Treatment of Piriformis Myofascial Pain Syndrome Case Report

115
Case Report
Treatment of Piriformis Myofascial Pain Syndrome
related to Lumbar Facet Lesion: A Case Report
Nai-Phon Wang, Fang-Chuan Kuo,1 Yueh-Ling Hsieh,1,2 Shyi-Kuen Wu,1 Chang-Zern Hong1
Department of Orthopedics, Kuang-Tien General Hospital, Taichung;
1Department of Physical Therapy, Hungkuang University, Taichung;
2Graduate Institute of Rehabilitation Science, China Medical University, Taichung.
This case report describes a patient with chronic pain due to piriformis myofascial pain syndrome
related to lumbar facet joint lesion. The purpose is to demonstrate the elimination of the underlying etiological lesion by lumbar facet joint injection with steroid suspension for a complete and effective treatment of piriformis myofascial pain syndrome in order to obtain a permanent pain relief. A 46 year-old
male patient had chronic pain in the right gluteal region and right leg (with tingling) for many years. Initially, he had been treated as piriformis syndrome with oral medicine, physical therapy and local injection,
and had only temporary and incomplete pain relief. Finally, he visited our pain clinic and received
physical therapy to the lumbar spine based on the presence of positive facet sign that reproduced his
clinical symptoms. After physical therapy, he had pain relief much remarkably than before, but still incompletely. Then he received a lumbar facet joint injection at L5-S1 level. Immediately after the injection,
he had pain subsided completely. This effectiveness lasted for longer than one year. It is concluded that,
in some cases of piriformis myofascial pain syndrome is related to a lumbar facet joint lesion. Treatment
of the lumbar facet joint can suppress the symptoms completely for a significantly long period. ( Tw J
Phys Med Rehabil 2009; 37(2): 115 - 122 )
Key Words: injection, facet joint, piriformis myofascial pain syndrome, sciatica.
INTRODUCTION
Piriformis syndrome has been defined as a pain syndrome derived from the piriformis muscle, including all
intrinsic pathology of the piriformis itself, such as myofascial pain, anatomical variations, hypertrophy, trauma,
etc.[1-7] Other etiology causing pain similar to piriformis
syndrome includes herniated lumbar disc, lumbar facet
syndrome, trochanteric bursitis, sacroiliac joint dysfunc-
tion, endometriosis, etc.[4,8,9] However, according to the
traditional definition, piriformis syndrome should be
limited to those with sciatic nerve entrapment due to, or
related to, the compression of the piriformis muscle.[1-2] A
term of “piriformis myofascial pain syndrome” has been
used for those with pain caused by myofascial trigger
point (MTrP) of piriformis muscle.[1-2] Clinically, piriformis syndrome with sciatic nerve entrapment is different from piriformis myofascial pain syndrome. In the case
of mild or early sciatic nerve entrapment, the patient
Submitted date: 11 November 2008
Revised date: 11 December 2008
Accepted date: 18 December 2008
Correspondence to: Dr. Chang-Zern Hong, Department of Physical Therapy, Hungkuang University, No. 34, Chung-Chie
Road, Shalu Township, Taichung County 433, Taiwan.
Tel：(04) 26318652 ext 3301
e-mail：johnczhong@yahoo.com
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Tw J Phys Med Rehabil 2009; 37(2): 115 - 122
usually complains tingling in the region of peroneal
and/or tibial nerve territory as a consequence of direct
irritation to the sciatica nerve. The initial symptom of
compression neuropathy is tingling but not pain, since the
large fibers are compressed before the small pain fibers
have been compromised. On the other hand, the pain due
to piriformis myofascial pain syndrome is a type of
referred pain (but rarely tingling) from the MTrP of the
piriformis muscle, and is usually limited in the posterior
thigh above the knee, but not in the leg.[1,2]
In this case report, we presented a case with piriformis myofascial pain syndrome having long-standing
effect of pain relief from lumbar facet joint injection.
CASE REPORT
Medical history
A 46 year-old male patient had chronic pain in the
right gluteal region with episodic tingling in the leg for a
few years. Initially, the pain intensity ranged from 3/10 to
5/10 (numerical analog scale from 0 to 10 with 0 = no
pain and 10 = worst pain ever experienced in the life).
The pain intensity had been increased progressively, and
finally might go up to 9-10/10 episodically. The pain
frequently radiated to the posterior and lateral aspects of
the right leg, accompanied with tingling sensation. The
symptoms usually became severe after carrying heavy
weight or prolonged driving. He had been a truck driver
for more than 15 years prior to the development of
clinical symptoms. Frequently, he had to carry heavy
weight up and down the truck. As the symptoms were
getting worse, he had difficulty at work, particularly
during prolonged driving or carrying heavy weight.
He was initially treated with non-steroid anti-inflammatory medicine prescribed by his family physician
and had pain relief only partially and temporarily. He then
was referred to a physiatrist by his family physician. The
physiatrist suspected that he might have suffered from
piriformis syndrome since he had a severe tender spot in
the piriformis muscle and had severe pain and tingling in
the posterior and lateral aspects of right leg when the
right piriformis muscle was firmly compressed. He then
received radiological studies on the lumbo-sacral spine
and the pelvis. The X-ray films of lumbo-sacral spine
showed evidences of mild degenerative changes including
small osteophytes at the anterior-inferior L5 margin and
anterior-superior S1 margin with slightly reduced intervertebral disc space between L5 and S1 vertebrae. The
X-ray findings in the pelvis were unremarkable. Electromyographic study on the lumbar paraspinal and the
involved limb muscles was also performed and the
findings were normal. Under the impression of piriformis
syndrome, he received physical therapy (heat, electrotherapy, and massage to the right gluteal region) 2-3
treatments per week. He had remarkable but only temporary pain relief for 1-2 days after each session of physical
therapy. Since physical therapy provided no significant
overall improvement, MRI studies on lumbar spine and
pelvis were performed but showed no significant findings
other than mild degenerative changes in the lumbar spine
similar to that demonstrated in the plane X-ray film. The
physical therapy program was discontinued 2 months later.
Then he received an MTrP injection to the right piriformis
muscle and had complete relief of symptoms for about
1-2 weeks. However, the pain recurred and increased
progressively to the original pain level. Totally, he received 3 trigger point injections within 3 months and had
only temporary pain relief with no remarkable overall
improvement. Finally, he was referred to our pain clinic
approximately about 6 months after the initial medical
visit.
Physical examination
At the time of his first visit to our pain clinic, he reported a pain intensity of up to 7-8/10 in the right gluteal
region, and 4-5/10 in the lateral and posterior aspects of
right leg down to the foot. He also had tingling in the
posterior and lateral aspects of right leg.
Examination of the gluteal regions revealed diffuse
tenderness in the right gluteal muscles with the most
painful spot on the MTrP of right piriformis muscle. The
right piriformis muscle was much tighter than the left one.
All provoking tests for piriformis syndrome, including the
direct stretch (Lasègue's sign with bowstring maneuver)
or compression (Tinel’s sign) of the right sciatic nerve
and the aggravation of the right sciatic nerve entrapment
by the right piriformis muscle (stretching or active contraction against a resistance of the right piriformis muscle), showed positive findings to support the diagnosis of
Facet Joint Injection for Piriformis Myofascial Pain Syndrome 117
right piriformis syndrome. There were active MTrPs in
the right gluteus maximus, gluteus medius, gluteus
minimus, and piriformis (the most irritable one) muscles.
The diagnosis of MTrP was based on that described in the
“Trigger Point Manual”.[2,10]
Examination of the lumbar spine revealed slightly
reduced ranges of motion in the right rotation and right
side bending with mild back pain in the terminal ranges.
There was a normal alignment in the lumbar spine.
Lumbar facet sign (ipsilateral rotation followed by extension of lumbar spine) was positive on the right side with
pain referred to the right gluteal region. The referred
gluteal pain was similar to the usual complaint of this
patient (pain recognition). Provoking tests for sacroiliac
(SI) joint dysfunction, including the direct compression of
the SI joint and the direct stretch of the SI joint capsules
(including ligaments), were negative. Neurological examination was unremarkable.
Treatment
Based on the above information, the diagnosis of
“right piriformis syndrome and piriformis myofascial
pain syndrome related to lumbar facet lesion” was suggested. In addition to the treatment on the right piriformis
muscle similar to that he received previously, lumbar
traction and lumbar mobilization therapy after a local hot
pack with hydrocollator to the lower back was added into
the physical therapy program. He attended this physical
therapy program 3 times per week for 4 weeks and had
remarkable improvement. The pain intensity was reduced
to 2-3/10 level with occasional exacerbations up to 5-6/10
level. Due to incomplete symptom relief, this patient was
finally treated with a local steroid injection into the right
L5-S1 facet joint.
Technique of lumbar facet joint injection
A solution containing Kenacort-A (40 mg/ml) 1 ml
plus 1% lidocaine 1 ml was used for injection. The patient
was in a prone position with a pillow under his pelvis.
After sterilization, the mid-point between the spinous
process of L5 vertebra and the right posterior superior
iliac spine was marked as the site for needle penetration
(Figure. 1). A 5-cc syringe and a No.23 needle with a
length of 23/4 inches were used for injection. The location
of the right L5-S1 facet joint was just beneath this marked
spot. The syringe was held gently with the thumb and
middle finger of the dominant hand and the end portion of
syringe was controlled by the index finger, similar to
Hong’s technique for MTrP injection.[10,11] The needle
was moved slowly and perpendicularly to penetrate
through the skin and soft tissues under the marked spot
until it encountered the bone. Then the needle was pulled
out for a few mm and reinserted into another site about 1
mm in another direction. This procedure was repeated
continuously in a sequence to map the depth of bony
structures at and near the facet joint. When a narrow dip
(facet joint or near facet joint) could be felt, the solution
in the syringe was pushed into this space by the index
finger. In our clinical experience, usually 1-2 ml of
solution can be pushed out without any significant resistance if the facet joint is encountered. If the solution can
not be pushed out from the syringe due to a strong resistance, this procedure was repeated until reaching a space
where the solution could be smoothly pushed out. This
technique requires delicate feeling on the accurate location of needle tips via the sensation of thumb and index
finger that held the syringe.
Outcome of treatment
After the facet joint injection, the pain intensity of
right gluteal region reduced to only 0-1/10, and no pain
(0/10) in the right leg. A follow-up phone call about one
year later revealed no evidence of any recurrence.
DISCUSSION
This case report has demonstrated the therapeutic
effectiveness of lumbar facet joint injection to eliminate
the underlying etiological lesion of chronic recurrent
myofascial pain syndrome of piriformis.
Diagnostic issues of piriformis syndrome VS
piriformis myofascial pain syndrome
The diagnosis of piriformis syndrome is usually
based on the subjective complaints and the findings of
clinical examination.[4] Some degree of confirmation is
attributed to successful treatment targeted at the piriformis muscle. There are numerous tests to confirm
piriformis syndrome. The basic principle of those tests is
to provoke or aggravate symptoms either by a direct
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Tw J Phys Med Rehabil 2009; 37(2): 115 - 122
irritation of the sciatica nerve or by a pressure to the
sciatic nerve induced by the contracting or stretched
piriformis muscle (exacerbation of impingement).
Regarding the sciatic nerve irritation tests, Straight
leg raising (SLR) and Lasègue's sign are the most frequently used techniques. A nerve is usually hypersensitive
along the segment distal to the site of impingement
(Tinel’s sign).
During the provoking tests to aggravate the sciatic
nerve entrapment, a resistive force can be added to
against the active contraction of the piriformis muscle,[12,13] or the piriformis muscle can be stretched by
passive internal rotation of the leg with the hip in flexion
and adduction.[2,14]
On the other hand, the diagnosis of piriformis myofascial pain syndrome is based on the existence of one or
two MTrPs in the involved piriformis muscles.[1,2]
In our case, all the tests for piriformis syndrome
were positive, and MTrP could also be identified in the
piriformis muscle. Through a comprehensive literature
review, Cummings has concluded that any sciatic nerve
irritation caused by piriformis muscle can be diagnosed as
piriformis syndrome.[4] This patient also had symptoms
from both piriformis myofascial pain and piriformis
syndrome with sciatic nerve irritation (tingling in the leg).
Therefore, the correspondence author strongly believes
that this patient had both piriformis syndrome and piriformis myofascial pain syndrome. The compression of
the sciatic nerve by the piriformis is identical in clinical
presentation to low back pain with associated L5, S1
radiculopathy due to diskogenic and/or lower lumbar
facet arthropathy with foraminal narrowing.[8,9] In this
case report, we could exclude this possibility based on the
physical examination (lack of radicular symptom during
the facet provoking test, but only during the provoking
tests involving the compression of sciatic nerve by the
piriformis muscle), the radiological findings, and electrodiagnostic test.
The diagnosis of piriformis syndrome can be further
confirmed by nerve conduction studies on the proximal
segment of the sciatic nerve across the piriformis muscle.
In our case, we failed to measure the sciatic nerve conduction across the piriformis muscle, although the chance
of a positive finding could be very low when the sciatic
nerve was only irritated without significant axonal lesion
(negative EMG findings). When a nerve is entrapped with
a demyelinative lesion only in a short segment, the slow
nerve conduction may not be easily identified. H-reflex
study may show an increased latency when the hip is in a
FAIR position (hip flexion, abduction, and internal rotation).
[14,15]
Unfortunately, we did not perform this procedure
during the electrodiagnostic test.
Therapeutic issues of piriformis myofascial
pain syndrome with piriformis syndrome
Figure 1. Localization of L5-S1 facet joint for injection. A dark straight line connects the
spinous process of L5 and the ipsilateral
posterior superior iliac spine. The L5-S1
facet joint is just underneath the mid-point
(in the center of the dark circle) of this line.
Treatments for piriformis myofascial pain syndrome
with or without piriformis syndrome which have been
reported as successful vary from non-invasive physical
modalities, through the minimally invasive needling and
injection techniques, to invasive surgical procedures.[1,2,4,11]
The frequently used physical therapy programs include
stretch of piriformis muscle with or without the use of
vapocoolant sprays,[2,16] stretch with post-isometic relaxation,[17] pressure release techniques including ischemic
compression and deep pressure massage, and ultrasound.[16]
Dry needling or acupuncture therapy has been used
successfully in treating piriformis syndrome.[4] Local
anesthetic, with or without steroid, is frequently used for
injection into the piriformis muscle.[2,10,16] In our clinical
experience, surgical intervention is usually unnecessary.
Facet Joint Injection for Piriformis Myofascial Pain Syndrome 119
In many cases, physical therapy program can provide
complete pain relief without any invasive approach.
[15,16,18,19]
We had tried almost all the above techniques to treat
this patient. However, only temporary relief of pain was
obtained. It was obvious that there was an underlying
pathological lesion that cause recurrent piriformis myofascial pain syndrome with piriformis syndrome. It is
important to find out and treat the underlying etiological
factor.[11,20]
The correlation between piriformis syndrome
and facet joint lesions
Clinically, a patient with lumbar facet joint lesion
can have pain in the gluteal muscles.[21,22] MTrPs in the
gluteal muscles can be identified in such cases.[2] When
the MTrPs in the piriformis muscle become active, the
muscle tension would increase due to the taut band
phenomenon.[10,20] The tight muscle may subsequently
cause irritation to the sciatic nerve resulting tingling or
numbness in the leg similar to piriformis syndrome.
Therefore, when the facet joint is treated, the piriformis
MTrPs can be inactivated, and the sciatic nerve irritation
can be released. This is the most likely mechanism of
facet joint injection in treating piriformis myofascial pain
syndrome with piriformis syndrome.
Diagnosis and treatment of facet lesions
In clinical practice, facet joint lesions are very
common. The facet joint lesions can be caused by various
spinal pathological conditions including degenerative joint
disease, degenerative disc disease, compression fracture,
fracture-dislocation, meniscoid impingement, etc.[21] If
the facet joint capsules are over stretched, the facet joint
becomes unstable. If the facet joint is locked or even
fused, it becomes hypomobile. In either condition, the
nociceptors in the facet joint may become hyperirritable
and elicit referred pain to the remote regions. In many
cases, the facet joint instability (posterior segment lesion)
can be caused by the collapsed (desiccated) intervertebral
disc (anterior segment lesion) few years after the ligament
injury (rupture of annulus fibrosus) due to disc herniation.
In a few cases, the facet instability can be caused by a
direct trauma. Any injury to the facet joint capsule can
cause pain in facet joint syndrome.[23] Reviewing the
x-ray findings in our case, we did not see any decrease of
the intervertebral disc space (collapsed disc) but mild
degenerative change. Therefore, the facet joint lesion in
our patient might be caused by a direct injury with accumulation of chronic repetitive minor trauma, and could be
job related.
When the facet joint is unstable due to ligament laxity, a rotary movement of the corresponding vertebral
segments followed by hyperextension can induce extreme
stretch to the injured ligament so that a pain in the facet
joint itself and a referred pain to a certain corresponding
region can be elicited. This is a “positive facet sign”.
The first choice of treatment for a lumbar facet lesion is the physical therapy program including the local
thermotherapy of lumbar spine followed by a lumbar
traction with hip flexed and legs elevated.[24-26] Manual
therapy such as mobilization or manipulation may be
effective.[24,27] We have tried hot pack to lumbar spine
followed by lumbar traction and mobilization therapy on
this patient with good, but not the best, result. This is
probably due to chronicity of our case. If we could find
out the facet joint problem and treat it appropriately in the
early stage, we might be able to cure this patient completely without facet joint injection.
Lumbar facet joint injection is an option to treat a
lumbar facet lesion if conservative treatment is unsuccessful. It is usually under the guidance of fluorescent
direction.[28,29] We used this technique to avoid the radiation exposure. It was fast, less expensive and successful.
In a previous unpublished pilot study on the lumbar facet
injection with our technique, we had confirmed the
accurate position of the needle tip in the facet joint region
by a subsequent fluoroscopic study in 3 cases. However,
if an ultrasonography is available, the ultrasound guidance may be a better way to perform this procedure.[30]
CONCLUSION
Chronic recurrent piriformis myofascial pain syndrome with evidence of piriformis syndrome (sciatic nerve
irritation) may be caused by a lumbar facet joint lesion. It
is necessary to treat the underlying etiological lesion
appropriately (such as lumbar facet joint injection) in
order to avoid the recurrence of myofascial pain.
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腰椎小面關節治療對梨狀肌肌筋膜疼痛症候群病患之
成效：病例報告
王乃弘 郭芳娟 1 謝悅齡 1,2 吳錫昆 1 洪章仁 1
光田綜合醫院骨科 弘光科技大學物理治療系 1 中國醫藥大學復健科學研究所 2
本報告提出一位因腰椎小面關節損傷引起梨狀肌肌筋膜疼痛症候群之慢性疼痛病例，並以腰椎小面
關節類固醇注射方式使其達到完全緩解及止痛。患者為 46 歲男性，主訴多年右側臀部疼痛及右腿麻痛。
在一般診所接受口服止痛藥、一般物理治療及局部注射治療，但都只達到暫時性的緩解及減輕疼痛。經
我們檢查後發現患者的腰椎小面關節受損為造成其不適感的主因，便改以腰椎小面關節之物理治療處
理。經治療後疼痛獲得明顯改善但亦不能完全緩解。後來，以 L5-S1 之小面關節局部注射，患者的疼痛
即刻獲得完全的緩解，並持續超過一年以上。因此，對於某些梨狀肌肌筋膜疼痛症候群之慢性疼痛病例
而言，腰椎小面關節損傷可能是壓迫坐骨神經或是造成梨狀肌肌筋膜激痛點的主因之一。針對腰椎小面
關節的治療可以改善疼痛的症狀並使患者的症狀獲得長期完全的緩解。（台灣復健醫誌 2009；37(2)：115
- 122）
關鍵詞：注射(injection)，小面關節(facet joint)，梨狀肌肌筋膜疼痛症候群(piriformis myofascial pain
syndrome)，坐骨神經痛(sciatica)
抽印本索取地址：洪章仁醫師，弘光科技大學物理治療系，台中縣 433 沙鹿鎮中棲路 34 號
電話：(04) 26318652 轉 3301
e-mail：johnczhong@yahoo.com