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100 m a s s a g e & b o d y w o r k s e p t e m b e r / o c t o b e r 2 0 1 6 PATHOPHYSIOLOGY AND ETIOLOGY The piriformis muscle is primarily a lateral rotator of the hip. However, due to its attachment site, its action can change depending on the position of the hip. This also means the position to stretch the muscle taut can change along with hip position. When the hip is in a neutral position, the piriformis is a lateral rotator of the hip. However, once the hip fl exes past about 60 degrees, it becomes primarily a hip abductor (from the fl exed position) and can also contribute to internal rotation, thereby reversing its original action (Image 4). Based on these biomechanical factors, the piriformis is going to be stretched signifi cantly when the hip is fl exed or the person is sitting cross-legged. That is one reason piriformis syndrome occurs for people who sit for long periods. Repeated loading of the piriformis in various activities has also been implicated as a cause for the condition. The piriformis can get stressed from repeated loads applied across the sacroiliac and hip joints, such as those that occur from running. In a situation like this, the nerve compression may result more from chronic overuse of the muscle as opposed to other situations where external compression also plays a factor. Myofascial trigger points are also commonly present along with the nerve compression. One researcher noted that myofascial pain in the buttock region was present in 97 percent of the cases of piriformis syndrome they evaluated. 4 Most often, nerve pain is felt in the region of skin where the affected nerves supply cutaneous innervation. The nerves that are compressed in piriformis syndrome supply the posterior thigh and distal aspects of the lower extremity, but not the gluteal region specifi cally. There are very small nerve fi bers called nervi nervorum that innervate the nerves and actually give sensory supply to the nerve fi bers themselves. So, these are the "nerves of the nerves." It is likely that at least some of the pain in the gluteal region felt from nerves that supply the distal lower extremity may be from the nervi nervorum. ASSESSMENT A detailed history and physical examination can help pinpoint which of the different nerves may be most involved in the condition. Keep in mind that you could have more than one nerve being compressed at the same time, but following are the key signs and symptoms to look for. Superior Gluteal Nerve Characteristic nerve symptoms of pain, paresthesia, or numbness will be mostly absent. Instead, look for weakness in the hip abductor muscles (gluteus medius and minimus), as these are the muscles innervated by the superior gluteal orthopedic massage Whitney Lowe's In-Depth Online Training Work directly with Whitney Lowe Progressive, superior, & e ective education Improve your learning outcomes & retention Engaged, interactive, & dynamic learning activities Full, continued access to extensive video library Academy of clinical massage www.academyofclinicalmassage.com 541-719-8414 "...it is a pleasure to nd such depth, quality, & detail." "...one of the very best teachers I've had." Dive into training that takes you to new depths of learning! Atlanta, GA: Sept 24-25 Hackensack, NJ: Oct 22-23 Workshops: Limited Seating, Sign up Soon! Training excellence in science-based massage.