Management of Post-Traumatic Piriformis Syndrome: Case Study

Man epochment of Post-Traumatic Piriformis Syndrome Case cogitationDiagnosis and Chiropractic Management of Post-Traumatic Piriformis Syndrome A Case StudyChief complaintA 37-year-old male longanimous presented himself at a local chiropractic clinic with a promontory complaint of persistent low hazard off pain that was radiating into his left over(p) buttock, all along the posterolateral looking at of his left thigh and calf, and to the lateral aspect of the foot.History of the affected role illnessThe pain initiated 2 historic period ago. The unhurried reported a blunt trauma of his left buttock in a bicycle accident 8 months sooner his symptoms were first noticed. The patient was presented with low back pain, radiating from sacrum and gluteal vicinity to the lateral aspect of the foot, all along the posterolateral aspect of his left thigh and calf. The pain was occasionally accomp whatever by p besthaesia and burning sensation. When asked to rate his pain with a numeri c rating scale (NRS), he celebrated his low back pain to be 3/10 at best and 7/10 at worst.Prolonged sitting and car driving modify his symptoms. And standing up and move a few steps for a moment would make the pain partially sticking out(p). The patient also historied that prolonged remote rotation of the affected hip (sitting posture) made the symptoms more intense. He avoided sitting in a cross-leg posture due to the pain.The patient had a transient relief of his pain after word of physi differentapy. However, the pain came back after a few days.Other than the traumatic fall on his left hip in a motorcycle accident, the patients medical history was not remarkable. comparative family history, social and environment historyBoth of the patients p atomic number 18nts were diagnosed with dish aerial herniation of the lumbar toughie in their 50s.The patient went to gym 4 times per week, doing cardiovascular and weight bearing training. And he employ to play soccer once a week. However he had to stop playing since his low back pain and leg pain started to bother him.The patient was an attorney and his job required him to sit in front of his desk for more than 6 hours per day. He reported that he had to stand up and walk a few steps in the office every 30 minutes due to the pain.Relevant medicationsThe patients symptoms were partially relieved by taking Panadols. He was not taking both other prescribed or non-prescribed medications.List of executable diagnoses from the patient historyLumbar disk herniationThe patient was presented with symptoms and signs of radiculopathy including sensation kerfuffle of the dishonor limb, pain shooting to the foot, and pain worsened by sitting and relieved by walking. According to the dermatome, the nerve roots of L5, S1 or S2 were possibly affected.Considering that both of the patients pargonnts are diagnosed with lumbar disc herniation, it should be on top of the derivative instrument coefficient diagnosis list, fo r recent studies have suggested that lumbar disc herniation may be attributed more to genetic factors than to environmental and constitutional risk factors. The patients occupation which kept him sitting for a prolonged time increases the chance of lumbar disc herniation.The history of blunt trauma could also be a factor of developing lumbar disc herniation.Sciatic nerve irritation of other originsThe patients altered sensation on the humble utmost is in the distribution of sciatic nerve. Sciatica should be taken into consideration. However, the underlying cause of compression or irritation of sciatic nerve should be revealed with further examination and investigation.Piriformis syndromePiriformis syndrome is an uncommon form of sciatica in which the sciatic nerve is compressed and irritated by piriformis sinew-builderbuilder. It usually occurs in people who are middle-aged (mean age 38 years old).Robinson described 5 significant manifestations of piriformis syndrome in 1947, including (1) history of trauma in the gluteal region (2) pain in the sciatic nerve distribution (3) symptoms relieved by traction and aggravated by sitting or stooping (4) palpable love or mass over piriformis muscle (5) positive keen leg raise ladder.This patient was presented with the first 3 features of piriformis syndrome, whereas the 4th and 5th submit further examination.Sacroiliac word syndromeSacroiliac adjunction syndrome is the dysfunction of sacroiliac join that is attributed to either hypermobility or hypomobility, causing low back pain, buttock pain and sciatic lower limb pain. Lower abdomen, groin and medial thigh are occasionally affected as well. The symptoms of sacroiliac joint syndrome and sciatica are often similar.Hamstring syndromeAnother contingent differential diagnosis is dun syndrome. Hamstring syndrome is caused by entrapment of the proximal sciatic nerve by the hamstring tendons (1). It usually occurs associated with trauma such as hamstring tear s or strain (2). However, in many cases, not significant history of trauma is noted (1, 2).Patients with hamstring syndrome present with lower gluteal pain and shine down to posterior thigh and knee (2). The symptoms are similar to sciatica of other origins.Results of the neurological examsObservation, passive tactual exploration and range of motionObservation and static palpation are performed to look for any degree of antalgic posturing, any deviation from a normal spinal curve, pelvic position, and muscle spasm or bulks. Characteristic findings of each differential diagnosis are listed below.Lumbar disc herniation thinkable hyper-lordosis of lumbar spine in an antalgic postureSignificant falloff in lumbar supple and passive range of motion, oddly in lumbar flexion and unilateral lateral flexionPossible limited hip range of active motion due to muscle weaknessPossible palpable restricted lumbar vertebral segmentshypertonic or tender lumbar muscles on static palpation, especi ally erector spinae (ES) musclesPiriformis syndromePossible limping or walking with the assistance with crutches due to pain and lower extremity muscle weaknessPossible hip external rotation on the affected side due to excessive piriformis muscle contraction, which is also known as piriformis sign (3)Significant decrease in hip active and passive range of motion, especially in hip internal rotation and adductionIpsilateral short leg (3) mettle at the sciatic passing game on palpationPossible hypertonic gluteal muscles (3)SciaticaFindings depend on the causes of sciatica such as lumbar disc herniation, piriformis syndrome and hamstring syndrome.Sacroiliac syndromeThe posterior superior iliac spines (PSIS) on both sides are not at the same horizontal levelPossible redness and swelling at the affected sacroiliac jointPossible leg length discrepancySignificant decrease in sacroiliac joint mobilityPossible local tenderness on static palpationHamstring syndromeThe pain is more localized, but possibly radiatingTenderness of hamstring tendons or over ischial tuberosity on static in palpationSignificant decrease in hip active range of motion, especially in hip extensionOn observation, static palpation and range of motion assessment, the patient was noticed forPositive piriformis sign (hip external rotation) on the ipsilateral (left) sideA relatively shorter left leg compared with the right legTenderness over contralateral (right) sacroiliac jointA palpable sausage-shaped mass in the ipsilateral (left) gluteal region (3)hypertonic left hamstringsTenderness over left sciatic notch on static palpation particular(a) hip active and passive range of motion, especially internal rotationDecrease in sacroiliac joint mobilityOther findings were not remarkable. The moments of the assessment suggested that piriformis syndrome and sacroiliac syndrome were most possible diagnoses.Coordination and footstep analysisCoordination and gait should be examined before other assessments a re done, for this test provides us a big picture of the patients lower extremity function including motor function, joint rightfulness and coordination. Any gait dysfunction or antalgic gait should be recognized and further tests should be performed to look for the causes.No abnormal movement or disturbance of the patients gait was observed. He also reported a partial relief of symptoms when he was walking. The insignificant findings made lumbar disc herniation less likely, however, there was still a possibility. arresting examSensory exams of peripheral nerves were performed to look for any sensation change on the characteristic lower limb, which would lead to localization of the lesion. Assessments included fine play off, pain, temperature, and proprioception.Decrease in two-point discrimination and light touch was noticed over the lateral aspect of the left leg and foot.Motor examLower extremity muscle strength was tested to identify which nerve roots were affected according to myotomes.On examination, no significant findings were noticed.deep tendon ReflexAbnormal deep tendon reflex may be seen in lesions of muscles, sensory neurons, lower/upper motor neurons, neuromuscular junction and mechanical factors such as joint disease.On examination, the patients Achilles reflexes were normal (+2) on both sides. An abnormal Achilles reflex suggests a tibial nerve lesion (S1-2).Neurodynamic assessmentStraight leg raiseThe test is designed to look for any impingement of the dura and spinal cord or nerve roots of the lower lumbar spine, especially in sciatic nerve (L4, L5, S1).The patients result was negative (70), suggesting less possible lumbar disc herniation.Bonnets testBonnets test is a variant of straight leg raise and used to test for entrapment of sciatic nerve by piriformis muscle.The patients result was positive, indicating possible piriformis syndrome.Bowstring testBowstring test is another variant of straight leg raise and used to test for entrapment of sciatic nerve by hamstrings.The patients result was negative, suggesting less possible hamstring syndrome. orthopedical examinationsValsalva maneuverValsalva maneuver was done to look for any disc herniation causing radiculopathy. This would increase intrathecal thrust which may reproduce the patients symptoms.The patients result was negative, indicating less possible lumbar disc herniation.Lumbar compression-distraction testThis test is also designed to look for disc herniation. When the compressive force is applied, it increases the intrathecal ram and replicates symptoms if the patient has disc herniation. And the symptoms are relieved by distraction.The patients result was negative, suggesting it was less likely to be disc herniation.Gaenslens testGaenslens test is to assess sacroiliac joint involvement.The patients result is negative.Yeomans testYeomans test is designed to assess the integrity of the sacroiliac joint.The patients result is negative.Squat testSquat test is designed for quick concealment of lower limb pathologies including joint disease, motor and sensory neuron lesions.The patients result was positive. back up belt testSupported belt test assistants to determine whether the pain is of lumbar origin or pelvic origin.The patient was noticed for having pain only without supported belt, suggesting his symptoms were caused by pelvic dysfunction.List of possible diagnoses from the neurological examPiriformis syndromeSacroiliac syndromeFurther blood and radiological testsAt this stage, no further imaging or other tests are needed, for the diagnosis can be made based on the patients history and results of neurological and orthopaedic examinations.It is recommended that the patient should be treated for piriformis syndrome at the start. A conservative word plan should be designed to reduce pain intensity, stretch hypertonic muscles and increase lumbar and sacroiliac joint mobility.However, if the patient does not respond to the intercessio n or the symptoms are worsened after the treatment, further investigations should be done. Considering a large extent of soft tissue and nerve involvement, magnetic resonance imaging (MRI) would be the most effective imaging method. A lumbopelvic view should be taken. This does not only demonstrate possible hypertrophied piriformis muscle and sciatic nerve entrapment, but also helps to rule out other differential diagnoses such as lumbar disc herniation. Nevertheless, many studies failed to show consistence of radiographic abnormalities in piriformis syndrome. Therefore, no significant findings on MRI do not necessarily exclude piriformis syndrome.CT and ultrasound are also used to look for abnormality of piriformis muscle, but they are not as sensitive as MRI. EMG is an investigation to assess abnormal spontaneous activity of muscles which are innervated by sciatic nerve, indeed differentiating sciatica and lumbosacral radiculopathy however, EMG findings are often normal in pirifo rmis syndrome.Local injection of anaesthetics or steroid hormone can be applied for both diagnostic and therapeutic purposes (4). This technique is widely used after initial evaluation. However, the specificity and efficacy is not well determined by clinical trials (4). A certain hazard of patients with piriformis syndrome do not respond to piriformis muscle injection (5).Final diagnosisBased on the patients history, the results of neurologic and orthopaedic examinations, and likely radiographic findings, piriformis syndrome is the most likely diagnosis.Chiropractic managementConservative treatment is recommended at this stage, for 79% of patients with piriformis syndrome showed a significant utility with use of non-steroid anti-inflammatory drugs (NSAIDs), muscle relaxants, thermo-therapy and rest (fishman, osteopathic approach). The steer of the chiropractic treatment is to reduce the intensity of pain, relax piriformis muscle, increase the range of motion of the hip joint, an d increase mobility of lumbar and sacroiliac joint.The tone and length of the left piriformis muscle and other affected muscles (hamstrings, other lateral rotators, gluteus muscles) should be assessed with chiropractic muscle test and static palpation. Any trigger point, tenderness, hypertonia are noted. Stretching exercise and muscle release are introduced first to help the patient relax the hypertonic piriformis muscle. The patient needs to fool the muscle release training daily for 2 weeks until the muscle tone is assessed again and any improvement of his symptoms is seen. Stretching of other affected hypertonic muscles is also required.The mobility of the patients lumbar spine and sacroiliac joint should be assessed with orthopaedic examinations and chiropractic motion palpation. Any restricted segment is adjusted with high-velocity low-amplitude (HVLA) spinal manipulation. Chiropractic adjustments help to relieve pain, increase joint mobility and re-establish biomechanical sta bility of the body.References1.Saikku K. Entrapment of the proximal sciatic nerve by the hamstring tendons. Acta orthopaedica belgica. 2010 0676(3)321-4.2.Puranen J. The hamstring syndrome. A new diagnosis of gluteal sciatic pain. The American journal of sports medicine. 198816(5)517-21.3.Boyajian-ONeill LA. Diagnosis and management of piriformis syndrome an osteopathic approach. The diary of the American Osteopathic Association. 2008 11108(11)657-64.4.Jankovic D. Brief review Piriformis syndrome etiology, diagnosis, and management Article de synthse court Le syndrome du muscle piriforme tiologie, diagnostic et prise en charge. Canadian journal of anesthesia. 2013 1060(10)1003-12.5.Martin HD, Martin H. Diagnostic accuracy of clinical tests for sciatic nerve entrapment in the gluteal region. Knee surgery, sports traumatology, arthroscopy official journal of the ESSKA. 2014 0422(4)882-8.