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| Ref: https://mobilephysiotherapyclinic.in/ |
The pain and/or paresthesia radiating in the buttock or lower part of the back or from sacrum through the gluteal area and down back side aspect of thigh especially after sitting or squatting longer than 15 to 20 minutes. The pain develops with walking and worsens with no movement but does not relieve completely on changing position.
"It propagates the thought of “Piriformis syndrome”.
The main function of piriformis muscle is hip external rotation, and secondary function is hip abduction during flexion. To stretch piriformis need to reverse function that is hip internal rotation and adduction.
Stretching in normal piriformis for routine flexibility is acceptable. On the other hand, stretching in piriformis disorders or sciatic nerve irritation should be under supervision from doctor and physiotherapist.
Although, the way to stretch piriformis looks like the way to stretch gluteus muscles, the angle of muscle fibers determine the poses. Piriformis is almost horizontal muscle fibers that work on the transverse and frontal plane, so the stretching direction will not want high hip joint bending. Gluteus muscles are almost vertical muscle fingers that work on a sagittal plane where high hip joint bending provides more tension during stretching.
4 ways to stretch piriformis muscle
Exercise #1: Supine cross leg: supine with single hip bending between 90 - 120 degrees. The opposite hand is on the knee and pulls to the opposite side without pelvic and shoulder lifting.
Exercise #2: Seat cross leg with hip internal rotation: sit on chair with cross one leg. The opposite hand is on the knee and pulls to the opposite side. Keep back straight or lean to back rest that makes hip flexion is in between 90 - 120 degrees. If the torso and knee are too close, the glutes muscles will be stretching instead.
Exercise #3: Kneeling with pelvic rotation: Kneeling on any cushion with the target side next to the wall or stable objects. Keep both thighs and feet together, then turn toro and pelvic to the wall. If you feel bad pain in your hip joint and/or lower back, please stop stretching.
Exercise #4: Stand with the target side next to the wall or stable objects. Un - target leg steps forward, and then step to the wall with a pelvic rotation to the wall. If you feel bad pain in your hip joint and/or lower back, please stop stretching. Additionally, this stretching may be not safe in patients with knee problems.
Piriformis is the largest muscle among the deep short hip external rotators and a functionally important muscle which attaches two joints, sacroiliac, and hip joints.
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| Ref: https://wellbeinghealth.com.au/ |
Anatomically, origin of piriformis starting from the S2-S4 level of the pelvic surface of the sacrum, the gluteal surface of the ilium that is close to the posterior inferior iliac spine, the sacroiliac joint capsule, Sacro tuberous ligament, exiting pelvis, it advances through lateral by dividing greater sciatic foramen in two to form suprapiriform and infrapiriform foramen.
Its insertion terminates in the femur, in the medial upper side of greater trochanter. Its tendon often merges with gluteus medius muscle tendon, either in conjunction with gemelli muscles and obturator internus muscle joint tendon or by itself.
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| Piriformis muscle: Left (front view), Right (back view) (Ref: https://www.yogauonline.com/) |
Piriformis and sciatic nerve are strongly relative. There are also variations of sciatic nerve dividing into branches and variations of their adjacency with piriformis. Sciatic nerve or one of its branches is observed to pass through the muscle. This nerve is veryImportant neurovascular structures pass through infrapiriform foramen.
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| Ref: https://musculoskeletalkey.com/sciatic-neuropathy/ |
It is a small two articular muscle that is the reason why it is multi - function muscle. The main function of piriformis is femur external rotation especially while femur is in extension and its secondary function is to provide abduction especially while femur is in flexion. The secondary function helps to prevent Trenderlenburg’s gait during the stance phase of walking.
This muscle has an important role as postural muscles rather than creating power by providing pelvis with control over stable femur. So, it is regarded as a powerful stabilizer of sacroiliac joints. It helps stabilize the joint by preventing femur’s internal rotation during walking. It also tilts pelvis down laterally and posteriorly by pulling the sacrum downward toward the thigh.
So, while sacrum is stable, piriformis muscle brings femur to external rotation, abduction, and flexion, and while femur is stable, it brings pelvis to extension with bilateral contraction and causes pelvis to do internal rotation with unilateral contraction.
Piriformis syndrome is a complex condition that is often not considered in the differential diagnosis of chronic hip and low back pain. It is caused by “compression of the sciatic nerve” at its exit point in the gluteal region after the sacroiliac ligament as it passes under the piriformis muscle. due to muscle spasm or other inflammatory process of the muscle.
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| Ref: https://www.ormondphysiotherapy.com.au/ |
The cause of piriformis syndrome may be primary or secondary which is more common than primary. Primary cause involves an anatomic background such as split piriformis muscle, split sciatic nerve. Secondary causes occur as a result of precipitating causes including trauma, leg length discrepancy, cerebral palsy and narrowed sciatic foramen etc. Macrotrauma to the buttocks, leading to inflammation of the soft tissue, muscle spasm, or both causing nerve compression. Microtrauma may result from overuse of the piriformis muscle such as in long distance walking or running, excessive exercise. It may be due to direct pressure due to keeping the wallet in the right back pocket of trousers or jeans. Leg length discrepancy altered biomechanics leading to stretching and shortening of the piriformis muscle.
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| Fat wallet syndrome (Ref: https://www.pushphospital.com/) |
Sciatic nerve compression in piriformis syndrome may occur during the contraction for active range of motion in hip extension and/or abduction and/or external rotation. As well as, the movements that bring the muscle to the longest position or stretching in hip flexion and/or adduction and/or internal rotation.
Brett et al. studied to comparison of two stretching methods and optimization of stretching protocol for the piriformis muscle that conclude the longest position of piriformis muscle was observed that putting the hip into 115 -120 degrees of flexion, 30 - 40 degrees of external rotation and 25 -30 degrees of adduction increased the extension of muscle by 30-40% compared to conventional stretching movements. It made me confused and disagree about hip external rotation providing piriformis elongation because piriformis contraction which made it shorten to hip external rotation. So, piriformis elongation should be internal rotation.
The most common notable clinical presentation is increasing pain in the buttock especially over the piriformis muscle attachments or lower back after sitting or squatting longer than 15 to 20 minutes. The pain and/or paresthesia radiating from the sacrum through the gluteal area and down the posterior aspect of the thigh, usually stooping above the knee. Patients may complain of pain with hip internal rotation of the indisposed leg, such as occurs during cross-legged sitting or ambulation. There may be groin or pelvic pain. There may be palpable mass at the buttock and piriformis muscle may be tender. In chronic cases there may be gluteal atrophy that asymmetrical weakness of the limb may occur. Affected limb lies in external rotation with decreased internal rotation of the ipsilateral hip joint.
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| Freiberg sign is one of several piriformis special test (Ref: Retro - trochanteric sciatica - like pain: in - depth analyses of clinical symptoms, treatment option, histological and ultra structural findings in tendon biopsies) |
There are several physical diagnostic assessments that stimulate signs and symptoms by stretching the sciatic nerve and hip internal rotation to induce sciatic nerve irritation. When the pain occurs these mechanisms indicate positive tests.
Prevention of repetitive trauma (i.e., microtrauma) is effective in decreasing a patient’s risk of piriformis syndrome. Correction of the biomechanical deficiencies and functional adaptations to those deficiencies can reduce the incidence of piriformis syndrome
Home base self - rehabilitation should be recommended by physiotherapists; include a variety of motion exercises, stretching technique, and strengthening. The strengthening of the adductor muscles of the hip has been shown to be beneficial for patients with piriformis syndrome. The aim of stretching is to increase the range of motion of the surrounding muscle groups and joints i.e., gluteus muscle which you can learn more on . https://yimphysionearme.blogspot.com/2022/06/10-ways-physiotherapy-stretch-gluteus.html Do not stretch piriformis in case of inflammatory phase of piriformis because it will irritate the nerve and worse. Heat or cold therapy is usually most effectively applied before home therapy sessions because it may lessen the discomfort associated with direct treatment applied to an irritated or tense piriformis muscle.
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| Hip adductor exercise (Ref: https://www.avogel.co.uk/) |
The principle to stretch this muscle is the same as the others: stretch to the point where “tightness with pain” or “noticeable tension without pain” will hold at the point for 30 seconds of 3 - 5 reputations following demonstrated VIDEO.
Reference:
https://biomedres.us/pdfs/BJSTR.MS.ID.006110.pdf
https://www.jemds.com/data_pdf/subhasis%20ranjan%20mitra-.pdf
Othman I. K., et al. Risk factors associated with piriformis syndrome: A systematic review. Science, Engineering and Health Studies 2020, 14(3), 215-233.
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