Massage & Bodywork

SEPTEMBER | OCTOBER 2016

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Six variations of sciatic nerve pathway in relation to the piriformis. Image derived from 3D4Medical's Essential Anatomy 5 application. Actions of the piriformis change after significant hip flexion. nerve. Atrophy may be apparent in this muscle, but sometimes weakness will be more obvious by comparing a test of resisted hip abduction on the affected side with that of the unaffected side. Sciatic Nerve Gluteal pain is likely, but more frequently there will be shooting or radiating electrical-type pain that will extend down the lower extremity, possibly all the way to the foot. Motor weakness is not as common with the sciatic nerve compression, but can occur. Posterior Femoral Cutaneous Nerve This is a sensory nerve supplying the posterior thigh, not extending below the knee. Pain, burning, numbness, or paresthesia will be limited to the posterior thigh region when this nerve is compressed. Inferior Gluteal Nerve This nerve is predominantly a motor nerve for the gluteus maximus, so weakness or atrophy of the gluteus maximus is more common than sensory sensations. It is possible that some weakness in resisted hip extension will be evident compared to the unaffected side. Pudendal Nerve This is a mixed motor and sensory nerve, so its compression produces neurological- type pain sensations felt in the perineal region, anus, or genitalia, as these are all areas supplied by the pudendal nerve. It also supplies muscles of the pelvic floor, so there may also be reports of bowel, bladder, or sexual dysfunction associated with the pelvic floor muscle dysfunction. In addition to piriformis tightness from overuse or mechanical stress, some cases are caused by other factors. Other causes include blunt trauma to the area that can cause hematomas or myositis ossificans (calcification within the muscle). The hematoma or calcified tissue then presses on the affected nerve. Sacroiliac joint dysfunction can also be associated with the condition, as it may cause tightness or trigger points in the piriformis due to biomechanical overload. Vascular compression in this region may also play a part in nerve symptoms. There are arterial structures running immediately adjacent to the nerves, and pressure on those can compromise blood flow to the nerves. Neural ischemia (lack of blood flow to the nerves) results in, and is a known cause of, neurological symptoms such as pain, burning, or paresthesia sensations. It is clear that piriformis syndrome is much more involved than simple compression on the sciatic nerve in one location. One of the key factors that makes this condition so controversial in the rehabilitation literature is that there is no gold standard for identifying it. There are some key indicators presented in this article that can be found in the client history and initial physical examination. In a future installment, we'll look at some more effective strategies for assessing and treating piriformis syndrome. Notes 1. L. M. Fishman, C. Anderson, and B. Rosner, "BOTOX and Physical Therapy in the Treatment of Piriformis Syndrome," American Journal of Physical Medicine & Rehabilitation 81, no. 12 (2002): 936–42; D. Jankovic, P. Peng, and A. van Zundert, "Brief Review: Piriformis Syndrome: Etiology, Diagnosis, and Management," Canadian Journal of Anesthesia 60, no. 10 (2013): 1,003–12. doi:10.1007/s12630-013-0009-5. 2. K. Hopayian et al., "The Clinical Features of the Piriformis Syndrome: A Systematic Review," European Spine Journal 19, no. 12 (2010): 2,095–2,109. doi:10.1007/s00586-010-1504-9. 3. F. Michel et al., "The Piriformis Muscle Syndrome: An Exploration of Anatomical Context, Pathophysiological Hypotheses and Diagnostic Criteria," Annals of Physical and Rehabilitation Medicine 56, no. 4 (2013): 300–11. doi:10.1016/j.rehab.2013.03.006. 4. D. Jankovic, P. Peng, and A. van Zundert, "Brief Review: Piriformis Syndrome: Etiology, Diagnosis, and Management." Whitney Lowe is the developer and instructor of one of the profession's most popular orthopedic massage training programs. His texts and programs have been used by professionals and schools for almost 30 years. Learn more at www.academyofclinicalmassage.com. 3 4

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