Piriformis Syndrome differential diagnosis case study
Dr Barry L Marks
Chiropractor, Orange County, CA
This is a case study of a 41 year old female blogger with bilateral buttocks pain who has requested help diagnosing her problem after an unsuccessful course of treatment with her family medical physician. For background see the comments on this post: Piriformis Syndrome…a pain in the butt…
Dear Lisa,
I am sorry to hear of your plight.
The symptoms you describe can certainly be Piriformis Syndrome. There are a few other possibilities as well:
1. Gluteus muscle strain
2. Ischial bursitis
3. Lumbar disc disease
So how to rule them out?
Gluteus muscle strain:
· Clinch your “cheeks,” does it cause pain?
· Lift your knee towards your chest; does stretching your butt cause pain?
· Stand using a table for support or lie on your back, bend your knee at 90 degrees and slowly kick your leg backwards (donkey kick), does that hurt your buttocks?
If these are “yes” then a strain from Nordic trainer is possible.
Piriformis syndrome:
· Are you tender in the center of your buttocks muscles?
· When you put firm pressure into the center of your buttocks does it radiate pain downward or out to the hip area?
· Sit down and lift one thigh up. Reach down and grab your ankle and rotate your foot inwards towards the other leg (externally rotate hip), does this cause buttocks pain?
If these are “yes” then Piriformis syndrome is likely.
Ischial bursitis:
If the center of your buttocks is not unduly tender then try firm pressure on the area of your buttocks where you actually sit. Near the bottom of your buttocks just above the crease where it separates into your thigh you’ll find a bony prominence called the Ischial tuberosity. Firmly probe with your fingers all around that bony point. If it is painful, you may have bursitis.
Lumbar disc disease:
If direct palpation of the buttocks area does not produce pain try the following:
· Bend forward at the waist and try to touch your toes
· Sit and stretch your leg out in front of you
· Cough hard several times
· Lie on your stomach and bend your knee to bring your heel back towards your butt
If these do cause back, buttocks or thigh pain, then you may have a disc bulge or herniation.
Lisa, a competent doctor who specializes in musculoskeletal problems can easily differentiate between these conditions with a physical exam and a look at your x-rays.
Here is my very biased opinion as a Doctor of Chiropractic for over 22 years, a former Associate Clinical Professor at a leading Chiropractic College, a specialist with Post Doctorate Orthopedics training and someone who has worked along side medical physicians in a multidisciplinary Family & Urgent Care practice…
You need a competent chiropractor to evaluate you.
Your family doctor just does not possess the training and knowledge base to help with a musculoskeletal problem like yours. It’s not a knock on medicine; it’s just a fact that they have less training in this particular area. And the zenith of medical providers in medicine for muscles and joints, an orthopedist, will be very limited in his treatment options; more drugs, possibly physical therapy.
A good chiropractor will be able to evaluate you, try a period of treatment aimed at the working diagnosis and then assess your progress. After a brief clinical trial of treatment, if you are not responding, then your Chiro will want to change course and try something else or do further diagnostic testing like an MRI.
Here’s what I would try…
Assuming a physical exam that points towards Piriformis syndrome or other “muscular” problem:
- Heat and interferential electrical stimulation (IFC) surrounding the painful area for 12-15 minutes
- Very gentle post-isometric stretching of the Glute and Piriformis muscles
- 630 nM cold laser at 4,9,33 and 60 settings at the buttocks and thigh during the above stretching
- Chiropractic manipulation as needed of the pelvis and sacrum
- Ice for 10 minutes
I would do this treatment every other day for 2 weeks then re-evaluate.
You should see improvement in this short course of care.
If you do respond to this treatment:
- Continue at 2-3 times each week until the pain subsides and you can sit comfortably.
- Once you can sit comfortably, I would begin a course of rehabilitative exercises and stretches under your doctor’s supervision progressing to home care.
If there is no improvement at all:
- You may have a disc problem so I would order an MRI of the lumbar spine
- If the MRI scan shows dehydration (desiccation) and/or bulging of the L3, L4 or L5 disc, I would consider spinal decompression with a DRX9000
If you must take this path, let me know, because I may be able to find someone in your area within my decompression network whom I can refer you to.
Good luck and please feel free to contact me through this blog with further questions and/or updates of your progress.
Warmest regards,
Dr Barry L Marks
Chiropractor, Author & Lecturer
August 27, 2008 at 1:52 pm |
The question isn’t What is my diagnosis? it’s why do I have it? The answer, I think we would agree, is you are out of balance. A chiropractor can help you with that, but in order to make long lasting changes you’ve got to change the body’s muscular balance. Muscles move bones, so you’ve got to change the muscles. How would you suggest she go about that?
August 27, 2008 at 3:14 pm |
Palmbeachegoscue,
Thanks for your comments.
First, I disagree to a point: I think first we need to make sure it truly is a piriformis syndrome before we treat it like one. I see lots of mis-diagnosed people who have suffered through months of great treatment for the wrong thing. I don’t like wasting my patients’ time or money. So proper Dx is crucial.
Second, here’s where I totally agree with you. Many back and buttock problems involve muscular imbalance. If left imbalanced, pain will often return.
From your username I see you are a proponent of the Egoscue method. That is an excellent technique of balancing muscles. I have Pete Egoscue’s book and I have taken a few courses in Southern CA on his methods and really like the protocols. I incorporate them into my rehabiltiation programs.
I strongly believe chiropractic and muscle balancing like the Egoscue method together, is an excellent approach for a true correction or cure of similar problems.
Thank you again for your excellent comments/question.
August 27, 2008 at 9:24 pm |
[...] Are you tender in the center of your buttocks muscles? · When you put firm pressure into the center of your buttocks does it radiate pain downward or out to the hip area? · Sit down and lift one thigh up. Reach down and grab your ankle … [Read more] [...]
August 27, 2008 at 11:14 pm |
[...] Go to this artcile for a case study I recently did on a fellow blogger suffering from buttocks pain. Her question was, “Do I have Piriformis Syndrome?” [...]
August 28, 2008 at 11:59 am |
Right on Dr. M
All to often Good docs like yourself stop at treating the symptoms and neglect the underlying issues that brought the symptom on in the first place. The symptom is usually just a compensation for other muscles or joints that aren’t doing what they should be. Until you correct what is being compensated (dysfunction) for the symptom will return. Thats why I love the method. it is a great compliment to any modality, and it puts the client in control of their progress!
September 5, 2008 at 1:24 pm |
I think it is so cool that you take the time to help people out here on your blog.
September 24, 2008 at 4:10 pm |
Hi,
Is there any way to tell the difference between piriformis syndrome and herniated disc?
I have had 10 days in bed, unable to get up followed by 2 weeks back at work walking with pain. Yesterday I had my first MIR scan of the lumber region but have to wait 10 days for the results. Today a can’t walk again!!!!
First symptoms pointed at disc hernia but now it feels like someone has taken a sledgehammer to my left buttock…………
September 26, 2008 at 3:58 am |
Stig,
Sorry to hear about your pain.
If you put pressure into your buttock with your finger, does the pain radiate out or down? Or does it just make your butt hurt more? Radiation could be piriformis syndrome. No radiation can be painful butt due to disc.
Do you have pain on coughing, sneezing, bowel movement, straining or bending forward? If yes, it is likely a disc problem. Do you have increased back or leg pain when sitting and straightening one leg out in front of you? If yes, likely a disc.
Sorry, but 10 days is ridiculous for MRI results. When I send patients out for an MRI I get results back in 24-48 hrs. Then the day I get an MRI, I meet with the patient. Times a wasting and its no fun to be in pain. Things should go quick. If you have an HMO, the process can be like molasses.
I have sent you a private email with recommendations to get your MRI results NOW.
Go visit my other website for disc herniation info: http://www.orangespinaldecompression.com
and articles on this blog: http://www.spinaldecompression.wordpress.com
Let me know if there is anything else I can do for you Stig.
Warmest regards,
Dr Barry Marks
October 1, 2008 at 12:58 pm |
DrM,
I am a 30 year old male, 5′11″, and 180lbs.
About 4 years ago one of my legs went completely numb(no feed back at all, I could move it and walk but I had no sensation). It only lasted for a week but in that time frame I had an MRI and it showed a bulge at L5 S1. Before I even got an appointment with a surgeon the feeling completely returned to my leg and all was fine. About 2 years ago I awoke with excruciating pain in my back/hip/leg/foot. My doctor at the time told me to just take Advil/Tylenol as needed and that it would likely subside on its own within a few months or so. I am still in pain but have gotten some slight relief (new doctor) with Celebrex in the morning and Tramadol at night so I can get a full night’s sleep. I have tried every type of care (Chiropractic, Acupuncture, Inversion, Physical Therapy) but am still in continuous pain.
I am wondering if this pain is surely from the disk bulge. Or if it could be some other malfunction/misalignment/swelling. Just because I have a bulge doesn’t mean that it is definitely the cause of my pain.
Also, I don’t really understand why an analgesic would reduce the pain when I can’t imagine it shrinking a disk or nerve. Any thoughts on this would be great.
Also, I am thinking of going to a different Chiropractor to see if maybe the one I am seeing just isn’t good at what is wrong with me. Any advise on finding one that might be better at this.
Thanks,
Greg
October 1, 2008 at 3:32 pm |
Greg,
A sudden loss of sensation in the entire leg is a serious symptom. It can occur from one of two things:
1. Nerve impingement from a disc, tumor, etc
2. Blockage of blood flow from the femoral artery (in the groin area)
Nerve is the most likely candidate.
A positive MRI that matches up with clinical symptoms and exam findings is a fairly high indicator that the disc bulge is the culprit.
My questions are: Does the bulge on MRI show a bulge more on the affected leg side than the other? Does the MRI show foraminal stenosis on the affected side? If yes to these, it is likely due to the disc bulge.
The fact that is starts as leg numbness or lack of sensation then later you develop back pain is not uncommon for a deteriorating disc. At first the disc bulges out and affects the nerves causing irritation. At that point you may or may not have back pain. That eventually subsides then you feel normal, but the problem is still brewing. Activity over time then causes the disc to deteriorate more until other tissues are involved and then you develop back pain.
It’s all part of a relentless cycle of deterioration.
In answer to your questions about drugs, you are right; there is no drug that will cause the disc bulge to go away. Meds can only remove inflammation to make you feel more comfortable but cannot fix the underlying issue. BTW, see this post I just finished regarding drugs for back pain: http://spinaldecompression.wordpress.com/2008/09/30/low-back-pain-medication-which-works-best/
Don’t be too hard on your chiropractor if he or she cannot fix your problem. If you do have disc disease that is causing your pain, chiropractic may be able to relieve some pain, but it will not fix your disc. See “How to Choose A Chiropractor” here: http://www.drmarks.com/how_to_choose_a_chiropractor.html
For that, you will need to look into another procedure that has been proven to repair bulging discs not only to relieve pain, but to make the disc better so that it will not continue to deteriorate rapidly over time. The procedure does not involve surgery, chiropractic, drugs or physical therapy per se. For more info, see this blog: http://www.spinaldecompression.wordpress.com.
Greg, it is likely you do have a disc related problem, read over the resources I’ve given you then return here and ask any further questions. I can make a referral for spinal decompression in your area.
Good luck, I look forward to hearing from you soon.
Dr. Marks
October 9, 2008 at 10:03 pm |
Dr M
Thanks for your blog. It is very interesting. I have had back problems since childhood, haveing too much curve at L5 and a rotation of my right hip causing my right leg to shorten, for which i wear a small lift.
I am suffering from what my chiro said is bursitis on the hip bone. Trocan something. It is not getting better so have done some research on line. It now hurts in what appears to be the Iscial bursa as well though I didn’t hurt there a month ago and have been taking it easy. The Trocan thing doesn’t hurt that much if ever now, but the ischial bursa area does and my lower buttocks to the left of the Ischial sometimes feels like its on fire. Also, the muscle (lower buttocks on the left side of the left cheek) spasmed when having ultrasound theropy at the chiropractors. I’ve had 5 treatments on the bursa and other than the trocan feeling mostly better, I’m in a lot of pain. Walking is painful and I walk with a limp. The pain is all on the left side of my lower back going down the buttocks to the thigh and even some in my calf and achilis tendon. I have some tingling in the toes as well at various times.
I did the tests you gave on this site for the various causes of buttocks pain; the ischial bursitis is marginally painful when applying preasure, especially when sitting, moreso than pushing it with my hand,. The tests for the lumbar disc disease where all painful. I can’t touch my toes while standing and can’t even sit and extend my left leg. Sneezing is the most painful of all. I can lie on my stomach and bend my foot towards my buttocks without too much pain.
I have always done more than I should have as far as lifting and going beyond what some have thought I should do. I have suffered with back pain all my life because of it and in part I think because of the curve in L5 that I have. I have born 5 children and had back labor with all of them. I am now 42.
This pain is constant unless I am lying down but varies in its extent and lacation within the buttocks/hip/thigh/tendon area. Also, while sitting it feels as though something is pulling accross my lower spine. I don’t know how else to discribe that, it’s not a real pain, but rather a tension.
I see my chiro on Friday. I need some serious help, not just another adjustment.
Thanks so much,
Abigail
October 10, 2008 at 3:48 am |
Abigail,
I’m sorry to hear about your pain.
From what I can tell from your description, I beleive you are most likley suffering from a bulging, degernative or herniated disc that is causing your back, hip and leg pain.
Can you get an MRI? If an MRI shows a disc problem at L4 or L5 predominantly on the left side, then that would be pretty conclusive.
What to do about it if it is a disc problem, would be to check out DRX9000 spinal decompression. Go to my other blog for details: http://www.spinaldecompression.wordpress.com
In the meantime, I would ask your chiro to try moist heat and IFC electrical stim from your back down to the left thigh or calf, followed by gentle hamstring and glute stretching…very gentle.
Please keep me posted if and when you receive an MRI or for other developments.
Warmest regards,
Dr Marks
October 18, 2008 at 6:19 am |
In 1999 I had a right total hip replacment. I have had two prior back surgeries including fusion. I have started having pain down my right leg in butt, right leg and foot. The pain is constant, not affected very much by pain RX. I’ve had a recent MRI which showed two disc bulges L4 and L5 area. Steroid shot in low back did not give relief. Can you help diagnose my condition?
October 19, 2008 at 3:52 am |
Deborah,
Id be honored to help. Sounds like you’ve been through the ringer! With pain down to the foot it’s doubtful you have Piriformis Syndrome. It’s most likely sciatica from the discs in your back. Are the discs bulging more to the right than left, if so, that’s the most plausible reason for the pain. What type of fusion did you have? Bolts and screws? Or bone grafting?
How young are you and do you have severe osteoporosis?
When I receive the answers to these questions, Ill give you my opinion on your options.
Warmest regards,
Dr Barry Marks
http://spinaldecompression.wordpress.com
October 19, 2008 at 1:25 pm |
My age is 55, and yes, I’ve been through the ringer. I would say that I have sever osteoporosis.
My first back surgery was on the low back. I had a fusion to repair. The fusion was taken off my right hip.
Second back surgery was in the low back. I had a diskectmy.
I had a total right hip replacement in 2004. I had a labrial tear that went one year misdiagnosed. They tried to clean out the joint, but it was too late.
Since the hip replacement, I have been pretty unsymptomatic until July of this year. Initially I had pain in my low back where I could not stand straight, etc. Then started having sharp stabbing pains upon movement. I could not move without having a sharp stabbing pain. The sharp stabbing pain has quit. Now my pain radiates from the center of my right butt check, down my leg and to the top of my right foot. The pain is not stabbing or periodic. It is a constant burning pain. My foot even feels cold, but not to touch. When I push in on the side of my right butt check with my thumb, there is pain.
MRI shows one herniated disk and one bulging. My doctor scheduled me a steroid injection with nerve block. I felt like the shot made my pain worse. He is trying to pinpoint where the pain is coming from. Thursday had a nerve conduction study. Do not have the results yet.
I have fallen in the office twice in the last couple weeks. Now I have a concern that I’ve damaged my hip. I’ve been on Lortab … now changed to Norco. The Norco is 1 every 6 hours. This does not alleviate the pain. When I was taking the Lortab, 2 every 4 hours did not stop the pain. I do not understand why the pain won’t stop with RX.
I am confused, but just know that I need the pain to stop. I cannot sit or drive in the car.
Deborah
October 29, 2008 at 1:41 am |
Hi Deborah,
When you put pressure on your butt muscles does the pain radiate downward or just ache in the butt more? Makes a difference.
Reason why pain won’t quit despite drugs is that nerve pain, especially central nerve pain from the spine is difficult to turn off without rendering you unconscious.
Are your herniated or bulging disc at L4 and L5 on the right? By your symptoms that appears to be the cause.
Have you been clinically diagnosed with “severe” osteoporosis? If so, you are not eligible for spinal decompression. A bone fusion without metal would be ok.
If spinal decompression is not available to you and you wish to avoid a 3rd surgery, then look for someone who performs Erchonia Cold laser therapy. For patients that aren’t eligible for spinal decompression in my office, I use a combination of therapeutic post-isometric stretching, deep massage and laser therapy to relieve back and leg pain. If you are interested I can forward to you the treatment protocols I use for you to share with a doctor in your area.
Warmest regard,
Dr Marks
February 26, 2009 at 4:09 am |
Excellent advice! I’ve been through it and this DC knows what he’s talking about.
February 26, 2009 at 4:02 pm |
Thanks for visiting and for your most kind comments, Dee.
Warmest regards,
Dr Marks
http://www.drmarks.com
September 15, 2009 at 1:54 pm |
This might also help for pulled muscle(also known as muscle strain) on the glute http://www.webanswers.com/health/exercise-fitness/may-be-a-possible-pulled-muscle-in-the-back-of-my-leg-40676e