The Piriformis Muscle Syndrome: An Exploration Of .
Available online atwww.sciencedirect.comAnnals of Physical and Rehabilitation Medicine 56 (2013) 300–311Update article / Mise au pointThe piriformis muscle syndrome: An exploration of anatomical context,pathophysiological hypotheses and diagnostic criteriaMise au point sur le syndrome du muscle piriforme : contexte anatomique, hypothèsesphysiopathologiques et critères diagnostiquesF. Michel a,*,b, P. Decavel b, E. Toussirot c,d, L. Tatu a,e, E. Aleton b, G. Monnier a,e,P. Garbuio f, B. Parratte b,eaDepartment of Neuromuscular Examinations and Diseases, CHRU, hôpital Jean-Minjoz, 25000 Besançon, FrancebPhysical Medicine and Rehabilitation Department, CHRU, hôpital Jean-Minjoz, 25000 Besançon, FrancecClinical Investigation, Biotherapy Department CBT-506 & Rheumatology, CHRU, Besançon, FrancedUniversity Department of Therapy and Reception Team 4266 ‘‘Pathogenic Agents and Inflammation’’, IFR133, université de Franche-Comté, Besançon, FranceeAnatomy Laboratory, université de Franche-Comté, Besançon, FrancefDepartment of Orthopedic and Traumatology Surgery, Plastic and Reconstruction Surgery, CHRU, hôpital Jean-Minjoz, 25000 Besançon, FranceReceived 21 November 2011; accepted 27 March 2013AbstractIntroduction. – The piriformis muscle syndrome (PMS) has remained an ill-defined entity. It is a form of entrapment neuropathy involvingcompression of the sciatic nerve by the piriformis muscle. Bearing this in mind, a medical examination is likely to be suggestive, as a classicalrange of symptoms corresponds to truncal sciatica with frequently fluctuating pain, initially in the muscles of the buttocks.Pathophysiological hypotheses. – The piriformis muscle is biarticular, constituting a bridge in front of and below the sacroiliac joint and behindand above the coxo-femoral joint. It is essentially a lateral rotator but also a hip extensor, and assumes a secondary role as an abductor. Its action isnonetheless conditioned by the position of the homolateral coxo-femoral joint, and it can also function as a hip medial rotator, with the hip beingflexed at more than 908. The main clinical manoeuvres are derived from these types of biomechanical considerations. For instance, as it is close tothe hip extensors, the piriformis muscle is tested in medial rotation stretching, in resisted contraction in lateral rotation. On the other hand, when hipflexion surpasses 908, the piriformis muscle is stretched in lateral rotation, and we have consequently laid emphasis on the manoeuvre we havetermed Heel Contra-Lateral Knee (HCLK), which must be prolonged several tens of seconds in order to successfully reproduce the buttockscentred and frequently associated sciatic symptoms.Conclusion. – A PMS diagnosis is exclusively clinical, and the only objective of paraclinical evaluation is to eliminate differential diagnoses. Theentity under discussion is real, and we favour the FAIR, HCLK and Freiberg stretching manoeuvres and Beatty’s resisted contraction manoeuvre.# 2013 Published by Elsevier Masson SAS.Keywords: Piriformis muscle syndrome (PMS); Sciatic nerve; Clinical assessmentRésuméIntroduction. – Le syndrome du muscle piriforme (SMP) est une entité encore mal définie. Il s’agirait d’un syndrome canalaire par compression dunerf ischiatique par le muscle piriforme. Dans ce cadre, l’interrogatoire est évocateur, la symptomatologie clinique correspondant à une sciatalgietronculaire souvent fluctuante à début fessier.Hypothèses physiopathologiques. – Ce muscle piriforme est bi-articulaire, passant en pont en avant et en dessous de l’articulation sacro-iliaque eten arrière et au-dessus de l’articulation coxo-fémorale. Il est essentiellement rotateur latéral mais aussi extenseur de hanche et participeaccessoirement à son abduction. Pour autant son action est conditionnée par la position de l’articulation coxo-fémorale homolatérale. En effet, ildeviendrait rotateur médial de hanche, cette dernière étant fléchie au-delà de 908. De ces considérations biomécaniques découlent les principales* Corresponding author.E-mail address: fmichel@chu-besancon.fr (F. Michel).1877-0657/ – see front matter # 2013 Published by Elsevier Masson SAS.http://dx.doi.org/10.1016/j.rehab.2013.03.006
F. Michel et al. / Annals of Physical and Rehabilitation Medicine 56 (2013) 300–311301manœuvres cliniques. En effet, hanche proche de l’extension, il est testé en étirement en rotation médiale, en contraction contrariée en rotationlatérale. En revanche, au-delà de 908 de flexion de hanche, le muscle piriforme est étiré en rotation latérale, et ainsi nous mettons en avant laréalisation d’une manœuvre que nous avons appelé Talon Genou-Contro-Latéral (TG-CL), qu’il faut prolonger plusieurs dizaines de secondes pourreproduire la symptomatologie fessière et souvent sciatique associée.Conclusion. – Le diagnostic de SMP est clinique, le bilan paraclinique n’ayant pour but que d’éliminer un diagnostic différentiel. Son entité estréelle et nous privilégions les manœuvres d’étirement FAIR, TG-CL et de Freiberg, ainsi que la manœuvre de contraction résistée de Beatty.# 2013 Publié par Elsevier Masson SAS.Mots clés : Syndrome du muscle piriforme ; Nerf ischiatique ; Évaluation clinique1. English version1.3. Anatomy1.1. IntroductionThe piriformis muscle is actually a muscle pair possessing atriangular muscle of which the base is inserted on each side ofthe ventral surface of the sacrum at the edges of the 2nd and 3rdsacral foramens.The piriformis muscle exits the pelvic cavity by slidingunder the greater sciatic notch of the coxal bone, above thesacral spinal ligament. It then runs diagonally downwardsthrough the gluteal region and culminates on the upper side ofthe greater trochanter of the femur (Fig. 1). In the gluteal region,it is located under the gluteus maximus and above the internalobturator muscle ending, which is accompanied by the gemellimuscles. So it is that the piriformis muscle delimits the twozones of musculoligamentous passages known as the suprapiriformic and infra-piriformis foramens. The superior glutealnerves and vessels traverse the supra-piriformis foramen. Alongwith the inferior gluteal and pudendal nerves, the sciatic nervepasses through the infra-piriformis canal.With regard to the traversing of the infra-piriformis foramenby the sciatic nerve, anatomical variations exist, and theyThe piriformis muscle syndrome (PMS) is defined as anentrapment neuropathy involving compression of the sciaticnerve by the piriformis muscle and entailing a number ofsymptoms with truncal sciatic pain, initially in the muscles ofthe buttocks.An initial description was given by Yeoman in 1928 [54]. In1934, Freiberg recognized the signs specific to this syndrome[22], but it was only in 1947 that Robinson called this clinicalentity the ‘‘piriformis’’, or pyramidal syndrome [44].The clinical and paraclinical elements reported in differentdescriptions of the syndrome have at times been discrepant andcalled its reality into question [1,6,10,13,16,26,33,38,47,51]. Itnonetheless remains one of the rare causes of non-spinalsciatica consecutive to undeniable entrapment neuropathywhen the sciatic nerve crosses through the infra-piriformiscanal [7,17,19,29,32].The etiologies suggested in considerations of sciatic nervecompression are diversified: inflammatory, traumatic, tumoraland malformative [4,8,28,42]. In most cases, however, thecompression is originally muscular, and the piriformis muscleis suspected [11,12,31,43,45,46,53].In this work, we have focused upon the PMS originating inthe muscles.Our objective is, on the basis of anatomical descriptions ofthe piriformis muscle, to provide support for pathophysiological hypotheses and to subsequently discuss the clinical testsmost pertinent to diagnosis.1.2. MethodBased on the anatomical descriptions of the piriformismuscle, dissections were performed in the anatomy laboratoryon embalmed adult human cadavers. Dissection was carried outclassically, segment by segment, so as to highlight the relationsof the external pelvic portion of the piriformis muscle in theexternal iliac fossa. The different pathophysiological hypotheses were drawn from a review of the existing literature on thesyndrome, with biomechanical and functional referencesincluded.The clinical tests were discussed subsequent to review of theliterature and of our personal experience, and were premised onmuscle biomechanics.Fig. 1. Posterior view of the right gluteal region. SN: sciatic nerve, P: piriformismuscle, GM: gluteus medius muscle; GMax: gluteus maximus muscle; OI:internal oblique muscle; QF: quadratus femoris muscle; GT: greater trochanter;STL: sacrotuberous ligament.
302F. Michel et al. / Annals of Physical and Rehabilitation Medicine 56 (2013) 300–311specifically involve the traversing of the muscle by the tibial orperoneous contingent of the sciatic nerve (11.7%). The tibialcontingent can also run above the piriformis muscle, in thesupra-piriformic canal, while the common fibular nerve runsthrough the infra-piriformic canal (3.3%). Less frequently, thesciatic nerve taken as a whole can go so far as to span thepiriformis muscle (0.8%) (Fig. 2) [30,50]. These anatomicalconfigurations are neither clinically recognizable nor easilyidentifiable through imagery, yet they are suggested in the eventof possible PMS [2,23,40].The piriformis muscle is essentially a lateral hip rotator, but itis also an extensor. It may take on a secondary role as an abductorwhen its point of support on the sacrum is proximal [15].1.4. Pathophysiological hypothesesAnatomical acquaintance with the piriformis muscle and itsrelationships of proximity facilitates comprehension of thepathophysiology of sciatic nerve compression in the PMS. Cana morphological alteration (contracture, hypertrophy) lead tocompression of the sciatic nerve? Can the relationships of thedifferent anatomical structures modified by biomechanicalconstraints shrink the supra-piriformis and infra-piriformispassageways?Even when not taking into account any possible morphological modifications of the piriformis muscle body, itscomplex proximal insertion appears likely to create zones ofconflict. On this subject, Paturet has described two types ofinsertion of the muscle on the ventral or pelvic surface of thesacrum [39]. The first and principal type is composed ofaponeurotic fascia entwined with the fleshy fibres at theproximal extremity of the muscle. The ventral branches of the2nd and 3rd sacral spinal nerves emerge from their sacralforamen by passing through the muscle, thereby endowing itwith a bundled or fasciculated aspect, and then positioningthemselves on the ventral surface of the muscle body, againstwhich they are pressed by its fascia covering.The second and secondary type of insertion is less widelyextended, originating at the upper edge of the greater sciaticnotch in front of the sacroiliac joint space and the lateral side ofthe piriformis muscle tuber (Morestin’s tuber) belonging to thebony ridge. At this level, there also exist aponeurotic insertionson the lateral side of the sacrotuberous ligament at the locationwhere the piriformis muscle exits the greater sciatic notch.According to their development, the insertions may also limit insize the infra- and supra-piriformis foramens.The distal femoral insertions of the piriformis muscle alsoconstitute the locus of tendinous expansion toward the differentstructures located at the posterior superior edge of the greatertrochanter. In that way, the ending of the internal obturator muscleand the gemelli muscles is closely connected with the ending ofthe piriformis muscle by means of solid layers of fibrous material.The terminal tendon of the gluteus medius muscle likewise mixesits fibres with the terminal tendons of the preceding muscles.This mixture of fibres explains the involvement of thepiriformis muscle in the complex movements of the hip.
– The piriformis muscle syndrome (PMS) has remained an ill-defined entity. It is a form of entrapment neuropathy involving compression of the sciatic nerve by the piriformis muscle. Bearing this in mind, a medical exa
syndrome were considered to have probable piriformis syndrome and were referred for open MR imaging–guid-ed piriformis muscle injection. Real-time open MR imag-ing ensured that all injections were delivered into the pir-iformis muscle and that any leakage of injectate from the piriformis
discrepancy, piriformis myofascial pain syndrome, following vaginal delivery, and anomalous piriformis muscle or sciatic nerve. In this paper, we describe piriformis and bromyalgia syndrome in a -year-old young lady, an o en missed diagnosis. We also focus o
confirmed as the initial treatment for piriformis syndrome is conservative. Surgical release of the sciatic nerve and sectioning of the accessory belly of the piriformis muscle may be considered in refractory cases (2). In conclusion, an accessory belly of the piriformis muscle is a rare but im
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