Download Alleviating Piriformis Syndrome

Alleviating Piriformis Syndrome
4 Contact Hours
Learning Objectives
At the end of this workshop you will:
• Be able to list the relevant soft-tissue structures.
Instructor:
Bob McAtee, RMT, CSCS, C-PT
Pro-Active Massage Therapy
Colorado Springs, CO
719-475-1172
www.stretchman.com
Defining Piriformis Syndrome
• Piriformis syndrome, first
described in the
literature in 1928, is the
name given to a complex
of symptoms arising
from compression of the
sciatic nerve and/or
associated blood vessels
by the piriformis muscle.
Sciatica or Piriformis Syndrome?
• In PS, pain generally
originates at or below the
sciatic notch of the sacrum
(neuritis).
• In sciatica, the pain originates
at the lumbar spine, because
the sciatic nerve is being
entrapped at the spinal level
(radiculopathy).
• Be able to demonstrate proper palpation techniques.
• Be able to perform seated, prone, and side-lying assessment
techniques.
• Be able to demonstrate the three-part treatment protocol.
• Leave the seminar confident and capable of integrating these
techniques into your repertoire.
Typical Symptoms
• The most common symptoms of piriformis
syndrome are pain and paresthesia in the buttock
and down the back of the thigh.
• Commonly felt when sitting, climbing stairs (or
hills), squatting, running, cycling.
Differential Diagnosis
• Trochanteric Bursitis
• Lumbar Degenerative Disc
• Lumbar Facet Dysfunction
• Lumbar Spondylosis or Spondylolisthesis
1
Elements of Piriformis Syndrome
• Three components: nerve and
vascular entrapment, SI joint
dysfunction, and trigger points in the
muscle.
• Entrapment most often occurs at the
sciatic notch. In some cases, the
piriformis is too large, and leaves
little room for the sciatic nerve and
associated blood vessels.
• Chronic hypertonicity of the piriformis
can be sufficient to fill the foramen
and compress the nerve.
S-I Joint/Piriformis
Because of its origin on the
anterior sacrum, piriformis
can produce a rotary
shearing force on the SI
joint which would tend to
displace the top of the
sacrum anteriorly.
• This may force the PSIS
anteriorly when compared
to the opposite side.
Sacrum Variations
These sacrum are curved differently because the five vertebral
bones that form them are differently shaped.
This leads to different natural spinal curves and different
ranges of motion.
Sciatic Nerve Variations
From Beaton, L.E. and B.J.
Anson.
The relation of the sciatic nerve
and its subdivisions to the
piriformis muscle.
Anat. Rec. 70:1-5, 1938
S-I Joint/Piriformis
• Manipulation of the
SI without resolving
piriformis
hypertonicity gives
only temporary relief.
• Attempting to relieve
piriformis tightness
without addressing
the SI displacement
is also a temporary
fix.
Perpetuating Factors
• Symptoms may be aggravated by:
• Prolonged sitting
• Sitting with the affected leg crossed over the
opposite knee
• Overstretching (not too often, but to aggressively).
• Activity, such as running uphill or downhill, cycling
in low gears, ballet and modern dance, or
repetitive motions that overload the piriformis in its
role as a stabilizer of the hip (eccentric stress).
2
No Diagnosis
• As massage therapists, we are not
legally qualified to diagnose or
prescribe.
• However, it is within our scope of
practice to evaluate soft-tissue to
determine if we can offer appropriate
treatment or if the client needs to be
referred to another professional.
• For this seminar, we will be using an
abbreviated form of assessment that
focuses on the functional integrity of the
musculotendinous tissues.
Acetabulum Variations: Rotation
• Front view of two pelvises: You can see the hip sockets of the
left specimen but not the right. This is because the sockets are
oriented in different directions.
• Side view:Same specimens, side-view. Movements of the
femur that are easy for one might be impossible for the other
because the femur would compress against the edges of the
hip socket (acetabulum).
Normal Rotation ROM of the Hip
Internal rotation: 35°- 45°
External rotation: 45°
It’s best to compare
affected and
unaffected sides to
try and establish
“normal” for each
client.
Visual Assessment
• With client supine and
relaxed:
• Compare lateral
rotation of the legs.
• Excessive lateral
rotation (>450)
indicates piriformis
shortening on that side.
Femur Variations: Rotation
• This view illustrates how femurs all have
different degrees of spiral or twist to their
shafts.
Assessment: Pace Abduction Test
This is a standard test for piriformis syndrome
• With the client seated, knees flexed and
hanging over the edge of the table, place
your hands on the lateral knees and ask
the client to push against your resistance.
• Pain, faltering or weakness is positive for
piriformis involvement.
• This test is better than resisted lateral
rotation because it eliminates the other
five lateral rotators.
3
Sidelying Assessment
•Sidelying, with the hip flexed to 90°:
–Resisted horizontal abduction:
–may put stress on the sciatic
nerve, as the muscle contracts.
–Passive horizontal adduction:
–stretches the piriformis and may
compress the sciatic nerve.
Palpation: Piriformis
• The piriformis lies
deep to the gluteus
maximus, which
must remain relaxed
during palpation.
Palpating Piriformis
• Palpate the piriformis at the level of its insertion
into the greater trochanter.
• Deep tenderness inferior to piriformis is probably
coming from the gemelli, obturator internus, or
quadratus femoris.
• Palpation along the length and across the grain of
the muscle may reveal tenderness, taut bands,
trigger points, and “nervy” pain.
Additional Assessment
• Assessment of the piriformis can also
include:
• Prone, with the knee flexed to 90°:
– Passive medial rotation, stretches
the piriformis and may compress
the sciatic nerve.
– Passive lateral rotation, shortens
and bunches the piriformis at the
sciatic notch.
– Resisted lateral rotation, may put
stress on the sciatic nerve as the
muscle contracts.
Palpation: Bony Landmarks
• To accurately locate the
piriformis, identify these
bony landmarks:
• Superior aspect of the
greater trochanter (the
insertion) and
• The top and bottom of the
sacrum and its lateral
border.
Avoid Sciatic Nerve Palpation
The most likely places to
palpate the sciatic nerve:
• at the greater sciatic
foramen
• at a point halfway
between the ischial
tuberosity and the greater
trochanter as the nerve
passes into the leg.
4
Pain on Palpation
Treatment Techniques
• Help the client distinguish between muscle pain,
and nerve pain.
• Our goal is to practice some hands-on therapeutic
interventions for piriformis syndrome.
• Nerve pain is usually described as: shooting,
electrical, hot, numbing, pins and needles, etc.
• Soft-tissue work designed to relieve hypertonicity of
the gluteal muscles and all of the lateral rotators of the
hip will be the most effective treatment.
• If palpation elicits nerve pain, move your contact
slightly to get away from the sciatic nerve and
check to see if the quality of pain changes.
Transverse Friction
• Transverse friction, popularized by British Orthopedic
physician, Dr. James Cyriax.
• Transverse friction helps to release nerves entrapped in
these tissues.
• Can be applied very specifically or more generally across an
entire structure.
• The key to performing transverse friction well is to palpate
the desired structure and then work across the grain of the
tissue.
• Apply the stroke using a thumb or finger, as if glued to the
skin.
Transverse Friction: Piriformis
• Adding these options to your current repertoire of skills
will allow you more flexibility in designing client
sessions and increase your likelihood of success in
dealing with this condition.
Transverse Friction: Piriformis
• Because piriformis syndrome is primarily a nerve
compression problem, treatment must be aimed at
relieving the pressure on the nerve.
• Light friction is appropriate as it helps warm the
surrounding tissue and stimulate blood flow.
• Light friction work along the sacral border and at the
insertion point on the greater trochanter is especially
effective when the piriformis has been softened up
with other techniques.
Applying Friction: Piriformis
• Mild friction is applied across the grain of the
tissue, using thumb, fingers, or knuckles to rub
against the lateral border of the sacrum and the
superior and posterior trochanter.
• Be certain that the friction does not cause any
numbness or tingling, since this indicates that
you’re frictioning right on the sciatic nerve.
Light friction along
sacral border.
Light friction at the
attachments on the
greater trochanter.
5
Pin and Stretch Technique
• Pin and stretch techniques have become popular in recent
years through the work of Michael Leahy, D.C., Stuart
Taws, Whitney Lowe, and others.
• The basic protocol has the practitioner applying pressure to
selected tissues while actively or passively moving the
tissues from the shortened position to the lengthened
position.
• The exact application of the technique varies, depending
on which “expert” is teaching it. The rationale for this
technique is based on several hypotheses:
Pin and Stretch: Piriformis
• Client prone, stand at the affected
side and ask her to flex her knee
to 90 degrees, externally rotate
the thigh to bring the lower leg
across the midline.
• Use your distal hand to lightly
grasp the client’s foot and ankle,
your proximal hand will apply
pressure to the piriformis during
the application of this technique.
• A loose fist is used for general
contact, the thumb is used for
Beginning position,
more specific contact.
loose fist contact.
Isolytic Contractions
• Discussed at length in “Muscle Energy Techniques” by Leon
Chaitow N.D., D.O.
• An isotonic eccentric contraction occurs when a muscle is
lengthening against resistance. For instance, after
performing a biceps curl (a concentric contraction), the
biceps is contracting eccentrically as you lower the weight.
• Isolytic contractions (specialized isotonic eccentric
contractions) are thought to break down adhesions or fibrotic
tissue that may have formed within and between layers of
tissues.
Pin and Stretch: Hypotheses
•
Maintaining constant contact on the tissue while
lengthening it draws the scar tissue/adhesion beneath the
contact and helps to release it.
• Pressure in the presence of motion helps to reset the
autonomic nervous system so the tissue functions more
normally.
• Working on all the tissues that move the joint during each
session will give the best results.
Pin and Stretch: Piriformis II
• With the leg in the starting position just
described, apply pressure to the
piriformis with a loose fist and maintain
that pressure while you passively rotate
the thigh internally, that is, pull the foot
and ankle toward you as far as
possible.
• Release the pressure on the piriformis,
return the leg to the starting position,
reapply pressure in a different place on
the piriformis and repeat.
• Systematically work the whole
piriformis, then the rest of the lateral
rotators of the hip. After the first round
using a loose fist is completed, repeat
using a flat thumb, for more specific
contact.
Video clip
Maintain moderate
pressure as you draw
the leg toward you,
stretching the
piriformis under
pressure.
Isolytic Contractions II
• Isolytic contractions make use of therapeutic levels of
resistance to help improve muscle pliability and function.
This technique should be pain-free at all times, but may be
uncomfortable.
• Hypothesis:
• Isolytic contractions cause “controlled trauma” to fibrotic
tissues. This is followed by a healing process in which the
fibrotic tissue is replaced with healthier tissue.
6
Isolytic Contractions: Protocol
•The client should be positioned for maximum comfort.
• The muscles to be treated should be fully shortened, then
the client is asked to resist, but allow, the practitioner’s
attempt to lengthen the muscles.
•The isolytic contraction lasts 3-5 seconds. In the first round,
the client should be working at 15- 20% of maximum and
pain-free.
•In subsequent rounds (3-4), the client works harder, even up
to maximal effort, as long as the therapist can overcome the
effort, and the client remains pain-free.
Isolytic Contractions: Piriformis
• Client prone, stand at the affected side
and ask the client to flex his knee to 90
degrees, externally rotate the thigh to
bring the leg across the midline as far
as possible.
• Use your distal hand to lightly grasp the
client’s foot and ankle, your proximal
hand stabilizes the pelvis.
• Client lightly resists as you slowly pull
the leg toward you, internally rotating
the thigh as far as possible.
• In the beginning, the client’s resistance
is minimal, then with each subsequent
isolytic contraction, the client resists
more strongly.
video clip
Self-Care
Piriformis Sequence
• Assessment
• Warm-up Massage
• Pain-free stretching.
• Foam Roller.
• As symptoms decrease, begin adding
pain-free exercise, especially eccentric
work for the lateral rotators.
• Light Transverse Friction
• Pin and Stretch
• Isolytic Contractions
• “Make Nice”
• Re-Assess
Further Reading
Myofascial Pain and
Dysfunction:
The Trigger Point Manual
Volume 2: Lower Extremities
Travell, Janet & Simons, David
Williams & Wilkins,
Baltimore 1992
Illustrated Manual of
Orthopaedic Medicine
Cyriax, James & Patricia
Butterworths 1985
Muscle Energy Techniques,
2nd edition
Chaitow, Leon
Churchill Livingstone,
Edinburgh 2001
Facilitated Stretching,
3rd edition
McAtee, Robert & Charland,
Jeff
Human Kinetics,
Champaign 2007
7