newsprompt.coSTRETCHING EXERCISES
Piriformis Stretches
Piriformis syndrome, sciatica caused by compression of the sciatic nerve by the piriformis muscle, has been described for over 70 years; yet, it remains controversial. The literature consists mainly of case series and narrative reviews. The objectives of the study were: first, to make the best use of existing evidence to estimate the frequencies of clinical features in patients reported to have PS; second, to identify future research questions. A systematic review was conducted of any study type that reported extractable data relevant to diagnosis. The search included all studies up to 1 March 2008 in four databases: AMED, CINAHL, Embase and Medline. Screening, data extraction and analysis were all performed independently by two reviewers. A total of 55 studies were included: 51 individual and 3 aggregated data studies, and 1 combined study. The most common features found were: buttock pain, external tenderness over the greater sciatic notch, aggravation of the pain through sitting and augmentation of the pain with manoeuvres that increase piriformis muscle tension. Future research could start with comparing the frequencies of these features in sciatica patients with and without disc herniation or spinal stenosis.
Deep gluteal syndrome (DGS) is an underdiagnosed entity characterized by pain and/or dysesthesias in the buttock area, hip or posterior thigh and/or radicular pain due to a non-discogenic sciatic nerve entrapment in the subgluteal space. Multiple pathologies have been incorporated in this all-included “piriformis syndrome”, a term that has nothing to do with the presence of fibrous bands, obturator internus/gemellus syndrome, quadratus femoris/ischiofemoral pathology, hamstring conditions, gluteal disorders and orthopedic causes.
Methods
This article describes the subgluteal space anatomy, reviews known and new etiologies of DGS, and assesses the role of the radiologist and orthopaedic surgeons in the diagnosis, treatment and postoperative evaluation of sciatic nerve entrapments.
Conclusion
DGS is an under-recognized and multifactorial pathology. The development of periarticular hip endoscopy has led to an understanding of the pathophysiological mechanisms underlying piriformis syndrome, which has supported its further classification. The whole sciatic nerve trajectory in the deep gluteal space can be addressed by an endoscopic surgical technique. Endoscopic decompression of the sciatic nerve appears useful in improving function and diminishing hip pain in sciatic nerve entrapments, but requires significant experience and familiarity with the gross and endoscopic anatomy.
Subgluteal space anatomy
The subgluteal space is the cellular and fatty tissue located between the middle and deep gluteal aponeurosis layers. This space is anterior and beneath the gluteus maximus and posterior to the posterior border of the femoral neck, with the linea aspera (lateral), the sacrotuberous and falciform fascia (medial), the inferior margin of the sciatic notch (superior), and the hamstring origin (inferior). At its inferior margin it continues into and with the posterior thigh. Laterally it is demarcated by the linea aspera and the lateral fusion of the middle and deep gluteal aponeurosis layers extending up to the tensor fasciae latae muscle via the iliotibial tract. The anterior limit is formed by the posterior border of the femoral neck and the greater and lesser trochanters. Within the space, superior to inferior, the piriformis, superior gemellus, obturator internus, inferior gemellus and quadratus femoris are included. The medial margin is comprised of the greater and minor sciatic foramina. The greater sciatic foramen is bounded by the outer edge of the sacrum, greater sciatic notch (superior) and sacrospinous ligament (inferior). The limits of the lesser sciatic foramen are the lesser sciatic notch (external), sacrospinous lower border (superior) and the upper edge of the sacrotuberous ligament (inferior).
Compression or irritation of the sciatic nerve can occur when the piriformis muscle becomes inflamed, has spasms, or becomes tight. Typically, this results from overuse, prolonged sitting, and activities such as rowing in the sitting position. In addition, weak hip abductor muscles, such as the gluteals, combined with tight adductors, increase the risk if they do not engage regularly. Athletes performing forward-moving activities such as running and cycling are more susceptible to the disorder, especially if they do not engage regularly in lateral stretching and strengthening exercises. Excessive or prolonged sitting (e.g.,the hips flexed while sitting at work) also increases the likelihood of developing piriformis syndrome.
Piriformis syndrome is not diagnosed frequently because the symptoms of the disorder mimic those of sciatica and a definitive diagnostic test is lacking. Typical symptoms can include:
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Tenderness or pain behind the hip, in the buttocks
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Pain can radiate down the back of the leg into the hamstring muscles and, at times, the calf muscles.
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Numbness and tingling in the lower extremity
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Tenderness when pressure is applied on the piriformis muscle, such as with sitting
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Low-back tenderness and pain
Conservative treatment includes nonsteroidal anti-inflammatory medications for symptom relief, kneading, simple stretching exercises, and avoidance of contributing activities such as running, cycling, and rowing. Avoidance of prolonged sitting is highly recommended, and short movement breaks every 30 minutes also are recommended. Light stretching is recommended three to four times per day up to, but not beyond, the point of pain.
As symptoms alleviate, strengthening exercises should be added that involve the hip abductors, adductors, external rotator, and extensor muscles. A physical therapist or personal trainer can provide guidance with developing an appropriate strengthening and stretching routine.
Most causes of piriformis syndrome are preventable and frequently are related to activities of daily living. Avoidance of prolonged sitting and utilization of correct sitting posture are two important prevention strategies and essential for other aspects of overall health and wellness. Other preventive strategies include:
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Using a proper warm-up and cool-down period
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Maintaining correct posture with even weight distribution on both feet
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Wearing proper-fitting shoes that are not worn out
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Using correct lifting techniques
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Regular stretching
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Strengthening exercises that include activities such as:
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Resistance band abduction and adduction exercises
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Side-lying clam shells
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Stability ball wall squats
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Although a painful and restricting condition, piriformis syndrome largely is preventable. Avoidance of prolonged sitting and chronic repetitive activities, along with undertaking proper warm-up, stretching, and strengthening exercises, will minimize the risk of developing this debilitating condition.
