Treatment of piriformis syndrome. Exercises, exercise therapy.

Piriformis syndrome is a pain syndrome that is localized in the gluteal region with possible return (irradiation) to the upper thigh, lower leg and groin area.

Piriformis syndrome occurs in at least 50% of patients with discogenic lumbosacral radiculitis. Reflex tension in the muscle and neurotrophic processes in it are caused, as a rule, by irritation not of the fifth lumbar, but of the first sacral root.

If the patient is diagnosed with this, the assumption of the presence of piriformis muscle syndrome may arise in the presence of persistent pain along the sciatic nerve that does not decrease with drug treatment. It is much more difficult to determine the presence of this syndrome if there is only pain in the buttock area, which is limited in nature and associated with certain positions (movements) of the pelvis or when walking.

CAUSES OF PIRIFYFORMUS SYNDROME

Piriformis syndrome has been familiar to general practitioners for a long time; it can be a complication of lumbar osteochondrosis, a symptom of diseases of the pelvic organs, and a consequence of overload of the piriformis muscle, muscles and ligaments of the lower extremity girdle.

Primary damage to the piriformis muscle is observed in myofascial pain syndrome; the immediate causes of its occurrence may be:

• stretching
• hypothermia
• muscle overtraining
• injury to the lumbosacral and gluteal regions
• unsuccessful injection of drugs into the piriformis muscle area
• myositis ossificans
• prolonged stay in antalgic position

Secondary piriformis syndrome can occur when:

• diseases of the sacroiliac joint
• diseases of the pelvis, in particular gynecological diseases

With vertebrogenic pathology, a reflex muscle spasm may occur. Piriformis syndrome, which develops according to this pattern (not radicular), with muscle-tonic manifestations, is the most common variant of lumbar and hip pain. Pathological tension of the piriformis muscle in the form of a spasm is observed in discogenic radiculopathies with damage to the spinal roots. In these cases, there will be a clinical combination of both radicular and reflex mechanisms with the occurrence of neurological manifestations of vertebrogenic pathology.

Possible vertebrogenic causes include:

• radiculopathy of L1 - S1 roots
• tumors of the spine and spinal roots
• injuries of the spine and spinal roots
• lumbar stenosis

The function of the piriformis muscle is to abduct and externally rotate the hip. At the same time, she extends and abducts the hip, and with a sharp flexor-abduction pose, rotates it. The muscle is involved in “anchoring” the femoral head, similar to the function of the supraspinatus muscle in relation to the head of the humerus. It prevents rapid internal rotation of the hip in the first stage of walking and running. It creates an oblique force on the sacrum; due to its lower part, it provides a “shearing” force to the sacroiliac joint - it pulls its side of the base of the sacrum forward and the apex back. The muscle promotes antinutation (swinging) of the sacrum. If the nutating muscles pull it forward, wedge the sacrum forward, the piriformis pulls its lower sections back towards the posterior sections of the innominate bones.

In 90% of cases, the trunk of the sciatic nerve exits the pelvic cavity into the gluteal region under the piriformis muscle. In 10% of cases, the sciatic nerve pierces the piriformis muscle as it passes into the gluteal region. A prerequisite for compression of the sciatic nerve is induration of the piriformis muscle during its aseptic inflammation. The altered piriformis muscle can compress not only the sciatic nerve, but also other branches of the second to fourth sacral nerves - the pudendal nerve, the posterior cutaneous nerve of the thigh, the inferior gluteal nerve.

Thus, with piriformis syndrome it is possible:

• compression of the sciatic nerve between the altered piriformis muscle and the sacrospinous ligament
• compression of the sciatic nerve by the altered piriformis muscle as the nerve passes through the muscle itself (a variant of the development of the sciatic nerve)
• compression of the branches of the second to fourth sacral nerves - the pudendal nerve, the posterior cutaneous nerve of the thigh, the inferior gluteal nerve

Symptoms

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Spasm of the piriformis muscle is usually very acute, so it is easy to notice. Therefore, the main symptom is usually severe pain.

In addition, the following signs of pathology may appear::

• Local , which are directly related to the spasm itself.
• Neuropathic , caused by compression of the sciatic nerve. This includes sciatica, autonomic and motor disorders in the lower extremities from the location of this muscle.
• Vascular symptoms , which are caused by compression of the artery of the buttocks and other vessels passing through this hole.

Symptoms of this disease also include paresis in the muscles of the foot and leg. In some cases, intermittent claudication appears. Dysfunction of the rectal and urethral sphincter may occur.

Diagnostics

To determine the development of spasm of the piriformis muscle, the specialist first uses the palpation method. In this way, he determines whether there are any compactions in the muscle tissue.

During a general examination, the doctor checks for pain in the following positions::

• when rotating the leg inward with the bent hip;
• while raising the knee from a lying position on the healthy side;
• during flexion, adduction and internal rotation of the hip;
• when slowly bending forward from a standing position on straight legs;
• with a light tap on the buttock.

X-rays, novocaine blockade, magnetic resonance or computed tomography can also be used in diagnosis.

CLINICAL PICTURE OF PIRIFOID MUSCLE SYNDROME

Local symptoms

• aching, nagging, “brainy” pain in the buttock, sacroiliac and hip joints, which intensifies when walking, standing, adducting the hip, and also in a squatting position
• the pain subsides somewhat when lying down and sitting with legs apart
• with good relaxation of the gluteus maximus muscle, a dense and painful when stretched (Bonnet-Bobrovnikova symptom) piriformis muscle is felt underneath it
• upon percussion at the point of the piriformis muscle, pain appears on the back of the leg - Vilenkin’s symptom
• soreness of the ischial spine is detected: a palpating finger encounters it, intensively sliding medially upward from the ischial tuberosity
• often tonic tension of the piriformis muscle is combined with a similar condition of other pelvic floor muscles - coccygeus, obturator internus, levator anus, etc. in such cases, symptoms of compression of blood vessels and the sciatic nerve in the infrapiriformis space speak of pelvic floor syndrome
• pain due to compression of the sciatic nerve is dull, “brainy” in nature with a pronounced vegetative coloring (feelings of chilliness, burning, stiffness)
• irradiation of pain throughout the leg or mainly along the innervation zone of the tibial and peroneal nerves
• provoking factors are heat, weather changes, stressful situations
• sometimes the Achilles reflex and superficial sensitivity decrease
• with predominant involvement of the fibers from which the tibial nerve is formed

Certain manual tests help recognize piriformis syndrome:

• pain on palpation of the superior internal region of the greater trochanter of the femur (attachment site of the piriformis muscle)
• pain on palpation of the lower part of the sacroiliac joint - projection of the insertion site of the piriformis muscle
• reproduction of pain during passive adduction of the hip with simultaneous internal rotation (Bonnet-Bobrovnikova symptom)
• test for the examination of the sacrospinous ligament, which allows you to simultaneously diagnose the condition of the sacrospinous and iliosacral ligaments
• tapping on the buttock (on the sore side) - this causes pain spreading along the back of the thigh
• Grossman's symptom - when struck with a hammer or folded fingers on the lower lumbar or upper sacral spinous processes, the gluteal muscles contract

Etiology

Pathology provokes abnormal changes in the piriformis muscle. Provoking factors include:

• injury;
• spasm;
• fibrosis;
• inflammatory process;
• increase in size.

The human piriformis muscle can be damaged due to intramuscular injections, which can provoke the occurrence of an intramuscular abscess and the formation of an infiltrate. The main etiological factors of pathology include the following:

1. Injuries. The cause of problems is excessive stretching of muscle tissue, tearing of fibers, and the development of fibrosis. With fibrotic processes, shortening and thickening of the muscle is observed.
2. Post-traumatic hematoma.
3. Vertebrogenic pathologies. This category includes spondyloarthrosis and osteochondrosis. These also include intervertebral hernias in the lower back. In addition, spinal and vertebral tumors are provoking factors. Damage to the fibers of the sacrum and spinal nerves causes a reflex spasm.
4. Inflammation. These include inflammation and prostate adenoma, damage to the bladder. Spasm of the piriformis muscle is associated with endometriosis, sacroiliitis, and myositis.
5. Muscle overload. Their cause is the prolonged stay of the pelvic-iliac segment in a forced position. With radicular syndrome, a person tries to take an antalgic position. Some sports can cause the disease - in particular, running and weightlifting.
6. Malignant tumors in the sacrum and proximal femur. They provoke anatomical processes in structures. Neoplasia can provoke spasm and inflammation of the piriformis muscle.
7. Pelvic asymmetry. It is observed with shortened legs or scoliosis.
8. Removal of the thigh. In this case, the muscle is in a state of constant spasm, which leads to the appearance of phantom pain.

METHODS FOR DIAGNOSIS OF PIRIFOID MUSCLE SYNDROME

One of the most reliable methods for diagnosing piriformis muscle syndrome is considered to be transrectal palpation of the piriformis muscle, determined in the form of an elastic, sharply painful cord. It is also possible to palpate the piriformis muscle through the gluteus maximus muscle, with the patient “lying on his side”

An important diagnostic test is infiltration of the piriformis muscle with novocaine and assessment of the positive changes that occur. A definitive diagnosis can be made when clinical signs improve as a result of post-isometric relaxation of the piriformis muscle.

Traditional medicine recipes

There are effective alternative medicines that can speed up recovery. They are used in the form of compresses, tinctures, ointments, and herbal decoctions. Most popular recipes:

• 200 g of horseradish root, radish, crushed using a blender. Add 1 tbsp each of salt and vinegar, mix, and leave for at least three days. Then apply the mixture to gauze and apply it to the affected area overnight.
• An effective remedy is burdock. You can simply apply a leaf to the sore spot, wrapping it for several hours, or squeeze out the juice from it, rubbing it into the sore spot. This can be done 5-6 times a day, between the use of other remedies.
• To prepare the ointment, take the iris root, soften it, add butter to obtain a consistency suitable for application. Apply to the sore spot 2-3 times a day.
• For herbal infusions, any plants with anti-inflammatory properties are used. For example, brew 1 tbsp in a liter of boiling water. chamomile, calamus root, calendula, leave for an hour, filter. Take half a glass before meals.

For treatment of the piriformis muscle to be effective, it must be comprehensive. Drug therapy is complemented by massage and physical therapy. Folk remedies are also useful, but they can only complement the main treatment. A doctor's consultation, examination, and an accurate diagnosis are first necessary.

PRINCIPLES OF THERAPY

In most cases, correction is required by the primary condition that caused the formation of muscular-tonic syndrome. When the primary source of pain impulse is eliminated, reflex muscular-tonic syndrome can regress. In cases where muscular-tonic disorders become the main or independent source of pain, both local and general effects are used. Stretching, massage of the affected muscle, warming physiotherapy, and manual therapy techniques aimed at mobilizing the affected spinal motion segment are performed. It is advisable to correct the motor stereotype, avoid provoking loads and poses

Block of the piriformis muscle. The point of infiltration of the piriformis muscle is found as follows. The greater trochanter of the femur, the superior posterior spine of the ilium and the ischial tuberosity are marked. These points are connected and a bisector is drawn from the superior posterior spine to the base of this triangle. The required point is located on the border of the lower and middle parts of this bisector. A needle is inserted here vertically to a depth of 6–8 cm and the muscle is infiltrated with a solution of an antiseptic and a steroid.

Then a massage will be performed with post-isometric relaxation of the muscles that rotate the thigh outward.

Gymnastic exercises that are recommended to relax the piriformis muscle and activate its antagonists can be performed in the following order. In the supine position with half-bent legs, the soles resting on the couch, the patient makes smooth movements of connecting and spreading the knees. Then, connecting the bent legs, the patient energetically pushes the other with one knee for 3-5 s. The next exercise, the “cradle,” is performed, if possible, without the help of hands while actively flexing the hips. Then, in a sitting position, they spread their soles wide apart, connect their knees and, leaning on the couch with the palm of their outstretched hand, begin to get up from the couch. By the time the palm comes off the couch, the other hand is offered to the instructor, who helps complete the straightening of the body. At this point, the connected knees are freely separated. When the condition improves, during the regression stage and during the period of remission, it is recommended to sit often (but not for long) in the cross-legged position.