What is Piriformis Syndrome?
If you are experiencing hip, buttock, hamstring or sciatic pain, then you may be suffering from Piriformis Syndrome.
It’s a disorder that occurs when your sciatic nerve is compressed and irritated as it passes deep through your buttock, resulting in pain or numbness down the leg. Sometimes the condition is called ‘pseudo sciatica’, as it is often confused with pain in the nerve resulting from a low back disc bulge.
Your diagnosis of piriformis syndrome should initially exclude spinal nerve root compression (e.g. disc bulge) as a cause of your sciatica symptoms.
Where is your Piriformis Muscle?
Your piriformis muscle originates mostly from your sacrum (base of the spine) to insert on the greater trochanter of the femur (thigh bone). In the standing position, your piriformis muscle is a lateral hip rotator muscle, but it changes to a medial hip rotator in hip flexion due to its orientation.
What are the Symptoms of Piriformis Syndrome?
You may experience one or more of the following symptoms:
- Pain felt in one buttock – but you may experience radiation of pain down the back of the leg (sciatica).
- Pain aggravated by prolonged sitting or activities that stress the piriformis muscle.
- To avoid pain and pressure on the area, you may sit lopsided with your sore buttock tilted up.
- Sometimes, you’ll walk with the foot turned out due to shortening of the piriformis muscle.
What Causes Piriformis Syndrome?
Piriformis syndrome is most commonly caused by overworking your piriformis muscle or decreased space in the buttock area, which in turn compresses the muscle and nerve.
The main reasons that the piriformis muscle overworks are:
- Protection or dysfunction of the adjacent SIJ or hip joints
- A weakness of your deep hip stability muscles
- Overpronating feet
Decreased space to the buttock area is most commonly due to:
- Hypertrophy of other buttock muscles
- Inflammation from the sciatic nerve or piriformis muscle itself
- After trauma to the buttock area
How is Piriformis Syndrome Diagnosed?
In most cases, a clinical examination excludes a potential lumbosacral spinal pathology.
Your physiotherapist performs clinical tests that potentially irritate your piriformis or provoke sciatic nerve compressions. They will then interpret the findings. Some piriformis-related tests are the Freiberg, the Pace, the FAIR, the HCLK and Laseguese’s manoeuvres.
CT, MRI, ultrasound, and EMG are mostly useful in excluding conditions that could replicate piriformis syndrome. Electromyography (EMG) can show sciatic nerve compression but only in cases of chronic piriformis syndrome.
Please consult your trusted physiotherapist to confirm or exclude piriformis syndrome.
What’s the Treatment for Piriformis Syndrome?
After a thorough assessment of your back, pelvis and hips, your physiotherapist will determine the cause of your pain.
Once diagnosed, your treatment could involve any of the following:
- Pelvis and spine re-alignment techniques.
- Joint mobilisation to restore normal joint mobility, range of motion and function.
- Massage or electrotherapy to help decrease any pain or piriformis spasm. They also help to increase blood flow and soft tissue extensibility.
- Stretching program for muscle length and flexibility
- Acupuncture or Dry Needling to reduce muscle tightness around the buttock.
- Deep core stability and hip strengthening exercise to stabilise your hip, pelvis and spine.
- Foot orthotics or foot arch exercises, if indicated by your physiotherapist or podiatrist, to help restore foot and lower extremity alignment.
What’s Your Prognosis for Piriformis Syndrome?
Piriformis syndrome responds favourably in the vast majority of cases. Short-term symptoms usually reverse within a few days. Longstanding symptoms may take a few weeks to address the biomechanical and muscle habits that have predisposed you to the injury.
Only rarely will surgery be required.
For more advice about Piriformis Syndrome, please seek the professional advice of your physiotherapist.
Common SIJ & Buttock Pain SourcesThe following conditions may cause buttock pain or SIJ issues.
- Piriformis Syndrome
- Poor Hip Core Control
- Core Stability Deficiency
- DOMS - Delayed Onset Muscle Soreness
Lateral Hip Pain
SIJ & Buttock Pain Treatment Guidelines?While SIJ and buttock pain treatment will vary depending on your specific diagnosis, your physiotherapist will have the following aims.
PHASE I - SIJ Pain Relief & Joint ProtectionPain ReliefWhile pain relievers or anti-inflammatory medications are often prescribed for acute SIJ dysfunction they will not address the true cause of SIJ pain. Chronic cases of SIJ dysfunction should be thoroughly assessed by a healthcare practitioner who has a comprehensive understanding of the biomechanics and muscular control of your SIJ, pelvis and hip complex. Managing your sacroiliac pain is the main reason that most people seek treatment for sacroiliac joint dysfunction. In truth, it was actually the final symptom that you developed and should be the first symptom to improve in most cases. If this is the case, the prevention of a recurrence becomes your priority.Natural short-term pain relief can often be achieved by using ice or heat packs applied to your SIJ's.Reduce InflammationManaging your inflammation. Sacroiliac joint inflammation it best eased via ice therapy and techniques or exercises that unload the inflammed structures. Your doctor may recommend a course of non-steroidal anti-inflammatory drugs such as ibuprofen. Some seronegative arthritis condition can predispose you to sacroiliitis. Special blood tests can be arranged by your doctor to assist diagnosis in these conditions. Prolonged morning stiffness is a common complaint. See Ankylosing Spondylitis.SIJ Protection & SupportSacroiliac joint instability occasionally requires additional passive support until your muscles successfully control the joint. Supportive taping is often beneficial during the initial pain reduction phase.SIJ Stability BeltLonger-term instability may be managed with a sacroiliac joint stabilisation belt. However, an exercise protocol to specifically address your SIJ issue is normally more effective.If you have any questions please seek the advice of your physiotherapist.
PHASE II - Restoring Normal ROM and Strength. Early Hip Core Exercises.As your SIJ pain and inflammation settle, your physiotherapist will turn their attention to restoring your normal pelvic joint alignment and normalisation of the dynamic muscle control that affects the SI Joints.Your physiotherapist may commence you on a lower abdominal core stability program to facilitate your important muscles that dynamically control and stabilise your lower back and pelvis. They will also implement a similar activation and strength program that addresses your deep gluteal muscles. These muscles are sometimes referred to as your hip core muscles. Your physiotherapist will assess your muscle recruitment pattern and prescribe the best exercises for your specific needs.
PHASE III - Restoring Full FunctionAs your sacroiliac joint dynamic control improves, your physiotherapist will turn their attention to restoring your normal pelvic alignment and maintaining sacroiliac joint range of motion during more functionally stressful positions and postures plus work on your muscle power, proprioception, balance and gait (walking pattern). Depending on your chosen sport or activities of daily living, your physiotherapist will aim to restore your SIJ function to safely allow you to return to your desired activities.Everyone has different demands for their sacroiliac joints that will determine what specific treatment goals you need to achieve. For some, it is simply to walk around the block. Others may wish to run a marathon. Your physiotherapist will tailor your sacroiliac joint rehabilitation to help you achieve your own functional goals.
PHASE IV - Preventing a RecurrenceSacroiliac joint dysfunction does have a tendency to return if a thorough muscle control program is not undertaken. The main reason it is thought to be chronic and specific muscle weakness. Your physiotherapist will assist you in identifying the best exercises for you to continue indefinitely or periodically.In addition to your muscle control, your physiotherapist will assess your SIJ, spine, hip and lower limb biomechanics and correct any deficits that may predispose you to SIJ pain and dysfunction. Fine-tuning and maintenance of your sacroiliac joint stability and function are best achieved by addressing any deficits and learning self-management techniques. Your physiotherapist will guide you.
What is Physiotherapy Treatment?
Physiotherapists help people affected by illness, injury or disability through exercise, manual joint therapy, soft tissue techniques education and advice. Physiotherapists maintain physical health, help patients to manage pain and prevent disease for people of all ages. Physiotherapists help to encourage pain-relief, injury recovery, enabling people to stay playing a sport, working or performing activities of daily living while assisting them to remain functionally independent.
There is a multitude of different physiotherapy treatment approaches.
Acute & Sub-Acute Injury Management
Hands-On Physiotherapy Techniques
Your physiotherapist's training includes hands-on physiotherapy techniques such as:
- Joint Mobilisation (gentle joint gliding techniques)
- Joint Manipulation
- Physiotherapy Instrument Mobilisation (PIM)
- Minimal Energy Techniques (METs)
- Soft Tissue Techniques
Your physiotherapist has skilled training. Physiotherapy techniques have expanded over the past few decades. They have researched, upskilled and educated themselves in a spectrum of allied health skills. These skills include techniques shared with other healthcare practitioners. Professions include exercise physiologists, remedial massage therapists, osteopaths, acupuncturists, kinesiologists, chiropractors and occupational therapists, just to name a few.
Your physiotherapist is a highly skilled professional who utilises strapping and taping techniques to prevent and assist injuries or pain relief and function.
Alternatively, your physiotherapist may recommend a supportive brace.
Acupuncture and Dry Needling
Many physiotherapists have acquired additional training in the field of acupuncture and dry needling to assist pain relief and muscle function.
Physiotherapists have been trained in the use of exercise therapy to strengthen your muscles and improve your function. Physiotherapy exercises use evidence-based protocols where possible as an effective way that you can solve or prevent pain and injury. Your physiotherapist is highly-skilled in the prescription of the "best exercises" for you and the most appropriate "exercise dose" for you depending on your rehabilitation status. Your physiotherapist will incorporate essential components of pilates, yoga and exercise physiology to provide you with the best result. They may even use Real-Time Ultrasound Physiotherapy so that you can watch your muscles contract on a screen as you correctly retrain them.
- Muscle Stretching
- Core Exercises
- Strengthening Exercises
- Balance Exercises
- Proprioception Exercises
- Real-Time Ultrasound Physiotherapy
- Swiss Ball Exercises
Biomechanical assessment, observation and diagnostic skills are paramount to the best treatment. Your physiotherapist is a highly skilled health professional. They possess superb diagnostic skills to detect and ultimately avoid musculoskeletal and sports injuries. Poor technique or posture is one of the most common sources of a repeat injury.
Aquatic water exercises are an effective method to provide low bodyweight exercises.
Sports physio requires an extra level of knowledge and physiotherapy skill to assist injury recovery, prevent injury and improve performance. For the best advice, consult a Sports Physiotherapist.
Women's Health Physiotherapy is a particular interest group of therapies.
Not only can your physiotherapist assist you in sport, but they can also help you at work. Ergonomics looks at the best postures and workstation set up for your body at work or home. Whether it be lifting technique improvement, education programs or workstation setups, your physiotherapist can help you.
Plus Much More
Your physiotherapist is a highly skilled body mechanic. A physiotherapist has particular interests in certain injuries or specific conditions. For advice regarding your individual problem, please contact your PhysioWorks team.
Pins and Needles - Paraesthesia
What Causes Pins & Needles?
A moderately pinched nerve is the most common cause of "pins and needles". Pins and needles are referred to as "paraesthesia" in the medical community. Did you know that feeling "pins and needles" can be a worse sign than having pain in your arm or leg? The reason is that you can't even feel pain anymore when you significantly squash the nerve.
Even worse than "pins and needles" is "numbness" or "anaesthesia", which is a total lack of sensation. You will experience anaesthesia when there is severe nerve compression. Anaesthesia or numbness that persists for more than a few hours can be a sign of permanent nerve compression. Please seek prompt medical attention to prevent the nerve from permanent damage and the muscles it innervates to weaken drastically.
The majority of pinched nerves and nerve compressions are only transient and quickly reversed with early treatment. However, neglect can lead to permanent nerve compression injuries, which may never recover.
Common Causes of Pinched Nerves
The most common forms of nerve compression are in the spinal joints where either a disc bulge or a bony arthritic spur can irritate and compress the nerve. Compressions can also occur as the nerve passes through or around muscles. Your physiotherapist will know where to look.
How Can You Fix "Pins and Needles"?
If you know of someone who is experiencing chronic or permanent "pins and needles", "numbness" or "muscle weakness", please encourage them to seek urgent professional advice. The secret to quick success is the correct diagnosis. A highly trained health practitioner such as your physiotherapist or doctor is your best port of call.
What is Therapeutic Ultrasound?Therapeutic ultrasound is an electrotherapy modality which has been used by physiotherapists since the 1940s. Via an ultrasound probe through a transmission coupling gel in direct contact with your skin, ultrasound waves are applied. Therapeutic ultrasound may increase:
- healing rates
- tissue heating
- local blood flow
- tissue relaxation
- scar tissue breakdown.
How Could Ultrasound Help?Ultrasound increases local blood flow. This increase may help to reduce local swelling and promote soft tissue healing rates. A higher power density may soften scar tissue.
Specific Ultrasound UsesMastitis or blocked milk ducts successfully respond to therapeutic ultrasound. The effect is quite dramatic, with improvement within 24 to 72 hours.The most common conditions treated with ultrasound include soft tissue injuries such as muscle, ligament injuries or some tendinopathies.Phonophoresis uses ultrasound in a non-invasive way of administering medications to tissues below the skin. This method may assist patients who are uncomfortable with injections. With phonophoresis, the ultrasonic energy forces the drug through the skin.
What is an Ultrasound Dose?A typical ultrasound treatment will take from 3-10 minutes. Where scar tissue breakdown is the goal, this treatment time could be much longer. During the procedure, the head of the ultrasound probe is in constant motion. If kept in continuous motion, the patient should feel no discomfort at all.Some conditions treated with ultrasound include soft tissues injuries such as muscles or ligament injuries, tendinopathy, non-acute joint swelling and muscle spasm.
How Does an Ultrasound Work?A piezoelectric effect, caused by the vibration of crystals within the ultrasound head of the probe creates the sound waves. The ultrasound waves generated then pass through the skin cause a vibration of the local soft tissues. This repeated cavitation can cause a deep heating locally though usually no sensation of heat will be felt by the patient. In situations where a heating effect is not desirable, an athermal application occurs. Athermal doses are typical during acute fresh injury and the associated acute inflammation.
When Should Ultrasound be Avoided?Contraindications of ultrasound include:
- local malignancy,
- over metal implants,
- local acute infection,
- vascular abnormalities,
- active epiphyseal regions (growth plates) in children,
- over the spinal cord in the area of a laminectomy,
- over the eyes, skull, or testes
- and, directly on the abdomen of pregnant women. Treatment ultrasound differs from diagnostic ultrasound!
Core Stability MusclesThe deep core stability muscles of the lower spine include:
- Transversus Abdominis (TA)
- Multifidus (MF)
- Pelvic Floor (PF)
Transversus AbdominisThe Transversus Abdominis (TA) is the deepest abdominal muscle. It is the "corset muscle" of the spine and pelvis. In the typical situation, TA contracts in anticipation of body motion to guard the spinal joints, ligaments, discs and nerves.
MultifidusMultifidus (MF) muscles are very short muscles running from the transverse processes (on the sides) of one vertebra up to the spinous process (the middle of the back) of the next vertebra upwards. Their primary function is back stability. They do not produce an extensive range of movement, but work to provide small, "fine-tuning" postural changes, all day long.
Pelvic Floor & DiaphragmThe TA and the MF work in conjunction with your pelvic floor and diaphragm to make a flexible but stable region around your lumbar spine. It is this ability to stabilise your lumbar spine in its many positions that enable you to overcome back problems and reduce your chances of a reoccurrence.
What Are The Ideal Core Exercises?Your deep core stability muscles retraining uses specific low-level activation exercises. While a very skilled physiotherapist who has training in deep core activation can observe and palpate for the correct muscle contraction, the best way is to see them working on a real-time ultrasound scan.Real-Time Ultrasound Physiotherapy guidance allows you to see how your muscles are contracting in real-time. This visual feedback will enable you to correct your specific deep core muscles inside your stomach, lower back, and pelvic floor as you attempt to contract those muscles.
Beware of “Core Stability” Exercises!The fitness industry is full of fitness instructors who profess to know how to activate your core stability muscles. Unfortunately, the wrong core exercises will do you harm. Most progress your core exercises far too quickly and bypass these critical muscles to strengthen your outer abdominal muscles further and leave your deep core muscles weak. Research evidence has found that this renders you vulnerable to lower back pain and injury.
Core Stability vs PilatesThe whole 'core stability' phenomenon started back in the 1920s with a chap named Joseph Pilates, who's exercise regimes have become quite trendy in the last ten years.Pilates talked about developing a 'girdle of strength' by learning to recruit the deep-trunk muscles. Even without complete knowledge of anatomy and the benefits of the latest muscle activity research, he was aware of the importance of these deep muscles and their supportive effects.Put simply; core stability training targets explicitly the smaller and deeper back and stomach muscles. Once recruited, these muscles control the position of the spine during dynamic movements of your body.
Is Pilates for Everyone?Sadly, No! Exercise programs that aim to develop your deep core strength can often do just the opposite. The most common reason for injury and back pain is the incorrect timing of core muscle recruitment. Pilates, Yoga, gym strengthening and other forms of exercise place high demands on your core stability system. Abnormal core muscle recruitment order increases your injury chance proportion with the exercise difficulty.Remember, if you build a tower on a weak foundation, it will eventually topple. Look what happened to the Leaning Tower of Pisa. It's got lousy core stability! The same goes for your core stability muscles.However, recruiting the deeper core muscles before your superficial layers just like adding floors to a sturdy skyscraper and your back will be healthy and pain-free forever.
Why is it Important to Specially Retrain your Core Stability Muscles?Once the core muscles become weak, and their timing is incorrect, you can experience prolonged back pain and are at much higher risk of re-occurrence. Research has identified that the order of core muscle recruitment is one of the most critical factors in the prevention or resolution of pain. Real-Time Ultrasound Physiotherapy has proven particularly useful to correct the muscle recruitment order.To solve your back pain and to reduce your re-injury risk, you must retrain these muscles back to an appropriate level for your needs. If you are relatively sedentary, you may only need a low level of control, however, if you are a high-level sportsperson or a manual worker you will need to work up to a much higher level of core strength.
What Should You Expect?In the initial stage, you need to be able to activate these muscles consciously and incorporate them into an exercise program. A lot of people find it difficult to isolate these muscles and need help to be able to activate them effectively.Research has discovered that real-time ultrasound-guided treatment is the most effective way to retrain an isolated and well-timed core stability contraction successfully.
Common Sources of Spinal Pain & Injury
- Neck Pain - Cervical Spine
- Upper Back Pain - Thoracic Spine
- Lower Back Pain - Lumbar Spine
- Sacroiliac Pain - SIJ
- Scheuermann’s Disease
- Spinal Stenosis
- Rib Stress Fracture