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Piriformis Syndrome
Douglas R. Keskula, MS, PT, ATC
Michael Tamburello, MS, PT
ABSTRA CT: Piriformis syndrome is aques- indicate (1). Whether or not one embraces ever, variations in this arrangement have
tionable clinical entity that has been cited this as a clinical entity, our purpose is to beenreportedwith thenervecrossing above
as a cause of buttock pain and sciatica. provide the reader with an understanding or through the muscle belly itself (3,4).
The intimate relationship between the of piriformis syndrome by reviewing the The typical relationship of the sciatic nerve
piriformis and the sciatic nerve has been relevant anatomy and the proposed and the piriformis is presented in Fig 1.
suspected as being the source of the signs pathomechanics of this syndrome. More-
and symptoms that often appearfollowing over, practical and systematic strategies
minor trauma to the pelvic or buttock re- for evaluating and managing the athlete
gion. Muscle function is an important with suspected piriformis syndrome will
consideration in the evaluation and treat- be offered.
mentoftheathletewithsuspectedpiriformis
syndrome. The action of the piriformis Incidence/Etiology
muscle on the hip varies as the hip moves The incidence of piriformis syndrome
from a neutral to aflexed position. While in has been reported to be six times more
aflexed position, the piriformis internalty prevalent infemalesthanmales (11). While
rotates and abducts the hip; however, in a no dominant etiological factors have been
neutral position, the piriformis acts as an reported, piriformis syndrome often oc-
external rotator of the hip. A comprehen- curs following a minor trauma to the but-
sive evaluation provides the information tocks or pelvis (1,2,12). The trauma is
necessary to design a treatment plan spe- thought to precipitate a spasm of the
cific to the involved structures, while meet- piriformis muscle, which subsequently in-
ing the functional needs of the individual flames the adjoining sciatic nerve (2).
athlete. This paper describes the anatomy, Piriformis syndrome has typically been
pathomechanics,physicalexamination, and characterized by symptoms consistentwith Fig 1.-Posterior view of the pelvis and right
treatment options relevant to the piriformis irritation of the sciatic nerve. Isolating the proximal lower extremity, illustrating the ana-
syndrome. Treatment protocols stressing dysfunction to this region usually follows tomical relationship between the piriformis
exercises that promote strength, flexibil- exclusion of the more common causes of muscle and the sciatc nerve
ity, andfunctional activities are believed to buttock pain and sciatica. More specifi-
be essential in restoring the athlete's abil- cally, complaints of buttock pain with dis- Some tiink tfiat the piriformis can
ity to return to pain-free competition. tal referral of symptoms are not unique to become hypertrophied or can spasm, re-
piriformis syndrome. Similar symptoms sulting in compression of the nerve against
are prevalent with the more clinically evi- the ischium, or, more specifically, against
r he piriformis syndrome has been im- dentlowerbackpain syndromes and pelvic the bony edge of the sciatic notch (3). It
plicated as a potential source of pain dysfunctions. Thus, a thorough evaluation also has been suggested that an accentu-
and dysfunction, not only in the general of these regions must be performed to ated lumbar lordosis and hip flexor tight-
population, but in athletes as well (2,8,11). exclude underlying pathology. ness predisposes one to increased com-
While there is disparity in the literature as pression of the sciatic nerve against the
to whether this syndrome actually exists Anatomy sciatic notch by a shortened piriformis (7).
(1,8,12), some suggestthatitismore preva- The key elements of the piriformis Although differences in the anatomical re-
lent than citations in the literature would syndrome are the anatomical relationships lationships are helpful to facilitate under-
ofthepiriformismuscletothesciaticnerve. standing the mechanism of dysfunction,
Douglas Keskula is a doctoral candi- The piriformis muscle arises from the pel- these differences do not affect conserva-
date at the University of Virginia in vic surface of the sacrum, the greater sci- tive treatmnent strategies.
Charlottesville, VA. atic notch, and the sacrotuberous ligament. The pirifonmis muscle primarily is in-
Michael Tamburello is a commander The lower attachment is the superior bor- nervated by the S1 and S2 spinal nerve
in the United States Navy and a doctoral der of the greater trochanter of the femur. segments viathe sacral plexus. The sciatic
candidate at the University of Virginia. The pirifonnis muscle passes over the sci- nerve is derived from the same spinal seg-
atic nerve in the majority of cases. How- ments with contributions from theL4, L5,