drugs and/or muscle relaxants, although the use of such drugs or even more powerful prescription drugs to remove sciatica is often rated by the patient to be highly ineffective at removing pain. Conservative treatment usually begins with stretching exercises, myofascial release, massage, and avoidance of accompanying activities such as running, cycling, rowing, weight lifting, etc. Some doctors recommend formal physical therapy, including soft tissue mobilization, hip joint mobilization, teaching stretching techniques, and gluteus maximus, gluteus medius, and biceps femoris to reduce tension in piriformis. Further physical therapy treatments may include isometric stretching of the pelvis-trochanter, pelvic abductor, external rotator and extensor strengthening exercises, transcutaneous electrical nerve stimulation (TENS), and massage physiotherapy from the piriformis muscle area. One study of 14 people with what appeared to be piriformis syndrome suggests that rehabilitation programs that include physical therapy, low-dose muscle relaxants and effective painkillers to reduce most of the muscle and nerve pain caused by what the study subjects have been told are piriformis. syndrome. However, since this study included very few individuals and no control group who did not receive treatment (both seriously methodological defects), this does not provide insight into whether piriformis pain will disappear by itself without treatment at all, and therefore not only informative, it can actually be misleading. These injuries are mostly considered self-limiting and spontaneous recovery usually in the order of a few days or a week to six weeks or longer if left untreated.
Stretching
Most practitioners agree that muscle spasm, tension, or pain can often be treated with regular muscle stretching exercises, regardless of the cause of the pain. Stretching is recommended every two to three hours of waking. Anterior and posterior motion of the hip joint capsule can help optimize the patient's stretching capacity. Muscles can be stretched manually by applying pressure perpendicular to the long axis of the muscle and parallel to the buttocks surface until the muscles become relaxed. Other stretching exercises are lying on the opposite side with pain with the hips and knees of the upper leg flexed and curled to the ground while the torso is turned so that the back of the upper shoulder touches the ground. Physical Therapists may suggest stretching exercises that will target piriformis, but may also include the hamstring and hip muscles to adequately reduce pain and increase the range of motion. Patients with piriformis syndrome may also find relief from ice applications that will help reduce inflammation and so may help limit the pressure on the sciatic nerve. This treatment can be helpful when the pain starts or soon after an activity that may cause pain. Over time, heat can provide temporary relief from many types of muscle pain and will temporarily increase muscle flexibility.
Reinforce
One study group reported a case study of an individual with piriformis syndrome whose symptoms were resolved entirely through physical therapy sessions that worked to strengthen the abductor's hips, external rotators and extensors. This treatment involves three phases: weight training non-weight, weight training, and ballistic exercises. The goal of non-weight load training is to focus on isolated muscle recruitment. Ballistic and dynamic exercises consist of plyometrics. Since this is an individual case study, however, its statistical significance is meaningless and may indicate nothing significant about Piriformis syndrome.
Conservative treatment failures such as stretching and strengthening of piriformis muscles or high levels of direct pain intensity may consider a variety of therapeutic injections such as local anesthesia (eg, lidocaine), anti-inflammatory drugs and/or corticosteroids, botulinum toxin (BTX, Botox), or a combination of all three, all have well-documented effectiveness in reducing muscle-related pain. Injection technique is a significant problem because piriformis is a very deep sitting muscle. A radiologist may assist in this clinical setting by injecting small doses of drugs containing crippling agents such as botulinum toxin under high-frequency ultrasound or CT control. This disables piriformis muscle for 3 to 6 months, without resulting in leg weakness or impaired activity. Although the piriformis muscle becomes inactive, the surrounding muscles rapidly take over its role without any noticeable change in strength or gait. Such treatment may be more or less curative (without return to pain), or may have a limited duration of effectiveness.
Surgery
For rare cases with persistent chronic pain, surgery may be recommended. Piriformis muscle surgery release is often effective. Minimal access surgery using newly reported techniques also proved successful in large-scale formal results published in 2005. Like injections, the muscle roles that are paralyzed/excreted in foot movements are completely compensated by the hip muscles in the vicinity.
The failure of piriformis syndrome treatment may be secondary to an underlying internal obturator muscle injury.
Epidemiology
Piriformis syndrome (PS) data is often confused with other conditions because of differences in definitions, survey methods and whether the working group or general population is surveyed. This leads to a lack of group harmony regarding the diagnosis and treatment of PS, which affects its epidemiology. In one study, 0.33% of 1293 patients with low back pain mentioned incidence for PS. A separate study showed 6% of 750 patients with the same incidence. Approximately 6% - 8% incidence of low back pain associated with PS, although other reports concluded about 5% - 36%. In a survey conducted in the general population, 12.2% - 27% included lifetime occurrence of PS, while 2.2% - 19.5% indicated annual incidence. However, further research shows that the proportion of sciatica, in terms of PS, is about 0.1% in orthopedic practice. This is more common in women with a ratio of 3 to 1 and most likely due to the wider quadriceps femoral muscle angle in os coxae. Between 1991-1994, PS was found to be 75% common in New York, Connecticut, New Jersey, Pennsylvania; 20% in other urban centers of the United States; and 5% in North and South America, Europe, Asia, Africa and Australia. Common occurrences occur between thirty and forty, and are rarely found in patients younger than twenty years; this has been known to affect all lifestyles.
Piriformis syndrome is often undiagnosed and erroneous with other pain due to symptoms similar to back pain, quadriceps, lower leg pain, and buttock pain. These symptoms include tenderness, tingling and numbness starting in the lower back and lower buttocks and then radiating to the thighs and to the legs. The exact test for piriformis syndrome has not been developed and is thus difficult to diagnose this pain. The pain often begins with sitting and walking for longer periods of time. In 2012, 17.2% of low back pain patients develop piriformis syndrome. Piriformis syndrome does not occur in children, and is mostly seen in women between the ages of thirty and forty. This is due to hormonal changes throughout their life, especially during pregnancy, where the muscles around the pelvis, including piriformis muscle, are strained to stabilize the area for birth. In 2011, of the 263 patients between the ages of 45 to 84 treated for piriformis syndrome, 53.3% were female. Women are twice as likely to develop piriformis syndrome than men. In addition, women stay longer in hospitals during 2011 due to the high prevalence of pain in women. The median medication cost was $ 29,070 for an average hospital stay of 4 days.
References
Further reading
- Jassal, Navdeep Singh (2017). "Piriformis Muscle Syndrome". In the Pope, Jason E.; Deer, Timothy R. Treatment of Chronic Pain Condition . pp.Ã, 269-71. doi: 10.1007/978-1-4939-6976-0_78. ISBN: 978-1-4939-6974-6.
External links
Source of the article : Wikipedia
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