What is Piriformis Syndrome?

Ever have a literal pain in the buttock?  A gnawing, throbbing, aching pain in the buttock? This could well describe a condition called “piriformis syndrome”

Piriformis syndrome occurs when a the sciatic nerve is affected in the area of the piriformis muscle, resulting in neurologic symproms of pain down the leg and weakness.  These symptoms can mimic those of a disc herniation or nerve impingement at the vertebrae, making diagnosis difficult.  For this reason, piriformis syndrom is an often missed diagnosis.

Anatomy of the piriformis:

The piriformis one of the muscles found in the buttock area.  It lies with a group of small muscles beneath the large gluteus maximus.  The piriformis muscle attaches to the front of the sacrum and the greater trochanter of the femur, and works as an external rotator of the leg.  Because the piriformis attachment is so close to the spine, many nerve and arteries pass both over and under this muscle.  In fact, it has been found that the sciatic nerve, the largest nerve of the leg, passes through the piriformis muscle or tendon in 22% of the population. Therefore, the sciatic nerve is easily affected by this muscle.

Mechanism of injury:

There is no one clear mechanism behind the development of piriformis syndrome.  Often, adhesions on the piriformis muscle can be caused by an initial fall to the buttock area, resulting in entrapment of the nerve.   The sciatic nerve may be more easily compressed if the nerve passes through rather than around the muscle, causing nerve injury.  Other possible causes of piriformis syndrome include prolonged sitting, increased muscle tone and muscle shortness of the piriformis, pregnancy, leg length discrepancy, inflammation of the piriformis, and weakness of the gluteus maximus and hip abductors.

What does piriformis syndrome feel like?

Those who are diagnosed with piriformis syndrome often complain of pain in the low back and/or buttock area.  This pain might be neurologic in type- traveling or shooting down the back or side of the thigh or calf.  Because the sciatic nerve is primarily affected, sensory changes in the leg may be felt.  Symptoms might be increased by prolonged sitting or stretching of the deep gluteal muscles.

What treatment is available for piriformis syndrome

Once piriformis syndrome is properly diagnosed, there are many treatment options. Myofascial release and trigger point therapy can break up connective tissue adhesions causing entrapment or compression of the nerve.  Stretching of the piriformis can also be beneficial to reduce compression and entrapment.  Chiropractic manipulations or adjustments can correct abnormal biomechanics, such as a leg length discrepancy and pelvic rotation or malalignment.  Modalities such as ultrasound and laser therapy can reduce inflammation and increase tissue healing to the foreshortened piriformis and gluteal muscles.  With proper diagnosis and treatment, the debilitating symptoms felt with piriformis syndrome can be reduced or eliminated and you can be on your way to a carefree, free striding walk.

Osteoporosis medication and bone health

As most of us are well aware, osteoporosis is a large health problem.  Osteoporosis, or excessive bone loss, affects more than 10 million people in the United States.   Osteopenia, or reduction in bone density, occurs in three times as many people.  About 50% of women over 50 will sustain an osteoporosis-related fracture in their lifetime.  One in five of those women will die within 12 months, often resulting from blood clots.  An often prescribed medication for treatment of these diseases is a class of drug called the Biophosphonates.  Biophsophonates work by reducing the activity of cells that break down bone, resulting in increased bone mass.  Numerous studies have shown that taking Biophosphonates reduces the risk of osteoporotic fractures.

There has been some recent talk in the news about Biophosphonates actually causing fractures in older women, including an article in Good Housekeeping magazine’s July 2011 edition.  Biophosphonates work by inhibiting the ability of osteoclast cells to break down bone. In healthy bone, osteoclast cells work in conjunction with other cells to continuously remodel our bones, ensuring healthy bone tissue.  While inhibiting osteoclast activity helps to keep bone density high, it may not improve the overall strength of the bone.  Because Biophosphonates reduce bone remodeling, they may “freeze” the skeleton, allowing for accumulation of minerals in the bone.  Increased mineral in the bone may lead to bone brittleness.  It is thought that the bone loses the ability to repair microfractures, and becomes more fragile in general.   This might lead to an increased risk of fracture.

Two recent studies have examined this relationship.  Women in Sweden who had sustained the kind of fracture (a subtrochanteric or femoral shaft fracture) thought to be caused by Biophophonates were examined.  It was found that 78% of patients who had this kind of fracture were taking Biophosphonates.  It was concluded that the risk of subtrochanteric or femoral shaft fracture was 10 times as high after 2 years of drug use and 5 times as high after two years.  This risk diminished 70% for every year after the women stopped using the drug.  A study conducted in Toronto, Canada made similar conclusions.  Park-Wyllie et al. found that long-term Biophosphonate treatment was associated with increased risk of these fractures after 5 or more years of use.  Therefore, these drugs may increase the risk for certain types of fractures– the very condition the drugs were supposed to be preventing!

While these studies show a clear connection between the use of biophosphonaes and atypical femoral fracture, their use still reduces the occurrence of osteoporotic fractures.  For this reason these authors concluded that the benefits of taking this medication still outweigh the risks.  However, according to Good Housekeeping magazine, in April the FDA issued a warning to physicians and patients about the possible risks of taking biophosphonates.  Here at ORC will keep our eyes pealed for more information about this important topic!

In the meantime, there are a few things you can do to keep your bones healthy!

Everyone knows about the importance of calcium rich foods, and yet determining whether or not you get enough calcium can be confusing.  The RDA (Recommended Daily Allowance) for calcium is 1,000 mg for most people and 1,200 mg for post menopausal women.  Many nutritionists and health experts believe even this amount is too low.  The best way to get your RDA of calcium is to eat calcium-rich foods.  Dietary calcium, or the calcium you get from food, is more easily absorbed than that from a supplement.  Here is a list of calcium rich foods and estimated calcium they contain. Be sure to check the label on your food container if you’re keeping track of your calcium as it can vary from product to product.

Milk (1 cup) 300 mg
Cottage cheese (1/2 cup) 65 mg
Fortified soy milk (1 cup) 200-400 mg
Yogurt (1 cup) 450 mg
Cheese- 1 oz 200 mg
Broccoil- 1 cup cooked 180 mg
Spinach-1 cup cooked 240 mg
Kale-1 cup raw 55 mg
Arugula-1 cup raw 125 mg
Chard- 1 cup cooked 100 ml

However, if you don’t get the proper amount of calcium from the food you eat, taking supplements is a good option.  The body best absorbs 500 mg of calcium at a time. Therefore, spacing out when you take your calcium supplements throughout the day insures the best absorption.  In order to be absorbed into the body, increased Calcium intake should be accompanied by Vitamin D and Magnesium. The National Osteoporosis Foundation recommends individuals under age 50 get 400-800 IU of Vitamin D every day and 800-1,000 for individuals over 50.  Often, you can find calcium accompanied by vitamin D and magnesium in the same supplement.  Here at Onion River Chiropractic we recommend and stock calcium by DaVinci Laboratories and Douglas Laboratories (two highly reputable, quality controlled supplement companies. Here are a links to their website with many options for calcium supplements.

http://www.davincilabs.com/vitamins_supplements/vitamins-supplements.php#minerals

http://www.douglaslabs.com/product_listing.cfm?products

Consult your doctor or chiropractor about which supplement is best for you.  In the meantime, have another cup of that delicious lowfat greek yogurt!

References:

Ince, Susan. (2011) Fractured. Good Housekeeping. July

Schilcher J, Michaelsson K, Aspenberg P. (2011) Biophosphonate use and atypical fractures of the femoral shaft. New England Journal of Medicine. 364:1728-37

Park-Wyllie LY, Mamdani MM, Juurlink DN, Hawker GA, Gunraj N, Austin PC, Whelan DB, Weiler PJ, Laupacies A. (2011) Biophosphonate use and the risk of subtrochanteric or femoral shaft fracture in older women.  Journal of the American Medical Association Vol 305, No.8

www.nof.org/ (website to National Osteoporosis Foundation)

http://www.uptodate.com/contents/pharmacology-of-bisphosphonates