pathology: piriformis syndrome

yogabook / pathologie / piriformis syndrome

piriformis syndrome / Deep Gluteal Syndrom (DGS)

Definition

Originally understood as a pain syndrome caused by compression of the sciatic nerve in the infrapiriform foramen by the piriformis muscle. Today generally considered to be a deep gluteal syndrome with irritation of the ischiadic nerve not induced by intervertebral disc events. Caused by pressure from dorsal gluteal, hip or hamstrings or space-occupying lesions.

The piriformis muscle is primarily the abductor when the hip joint is flexed and the exorotator when the hip joint is extended, as well as the extensor of the hip joint, which explains the deterioration when bending over. The pain can be triggered by voluntary contraction of the muscle, pressure on the muscle or stretching of the muscle. Therapy can be lengthy and treatment difficult without sustained muscular intervention. In most cases, contracture of the piriformis is not isolated; gluteus medius, tensor fasciae latae and the contralateral quadratus lumborum are often also affected by a contracture. Epidemiologically, a ratio of 6:1 W:M is suspected.

Cause

  1. Trauma to the buttocks
  2. Non-traumatic pressure lesion
  3. Space requirements such as local inflammation, adhesions, tumors
  4. Hypertrophy of the piriformis muscle due to training or as permanent tension due to incorrect posture, pain of other causes

Predisposing

– Behavior

  1. unusual exertion such as shoveling snow, inline skating, ice skating
  2. Sitting on one side for long periods (computer work, driving)
  3. Sitting for long periods on narrow objects such as a ladder
  4. Money pocket in the back pocket(print)
  5. Overexertion (especially bent forward posture)
  6. Lifting heavy objects from the straddle
  7. Sports such as running, trekking, especially with inadequate increases in exertion or neglected strength training
  8. Prolonged poor posture, especially with existing muscular imbalances or (functional or anatomical) leg length discrepancies

– Musculoskeletal system

  1. Endorotation of the thigh during movements
  2. Hyperpronation
  3. Weakness of the abductors (small gluteal muscles)

Diagnosis

  1. Painful pressure on the muscle
  2. Pain on stretching
  3. abducted supine position relieves
  4. Nerve conduction velocity measurement, may be o.B.
  5. Electromyography to rule out lumbar nerve affection
  6. MRI pelvis for the detection of asymmetry or hypertrophy
  7. Axial traction on the leg improves
  8. Lasegue can be positive, exorotation of the lower leg then improves
  9. Freiberg sign: pain on endorotation of the extended hip joint with the knee joint flexed, possibly additional abduction
  10. Filler sign: pain when stretching through active adduction, e.g. crossing the affected leg against resistance while lying down
  11. Pace/Nagle sign: pain when abducting the leg against resistance while sitting
  12. JAGAS test: pain with scissor movement of the affected leg, i.e. adduction over the midline
  13. Active Piriformis Test: Test for DGS through simultaneous movement dimensions of the piriformis
  14. seated piriformis test: test for DGS by stretching in endorotation and adduction
  15. FAIR test: test for DGS by stretching in adduction and endorotation in the hip joint
  16. Beatty Maneuver: Test for DGS by abduction
  17. Freiberg’s sign: pain on endorotation of the extended hip joint with the knee joint flexed, possibly additional adduction

Symptoms

  1. Pronounced pain symptoms in the area of the buttocks, pulling towards the hip joint, sacrum or the back of the thigh
  2. Improved extension in the hip joint
  3. Worsening due to hip flexion, especially under load, lifting, prolonged walking, sitting on a hard surface
  4. possibly abnormal sensations or sensory disturbances in the legs or
  5. Possible disturbed heel and toe position
  6. contraction-related pain when climbing stairs or exorotation in the hip joint
  7. Intolerance to sitting for more than 20 or 30 minutes
  8. Change in gait, limping
  9. Night pain with improvement during the day

Therapy

  1. Physiotherapy
  2. Symptomatic pain therapy (NSAIDs)
  3. Symptomatic local lidocaine infiltration of the piriformis
  4. Stretching, especially of the exorotators of the hip joint

DD

  1. neuroradicular pain syndromes such as sciatica, lumbalgia

Asana practice

If the piriformis presses on the sciatic nerve with too much tension, stretching is required to reduce its tone. The functional reversal of the muscle must be taken into account. Close to anatomically zero, i.e. when the hip joint is largely neutral in rotation and not or hardly abducted and approximately extended, the muscle has an abducting, extending and exorotating effect in the hip joint. However, it reverses the latter at approx. 60°-80° flexion in the hip joint to support endorotation. In order to achieve sufficient stretching, it is not necessary for all counter-movements to be simultaneous to the movements performed by this muscle, but at least a certain degree of at least two of these movements is required. Since muscles generally support the movement caused to different degrees due to their course, i.e. the position of origin and insertion, and therefore also generate different torques, a clever combination is required, for example to significantly counteract the two most supported movements and, if necessary, to allow a compromise in the third direction of movement. Due to the largely transverse course of the piriformis, it is wise to make rotation the most important parameter and, assuming that it supports extension more than abduction (which more caudal fibers may not support at all) (depending on the position of the femur, of course), to flex the hip joint as far as possible. This leads to postures such as the half lotus forward bend, the 3rd hip opening and the hip opening at the edge of the mat, all of which have proven to be quite effective. A special variation of parivrtta trikonasana, the variation with the wall and front leg turned in, is also very effective.

In addition to the necessary pressure relief of the sciatic nerve by stretching and reducing the tone of the piriformis, the question of how the increased tone came about must be investigated. This can be triggered by special, prolonged postures, repeated movements or activities. If the plausibility of these factors is only slight, the question must be raised as to how great the resilience of this muscle is to these demands. Strengthening this muscle may therefore also be indicated, but it should be done in areas of greater sarcomere length so that the tone is not increased. When strengthening, one would proceed in the opposite way to stretching and not necessarily move in the hip joint in the two directions that the piriformis mainly serves, so that the working range does not represent an interval of too short a sarcomere length, and if one does choose this approach because of its good effectiveness, then care must be taken to ensure that predominantly longer sarcomere lengths up to at best medium sarcomere lengths are worked, i.e. that the entire possible range of movement in this direction is not utilized. At this point it must be pointed out that strengthening and stretching are not mutually exclusive processes, but that large loads in long sarcomere lengths perform both.

In practice, it has been shown that the above-mentioned variation of parivrtta trikonasana works very well with less flexibility, while the forward bend of half lotus is much more effective with good flexibility (of the hip extensors). Taking parivrtta trikonasana, possibly with a small weight in the lower hand, also proves to be helpful, just as squats and utkatasana are also helpful because of the wide hip flexion.

Asanas