In this blog I thought that it might be interesting for both patients and possibly any clinicians that read our articles to discuss a case study about a recent patient and also look at a condition that provokes much debate in the physiotherapy profession and that some physiotherapists would dispute even exists.
I thought also that it might be nice to look at the process of clinical reasoning that we go through as physiotherapists and how sometimes there can be disagreements as to the underlying cause of a patient's symptoms. In this case the patient - Debbie, was an active, physically fit female in her early 50s who was suffering from severe pain in the outside part of the shin and had intermittent pins and needles in her foot and calf.
Her symptoms had started approximately 2 months earlier after she had increased the distance she was running and also had increased the number of sessions. Initially she was very sore on the outside of her right hip and gluteal region and into her right ITB but this had slowly changed over the last few months into pain in the lower leg and some discomfort in the right buttock on sitting.
She had been to see the GP who had initially thought it was simply a muscular strain but when things had worsened had ordered an x-ray of her hip and blood tests, all of which came back as clear. Finally the GP had referred her through to triage/physiotherapy with the NHS but Debbie was tired of waiting and so contacted us at ThreeSpires Physiotherapy. She found standing painful, internal rotation of the hip and also moving her leg towards the midline of her body (adduction) seemed to worsen her shin pain. Debbie had done some internet research and had already tried self massage of the glutes and McKenzie extensions with no success.
On physical assessment she had good forward flexion at the lumbar spine but extension, right side flexion and right rotation immediately triggered her shin pain. Her straight leg raise was bilaterally equal, slump test was negative and lower limb strength tests showed a reduction in strength in extension of the great toe on the right side. Palpation (touching) of her right gluteal region at the level of piriformis provoked an immediate increase in her shin pain which was reproducible. Extensions (in prone) seemed to immediately worsen her shin pain despite correcting problems with technique.
Prior to completing the physical assessment I had in my mind two possible diagnoses: firstly (and most likely) that her current symptoms where coming from her low back in the form of some form of disc or nerve root irritation and secondly it was an irritation of the piriformis muscle (less likely). During the physical assessment some parts pointed strongly towards a lumbar involvement - her reduction in great toe strength and her pain on right side flexion and rotation. Other components such as increased pain on adduction of the lower limb and her immediate and reproducible pain on palpation of the glutes pointed towards piriformis. Overall though, when I combined the events leading up to her injury (a rapid increase in running mileage) and her immediate pain with palpation of the right piriformis I thought that most likely what had happened was that she had possibly initially strained her glutes and irritated her ITB but after a month or so her piriformis had become overactive attempting to stabilise the pelvic and hip region and had then compressed her sciatic nerve.
So, what is piriformis syndrome? Well to understand this we need to take a brief look at some anatomy, in this case the gluteal (buttock) region. The sciatic nerve as it descends from the low back travels down through the buttocks and in so doing comes very close to a muscle called piriformis which runs across from the sacrum to the femur. In fact in some people the sciatic nerve has been found to actually pass through the muscle itself. Piriformis is an external rotator of the hip and is thought to be an important stabiliser of the hip and pelvic region due to its attachments at both the sacrum and femur. Now, in piriformis syndrome it is thought that some form of overload or strain causes the piriformis muscle to become irritated and either go into spasm or become inflamed and press onto the sciatic nerve. As mentioned before in Debbie's case I think that the initial injury was probably just a strain and irritation of the glutes but that after a while her piriformis was overloaded in trying to stabilise this region and thus put pressure on her sciatic nerve and gave her the shin pain.
Now, I think it is always important to be honest with patients and explain clearly what my diagnosis is and why, in this case I explained to Debbie that although I thought it most likely that her symptoms were caused by piriformis syndrome there was also a possibility that her symptoms were originating from her low back (and possibly a combination of the two!). I also explained that it would be wise initially to try and treat both possibilities (as they did not conflict) and we could decide later on which was the most likely cause. So over the next few weeks we used a combination of manual therapy and home exercises targeted at both piriformis and the low back. After the first follow up session it was apparent the exercises aimed at the low back (extensions) were not helping and so I advised her to stop these. After 2 weeks Debbie was showing significant improvements: her shin pain had reduced in intensity, she was progressing slowly with increasing her exercise levels and she was able to walk further. By now her appointment with triage via the NHS had come through and I encouraged her to attend as I was keen to find out what another physiotherapist thought without being biased by what I might say about her symptoms.
The extended scope physiotherapist at triage completed a full and thorough assessment and concluded that her symptoms were originating from her lumbar spine (possibly L5/S1) and also after Debbie mentioned my diagnosis stated that he did not believe in the idea of piriformis syndrome. He then advised her to carry on with extensions and referred her onto physiotherapy.
So, who was right as to the underlying cause of the pain? Me or the triage physiotherapist? Well on a pragmatic level it really didn't matter to the patient as she was improving and by now she was certainly back on the road to good health. She did find it disconcerting that two people could have different views and worried a bit about what to do but via a few email exchanges that was alleviated. I think that both of our assessments were good but we saw the patient at different times and with different symptoms and probably if I had seen the patient with the same symptoms as she had when she saw the triage physiotherapist I may well have thought it was coming from her low back. However, on reflection, I do think that overall my diagnosis was the correct one (well I would!) and that there were some clues from her history, the mechanism of injury, my physical assessment and finally her response to treatment that make it more likely than not that it was piriformis syndrome. Firstly she had increased her running dramatically prior to the initial injury which may have strained the piriformis muscle due to its role in stabilising the hip. Also her shin pain came on slowly after experiencing lateral hip and ITB pain which eventually both went away, which again could have caused her piriformis to become further overloaded. During the physical assessment adducting her leg passively and palpation of her piriformis produced immediate pain. Finally and possibly most importantly she got better after treatment and following the exercise program!
Please be aware that this blog post is not intended in any way shape or form as a criticism of the NHS physiotherapist, it is solely a piece of critical reflection by myself on my own performance as a physiotherapist. I think it is vital that as clinicians we continue to improve and learn and evaluate our performance in order to improve the results that our patients get. I thought that this case was interesting because the patient was able to see two physiotherapists who had different views of her symptoms and I wanted to explore what might have led us to our conclusions.
The patient, the most important person in this story, is now completely pain free and is slowly returning to her previous levels of exercise (although I have warned her strongly to avoid large increases in exercise levels!).
If you think you may be experiencing piriformis syndrome and would like to have a physiotherapy assessment then please get in touch. Our number is 0788 428 1623 or you can email us at firstname.lastname@example.org
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