Piriformis syndrome & acupuncture - Acupuncture and Moxibustion

Townsend Letter for Doctors and Patients, July, 2003 by Honora Lee Wolfe

Keywords: Chinese medicine, acupuncture, piriformis syndrome

The piriformis muscle lies deep to the gluteal muscles. It originates from the sacral spine and attaches to the greater trochanter of the femur. Its function is to externally rotate the hip as well as to help abduct the hip when the hip is flexed. In most people, the sciatic nerve, the largest nerve in the body, passes under the piriformis muscle. However, in approximately 15% of the population, the sciatic nerve runs through the body of the muscle. Piriformis syndrome refers to irritation of the sciatic muscle by the piriformis muscle. This may be due to either acute or chronic injury of the muscle which causes swelling and inflammation which then irritates the nerve. This condition most commonly occurs in females, with a 6:1 ratio of female to male predominance. It is also common in runners, skiers, truck drivers, tennis players, walkers, and long distance bikers, and other athletes.

The symptoms of piriformis syndrome are mainly pain deep in the buttocks which may possibly refer along the sciatic nerve down to, but rarely below the knee. This pain is typically worse when sitting, climbing stairs, walking, running, and doing squats. Pain is located in the middle of one side of the buttock and is often worse when getting up from bed. There is usually direct tenderness in the region of the piriformis tendon over the buttock region, and some women may experience labial pain or dyspareunia. The right leg is often affected after driving long distances when the foot has been externally rotated on the gas pedal. Similarly, the foot on the affected side is often externally rotated when relaxed. The Western medical diagnosis of this condition is mostly a diagnosis of exclusion. It is based on the symptoms and physical examination, with X-rays, MRIs, and nerve conduction tests used to exclude other diseases. The differential diagnosis of this condition includes hamstring injury, lumbar disk herniat ion, lumbosacral facet syndrome, lumbosacral radiculopathy, spondylolithiasis, spondylolysis, and sacroiliac joint injury or subluxation. It is estimated that six percent of all patients with sciatica have piriformis syndrome. In any case, this is a difficult condition to diagnose and it is resistant to treatment.

Western medical treatment of this condition consists of 23 weeks of rest from sports and activities which cause pain. Physical therapy may be used to strengthen the unaffected opposing muscles, and anesthetics, such as lidocaine and bupivacaine, may be injected locally at trigger points. Other therapies to consider include correction of any running flaws and stretching. Full return to activities may take 2-3 months. In some cases, cortisone is injected locally, and surgical exploration may be recommended in nonhealing cases.

Wu Han-yang of the Dong Tai Municipal People's Hospital in Jiangsu published an article titled, "A Survey of the Treatment Efficacy of Treating 80 Cases of Piriformis Syndrome with Multidirectional Needling." This article appeared in issue #9, 2002 of Ji Lin Zhong Yi Yao (Jilin Chinese Medicine & Medicinals) on page 47-48. Because Western medicine finds this condition recalcitrant to treatment, a precis of this article appears below.

Cohort description

Altogether there were 160 patients in this study which was conducted from 1990-2001 in the outpatient ward of the Chinese author's hospital. Among these, 113 were male and 47 were female. These patients were 16-68 years of age, with an average age of 39.5 years. The course of disease had lasted from as short as two days to as long as seven years. Ninety-six patients had a history of external injury, 53 patients had suffered from contraction of wind cold or cold dampness, eight had a history of chronic taxation detriment, and the original cause of this condition in three patients was unclear. All these patients had one-sided buttock pain. In 125 cases, it was right-sided, while in only 35 cases it was left-sided, these patients were randomly divided into two groups, a so-called usual or one-directional acupuncture group and a so-called multidirectional acupuncture group. In terms of sex, age, disease duration and condition, there was no marked statistical difference between these two groups.

Treatment method

In the multidirectional acupuncture group, patients were mainly needled at Huan Tiao (GB 30), Zhi Bian (Bl 54), and a shi points on the buttocks. These were needled with three inch 28, gauge needles which were inserted and manipulated with both hands. The heads of these needles were directed toward the site of the pain. Then the needles were twisted causing relatively strong soreness, numbness, distention, and pain which radiated down the sciatic nerve and up into the back. Then these needles were withdrawn and reinserted into the muscle with the tip of the needle pointed successively up, down, right, left. After this, three cones of warm needle moxibustion were burned on the handles of the needles. At the same time, needles were inserted into Yang Ling Quan (GB 34), Wei Zhong (Bl 40), Cheng Shan (Bl 57), Fei Yang (Bl 58), and Kun Lun (Bl 60). These were manipulated with even supplementing-even draining or draining hand technique. These needles were retained for 20-3 0 minutes and then removed. Treatment was given once every other day or once per day in acute cases, and 10 treatments equaled one course of therapy. The members of the conventional or unidirectional acupuncture group received acupuncture at the same points for the same amount of time. However, the points on the buttock region were not needled with the multidirectional technique but were simply inserted perpendicularly.