In spite of a number of articles discussing piriformis syndrome, it remains the most unrecognized cause of sciatica or sciatic like pain. Patients with this syndrome complain of pain and/or paresthesia in the distribution of the sciatic nerve, which is commonly misdiagnosed as compression from nerve root lesions.

The piriformis muscle originates from the front of the sacrum, the gluteal surface of the ilium in the region of the posterior iliac spine, the capsule of the adjacent sacroiliac joint, and sometimes from the upper part of the pelvic surface of the sacrotuberous ligament. It passes out of the pelvis through the greater sciatic foramen attaching to the greater trochanter of the femur by a rounded tendon.

The sciatic nerve passes under the belly of the piriformis in more than 80% of the cases . It varies in relation to the muscle in the remainder, passing either through the belly of the muscle or the nerve itself splits, with a portion passing through, as well as under, the muscle.

Freiberg and Vinle note that the piriformis muscle bridges over the sacroiliac joint, and a part of its origin is intimately bound up with the capsule of the joint and is therefore subject to reflex spasm from intra-articular irritation of the sacroiliac joint. The piriformis muscle is innervated by branches from the L5, S1, and S2 nerve roots. The piriformis rotates the extended thigh laterally and abducts the flexed thigh.

The three most common causes of piriformis syndrome are trauma to the sacroiliac joint producing a ligamentous sprain, hormonal changes such as occur in the female during the menstrual cycle, during pregnancy, or when taking estrogen replacement therapy or oral contraceptives as well as chronic overload as seen in long distance runners.

Patients with piriformis syndrome complain of a deep, boring, ill defined pain in the buttock, commonly radiating into the posterolateral thigh or calf, rarely to the foot. They may also report a burning sensation in the hips over the greater trochanter, particularly at night, when they are unable to lie on the side.

Examination of the patient while lying on their back normally reveals external rotation of the thigh on the affected side, known as the positive piriformis sign. Internal rotation of the thigh would normally be limited and very painful.
Trigger points are palpable in the belly of the muscle through the mass of the gluteus maximus muscle and at the tendinous insertion at the greater trochanter . These trigger points are exquisitely tender. Deep pressure at the belly of the muscle produces radiation down the course of the sciatic nerve, while pressure at the tendinous insertion produces a localized burning sensation.

Should these symptoms and signs sound familiar, you may be suffering from piriformis syndrome.

TREATMENT PROTOCOL:

1. As with all myofascial syndromes, it is imperative to normalize movement in the kinematic chain and therefore correct abnormal biomechanics specifically pertaining to the sacroiliac joints. Hip and/or contralateral sacroiliac fixations should be manipulated; however, caution is advised against repeated non-specific pelvic manipulation, since this tends to perpetuate the condition. The use of a stabilizing trochanteric belt, preferably with an elastic bandage, promotes stabilization of hypermobile sacroiliac joints. Visit your Chiropractor regularly and correct structure and function relationships before they manifest as myofascial pain and dysfunction syndromes.

2. Stretching the involved muscle also prevents recurrence and enhances prompt resolution of the piriformis syndrome. To stretch the piriformis muscle, the knee on the affected is tractioned slowly toward the opposite shoulder.

3. Surround yourself with a multi disciplinary support team comprised of a Physiotherapist, Biokineticist, Podiatrist, Kinesiologist and a sport massage therapist. Visit your team regularly to identify biomechanical aberrations early and to correct the abnormalities in a structured and professional way.

4. In the treatment of myofascial trigger points, use Traumeel S regularly. Biopuncture techniques using Traumeel S have proven to be the most effective treatment protocol by far. If one understands the physiology behind the effect of Traumeel S at cellular level, one cannot but agree to its efficacy.Traumeel S is a biotherapeutic antiphlogistic that contains many low potentised proteins and complies completely with the conditions for arousing an immunological bystander reaction. By stimulating the formation of Th3-cells, the inflammation will be restrained. It is important to note that this form of therapy is not suppressive, but stimulating. The self regulating control of the inflammatory process will not be touched. Nsaids, although effective in the short term, suppresses the inflammatory reaction by intervention at the cyclo-ogygenase level thereby limiting the formation of prostaglandins. Patients will however complain that pain will return as soon as the effect of nsaids diminishes within four to eight hours.
Where an antihomotoxic agent with low potentised proteins is introduced into the GRS (Ground Regulation System) patrolling macrophages will digest it almost completely. It does not matter whether the agents enter the body via the mucus (sublingual) or directly in the bloodstream or the GRS (injection). The residues are transported back to the macrophage surface in the form of short amino acid chains motifs. There they act like an antenna on thecell surface. The motifs are recognized by passing T-lymphocytes, taken away from the macrophages and bound to receptors of their own. This is the signal for transformation into Th3-cells (regulatory lymphocytes). Since the Th3-cells contain proteins, they will be transported to the lymph nodes (homing) where they will be multiplied (cloning). The activated Th3-cells search for inflammation promoting lymphocytes (Th1, Th2, T4, ....) from the inflammation area, which motifs are dependent on the foreign substances that caused the inflammation. The Th3-cell will look for lymphocytes with a similar motif (not equal, but following the simile principle). As soon as the similarity is confirmed, the Th3-cells immediately start with the synthesis of the highly active TGF-B (Transforming Growth Factor B), which will decrease the activity of the Th1 and Th2 lymphocytes and thereby modulating the inflammatory reaction allowing tissues to heal.

Traumeel S works by modulating the generation of reactive oxygen by activated neutrophils and by inhibiting the release of inflammatory mediators and neuropeptides.

The advantages of using a product like Traumeel S:

- No GI toxicity
- Does not inhibit platelet aggregation
- No sodium and fluid retention
- No adverse renal, hepatic, cardiovascular or CNS side effects
- Enhances cellular recovery and therefore healing

To conclude, train smarter, rest more, stretch more and modulate the adverse cellular and biochemical pathways in the muscle with products like Traumeel S.

5. Good luck!