Lower Crossed Syndrome
Lower Crossed Syndrome is a common muscular imbalance syndrome seen in chiropractic, which is often caused by poor posture, prolonged sitting and a lack of core stability for the spine.
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Piriformis Syndrome and Chiropractic Treatment
The piriformis muscle is located deep in the buttock. It reaches from the pelvis (sacrum) to the upper part of the thigh-bone (femur). There are times when this muscle goes into spasm. The cause is often relating to the spine or sacroiliac joints, or from overuse.
This can be a very painful condition and for some people is very disabling. Fortunately, for the majority, chiropractic treatment is very effective. An accurate diagnosis is always the key to successful treatment.
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What is piriformis syndrome?
The piriformis’ origin is on the pelvic surface of the sacrum and the sacrotuberous ligament, it extends through the greater sciatic foramen to its insertion point on the upper end of the greater trochanter.
When the muscle contracts it rotates the thigh outwards (external rotation). As with all muscles sitting close to a joint, its main function is to provide stability for the thigh and hip through a static or isometric contraction. It works in conjunction with several other muscles in the buttock area such as the Quadratus femoris, Obturator internus, Superior- and Inferior gemellus. It is almost impossible to isolate in muscle testing because of it, but it is easy to find and palpate if you know how.
In the majority the sciatic nerve passes immediately below the piriformis muscle, but in a small proportion of people (approximately 15% of the population) part of the sciatic nerve goes through the piriformis muscle. If the muscle is in spasm this can cause neurological symptoms such as pain, numbness, pins and needles, tingling and weakness due to compression of the nerve.
This is called piriformis syndrome. It is also important to know that the referred pain pattern from the piriformis muscle itself is felt down the leg in a path along the sciatic nerve. It is therefore often mistaken for a piriformis syndrome when it is not. Quite often it is not even considered as a diagnosis when somebody has sciatica or leg pain. And the cause of sciatica is often thought to be due to a disc injury. It is, of course, imperative to have an accurate diagnosis to give the right treatment.
So, sciatica can have many causes and it has been shown in many studies that disc herniations can be non-symptomatic. This is where it is easy to get into a muddle. Imagine if a disc herniation is visible on a MRI scan and the piriformis syndrome and referred pain has not been considered as a diagnosis. You have surgery for the disc and low and behold there is no improvement after surgery.
What are the symptoms of Piriformis syndrome?
According to some the piriformis syndrome can cause pain in the lower back, groin, perineum, buttock and hip, and can also cause dyspareunia (painful intercourse) and pain in the rectum during defecation. But the most common symptoms are pain in the lower back and/or pain that radiates to the buttocks and down the leg.
Often when people talk about the piriformis syndrome they mistake the referred pain from the muscle to be a piriformis syndrome. The difference is that the true piriformis syndrome has neurological symptoms associated with it, such as pain, numbness, pins and needles, tingling and weakness.
The Chiropractic examination
The chiropractic approach to diagnosing this syndrome includes a full evaluation of your spine and pelvis and the related musculature. A functional, orthopaedic and neurological examination is also performed. Dysfunction in the sacroiliac joints is one contributory factor, which can lead to neuromuscular dysfunction causing weakness in the other muscles in the area. Several activities are said to aggravate the pain in a piriformis syndrome such as walking, sitting, climbing stairs, performing squats and running, but they are so general and therefore unreliable for diagnostic purposes.
A possible sign of a tight piriformis muscle is having one foot pointing outwards more than the other when you lie relaxed on your back. Direct palpation (touch) of the muscle reveals a taut and tender muscle, often with trigger points present causing referred pain locally or down the leg. Either resisted external rotation or passive internal rotation of the hip may increase the pain. Resisted muscle testing can be used to see if a tendinitis is present. But since the piriformis works in conjunction with several other muscles in the buttock area such as the Quadratus femoris, Obturator internus, Superior- and Inferior gemellus, it is difficult to be specific.
If there are neurological signs and symptoms present several tests are performed to rule out a disc injury. Some of these tests are modified to find out if the sciatic nerve is being affected and irritated by the taut piriformis muscle, such as Bonnet’s test. The diagnosis is quite straight forward and there is no need for imaging such as x-ray, CT- or MRI in most cases. The diagnosis is made from the clinical tests. When neurological symptoms are present the chiropractor will do a full neurological examination in order to identify the cause of the symptoms. Disc herniations are the most common cause, but sometimes, although rarely, more sinister causes have to be excluded. In those cases a MRI scan is requested. Once a specific and accurate diagnosis has been made the treatment can start.
Chiropractic treatment of Piriformis syndrome
As with all orthopaedic problems rest and exercise modification is important to ensure a quick recovery. The chiropractic treatment is aimed at restoring the function of the pelvic and spinal joints, which is often the cause. A pronated foot (fallen arch) may cause rotation of the leg, which can put extra strain on the muscle, this is also addressed through foot orthotics and specific exercises for the feet. This is followed by trigger point therapy, massage, stretching and strengthening exercises. Acupuncture needles are sometimes used for the trigger points, but there is no need to inject corticosteroids or any other substance. Postural and ergonomic advice is given and you will be given core muscle exercises to help to prevent future problems.
Inactive and weak gluteal muscles can also be a predisposing factor of the syndrome. The Gluteus maximus is important in both hip extension and in aiding the piriformis in external rotation of the thigh. A major cause for an inactive Gluteus maximus is unwanted reciprocal inhibition from overactive hip flexors (psoas major, iliacus, and rectus femoris).
What is the prognosis?
The prognosis for piriformis syndrome is normally good. Once the underlying problems and symptoms have been addressed, you can usually resume your normal activities. In some cases, exercise routines may need to be modified in order to reduce the likelihood of recurrence or worsening.
What should you do? These are all risk factors for developing recurring and chronic back pain:
- Poor fitness levels and spinal stability (core muscle strength)
- Poor posture
- Previous episodes of back pain
- Pain for more than 8 days
So, the longer you have put up with the pain the more likely you are to become a chronic and recurrent sufferer. The general recommendation is to make sure you get the problem diagnosed properly, have a chiropractor evaluate your core stability, have treatment if necessary and do the right type of exercise to help your problem.