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A 35-year-old female presents with complaints of left numbness, tingling, and deep ache in the left buttock that migrates down the length of the back of her thigh, leg, and shin. The patient reports that the pain is aggravated with walking, and sitting on hard surfaces, but relieved when standing upright or lying prone. The patient's past medical and surgical history is unremarkable.

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What is your best working hypothesis for the patient based on the subjective reports?

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The subjective reports indicate a condition that is either referring or radiating symptoms down the patient's lower extremity. The two major culprits for such a history include a vascular or neurogenic cause. At this stage in the proceedings, based on the information provided, it would be impossible to be able to determine which of the two is at fault as further testing is needed.

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Does this patient warrant a lower quarter screening examination?

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This patient certainly warrants a lower quarter screening examination.

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The physical examination revealed the following positive findings:

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  • Excessive anterior tilting at the pelvis.
  • Deep localized pain in the posterior aspect of the hip near the sciatic notch with palpation.
  • Active range of motion of the hip and lower extremities are within normal limits except internal rotation of the left hip which is decreased by 25%. Passive overpressure into left hip internal rotation yields pain.
  • Lateral hamstring muscle group rated as 4/5 for strength. All other muscle groups within normal limits.
  • Flexibility exam reveals excessive adaptive shortening in the iliopsoas, quadriceps, and hamstrings bilaterally.
  • Decreased light touch and pressure in the fibular (peroneal) distribution.
  • Positive straight leg raise with symptoms reproduced at 50 degrees. When applying internal rotation of the hip and repeating the straight leg raise, the symptoms were reproduced at 45 degrees.

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Combining all of the information gleaned from the physical examination, which structure do you think is causing the patient's symptoms?

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The structure at fault is the piriformis muscle -- the diagnoses is one of piriformis syndrome.

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What is the anatomy of the sciatic nerve in relation to the piriformis?

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How would you describe the cause of this condition to the patient?

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How could the femoral anteversion angle have an impact on the tension of the sciatic nerve?

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Given the above diagnosis, what is your plan of treatment?

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How successful has physical therapy been found in the treatment of piriformis syndrome?

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