Chiropractic Management of a US Army Veteran With Low Back Pain and Piriformis Syndrome
SOURCE: J Chiropr Med. 2012 (Mar); 11 (1): 24-9
Cynthia Chapman, and Barclay W. Bakkum
Chiropractor, Private Practice,
Occoquan Family Chiropractic, PLLC,
Occoquan, VA 22125
OBJECTIVE: The purpose of this article is to present the case of a patient with an anatomical anomaly of the piriformis muscle who had a piriformis syndrome and was managed with chiropractic care.
CASE REPORT: A 32-year-old male patient presented to a chiropractic clinic with a chief complaint of low back pain that radiated into his right buttock, right posterior thigh, and right posterior calf. The complaint began 5 years prior as a result of injuries during Airborne School in the US Army resulting in a 60% disability rating from the Veterans Administration. Magnetic resonance imaging demonstrated a mildly decreased intradiscal T2 signal with shallow central subligamentous disk displacement and low-grade facet arthropathy at L5/S1, a hypolordotic lumbar curvature, and accessory superior bundles of the right piriformis muscle without morphologic magnetic resonance imaging evidence of piriformis syndrome.
INTERVENTION AND OUTCOME: Chiropractic treatment included lumbar and sacral spinal manipulation with soft tissue massage to associated musculature and home exercise recommendations. Variations from routine care included proprioceptive neuromuscular facilitation stretches, electric muscle stimulation, acupressure point stimulation, Sacro Occipital Technique pelvic blocking, CranioSacral therapy, and an ergonomic evaluation.
CONCLUSION: A patient with a piriformis anomaly with symptoms of low back pain and piriformis syndrome responded positively to conservative chiropractic care, although the underlying cause of the piriformis syndrome remained.
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The Full-Text Article:
Piriformis syndrome is an uncommon cause of low back pain and sciatica that results from entrapment and/or irritation of the sciatic nerve in the region of the greater sciatic foramen. [1-4] Although no definitive causative factors are known for this syndrome, the usual source is thought to be an abnormal condition of the piriformis muscle. A common basis of the problem appears to be trauma to the piriformis muscle that results in spasm, edema, and contracture of the muscle, which can cause subsequent compression and entrapment of the sciatic nerve.  Other possible etiologies include reflex spasm of the piriformis muscle and an abnormal course of the sciatic nerve through the piriformis muscle. Altered biomechanics of the lower limb, low back, and pelvic regions can lead to stretching and shortening of the piriformis muscle, which can also lead to piriformis syndrome. Although, in 1928, Yeoman  first described the clinical picture of what would later be called piriformis syndrome, this diagnosis still remains somewhat controversial. This controversy stems from several factors that include variable and sometimes unclear cause, similarity to other more easily recognizable causes of sciatica, lack of consistent objective diagnostic findings, and relative rarity. Piriformis syndrome had been thought to be a purely clinical diagnosis; but more recently, magnetic resonance imaging (MRI) has begun to be used to help with the diagnosis of this problem. 
The piriformis muscle is a pear-shaped muscle in the gluteal region that lies inferior to and in the same plane as the gluteus medius muscle. Normally, the piriformis muscle arises from the anterior surface of the second through fourth sacral segments in the regions between and lateral to the anterior sacral foramina (See Figure 1).
Figure 1: An anterior view of pelvic region showing the normal origin of the piriformis muscle in relation to the anterior sacral spinal nerve roots.
It also arises from the superior margin of the greater sciatic notch, the anterior sacroiliac ligament, and sometimes the anterior surface of the sacrotuberous ligament. The piriformis muscle exits the pelvis through the greater sciatic foramen, which it mostly fills, to insert on the upper border of the greater trochanter of the femur. Usually, the sciatic nerve emerges from the greater sciatic foramen inferior to the piriformis muscle (See Figure 2).