Is sciatica a frequent complaint in your practice? Did you know that the piriformis muscle, when inflamed, releases a biochemical agent that irritates the sciatic nerve? Find out how the Activator Adjusting Technique can help you bring relief to these patients.
One of the more common complaints in any chiropractic office is that of buttock and/or posterior thigh pain, generally referred to as sciatica. Once a radicular origin has been ruled out, the diagnosis of piriformis syndrome is considered. The piriformis muscle, located deep to the gluteal group, is a major external (lateral) rotator of the thigh. Originating on the anterior aspect of the sacrum and inserting into the greater trochanter of the femur, the piriformis is also a synergist for abduction and extension of the thigh.1 Piriformis muscle contracture can present with a pain deep in the buttock of the affected side. The muscle, especially at the musculotendinous junction near its insertion on the greater trochanter, is frequently tender to palpation.2 It is not uncommon for piriformis syndrome to present with pain and paresthesias in the buttock, hip, posterior thigh and leg to the foot. Prolonged sitting or activity aggravates piriformis syndrome.3 Due to the approximation of the sciatic nerve and the belly of the piriformis, spasm of the piriformis may occur with apparent sciatic neuralgia.4 The piriformis, when inflamed, has also been found to release a biochemical agent that irritates the sciatic nerve, possibly causing sciatic neuritis.5 Consequently, orthopedic tests like the straight leg raise test (LaSègue test) and Braggard test may be positive. However, with piriformis syndrome affecting the sciatic nerve, the Well leg raise test and Fajerstajzn test (contralateral Braggard) will not elicit a pain response.6
With piriformis syndrome, the greater trochanter tends to be pulled posterior, designated in Activator Methods Chiropractic Technique as external hip rotation, and a toe-out foot flare is typically observable in the patient’s walking gait. The prone patient on the adjusting table may also demonstrate pronounced toe-out foot flare. When a patient suffers from symptoms resembling sciatic neuralgia, hypertonicity of the hip extensors and rotators, and point tenderness over the greater trochanter, perform stress tests and adjustments as necessary for external hip rotation. Due to the muscle’s medial attachment on the anterior surface of the sacrum, test for an AI sacrum and adjust as indicated. The piriformis muscle, itself, can be adjusted with the Activator adjusting instrument.
With the patient out of weight-bearing posture, in the prone, extended position, leg length analysis will most likely reveal a functional or an apparent short leg. AMCT protocol would begin with testing and correcting this first. However, an actual LLI may aggravate the piriformis syndrome and should be measured and corrected, if necessary. Once the pelvis is balanced by correcting the functional PI or AS ilium, consider testing and correcting sacral malposition, for example, shortening of the left piriformis producing a left anterior inferior sacrum. With the Activator instrument contacting under the involved sacrotuberous ligament. The line of correction is superior, lateral and posterior.
External rotation of the hip should be considered when the patient demonstrates unilateral “toe-out” foot flare. A normal gait and resting stance will show slight toe-out flare, but it is symmetrical and balanced. If the hip has been in external rotation for an extended time, the patient’s shoes are likely to show excessive and asymmetrical wear on the posterior and lateral aspect of the heel on the side of involvement. Test for external hip rotation and adjust by contacting the posterior aspect of the greater trochanter with the Activator adjusting instrument. The line of drive is anterior and slightly inferior.
When a patient suffers from pain in the SI joint, buttock and/or posterior thigh or sciatica, consider testing the piriformis muscle. To stress test the piriformis, flex the involved side leg and, while stabilizing the medial distal tibia, ask the patient to externally rotate the hip against your resistance. This is the active resisted muscle test. Adjust the piriformis muscle with 3 thrusts. First, contact ½ inch lateral to the sacral border. The line of drive is posterior to anterior. The second contact is ½ inch medial to the greater trochanter; and the last is on the attachment of the piriformis to the greater trochanter. The line of drive is also posterior to anterior for each of these contacts.
After correcting the pelvic imbalance and commonly affected structures, following up with appropriate rehabilitative exercises to stabilize the pelvis and hips, postural and ergonomic corrections as well as corrective care for the rest of the patient’s spine would be vital to the reduction and prevention of symptoms. Activator Methods Chiropractic Technique can help you to determine where, when and when not to adjust, based on its series of isolation and stress tests and leg length analysis protocol.
References
1. Clemente CD. Gray’s Anatomy. Thirtieth American Edition. Philadelphia: Lea & Febiger, 1985.
2. Davis, DGm Manipulation of the Lower Extremity. In Subotnick, SI (ed.) Sports Medicine of the Lower Extremity. London: Churchill-Livingstone, 1989.
3. Travell, J and Simons, D. Myofascial Pain and Dysfunction: The Trigger Point Manual. Williams and Wilkins, 1992.
4. Cox JM. Low Back Pain Mechanism, Diagnosis and Treatment. Fifth edition. Baltimore: Williams & Wilkins, 1990.
5. Steiner C, Staubs C, Ganon M, Buhlinger CD. Piriformis syndrome: pathogenesis, diagnosis, and treatment. J Am Osteopath Assoc 1987; 87:318-22.
6. Fuhr, A et al. Activator Methods Chiropractic Technique. Mosby-Year Book, Inc, 1997.
Dr. Fuhr is the co-founder and president of Activator Methods International. He brings nearly 40 years of chiropractic experience and knowledge to the development of the Activator and the Activator Method. Activator Methods, Intl., is presenting the topic of rehabbing Piriformis Syndrome, along with many other common clinical conditions, during their 2005-06 seminar series. For more information and for a seminar near you, visit www.activator.com.