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Piriformis syndrome occurs most frequently between ages 40-60 and is more common in women than men. Some reports suggest a 6:1 female-to-male ratio for piriformis syndrome; , possibly because of biomechanics associated with the wider quadriceps femoris muscle angle (ie, “Q angle”) in the pelvis of women. Reported incidence rates for piriformis syndrome among patients with low back pain vary widely, from 5% to 36%.
The most common symptom of patients with piriformis syndrome is increasing pain after sitting for longer than 15 to 20 minutes. Many patients complain of pain over the piriformis muscle (ie, in the buttocks), especially over the muscle’s attachments at the sacrum and medial greater trochanter. Symptoms, which may be of sudden or gradual onset, are usually associated with spasm of the piriformis muscle or compression of the sciatic nerve; these symptoms include radiating/shooting pain or tingling or numbness in the back of the thigh, leg, or foot. These symptoms must be evaluated by a healthcare provider to differentiate the possible causes. Patients may also complain of difficulty walking and of pain with internal rotation of the involved leg, such as occurs during cross-legged sitting or walking. X-rays or an MRI offer little help in directly diagnosing piriformis syndrome but may be used to rule out other causes of sciatica such as a herniated disc in the lumbar spine.
There are many functional abnormalities that may have either caused or resulted from this condition. Once the diagnosis has been made, these underlying, perpetuating biomechanical factors must be addressed.
Functional biomechanical deficits associated with piriformis syndrome may include the following:
Functional adaptations to these deficits include the following:
Piriformis syndrome is a unique cause if sciatic nerve irritation (neuritis) or sciatica. The condition, which can mimic lumbar disc herniation, usually is caused by irritation of the sciatic nerve due to spasm and/or contracture of the piriformis muscle. Piriformis syndrome is also referred to as “pseudosciatica”, “wallet sciatica”, and “hip socket neuropathy”.
It frequently goes unrecognized or is misdiagnosed in clinical settings. Piriformis syndrome can “masquerade” as other common somatic dysfunctions, such as intervertebral discitis, lumbar radiculopathy, primary sacral dysfunction, sacroiliitis, sciatica, and trochanteric bursitis.
(Image from http://www.concordortho.com/patient-education/topic-detail-popup.aspx?topicID=4214fc65d020761633286131e407d037)
The proper understanding of piriformis syndrome requires knowledge of the anatomy and anatomical variations in the relationships between the sciatic nerve and the piriformis muscle.
The piriformis muscle is flat, pyramid-shaped, and oblique. This muscle originates on the front of the sacrum and inserts at the greater trochanter of the femur. With the hip extended, the piriformis muscle is an external rotator of the hip; however, with the hip flexed, the muscle becomes a hip abductor.
In most of the population, the sciatic nerve exits the pelvis deep along the lower surface of the piriformis muscle. However, many developmental variations of the relationship between the sciatic nerve in the pelvis and piriformis muscle have been observed. In as much as 22% of the population, the sciatic nerve pierces the piriformis muscle, splits the piriformis muscle, or both, predisposing these individuals to irritation of the sciatic nerve.
From http://www.anatomyatlases.org/AnatomicVariants/NervousSystem/Images/70.shtml
Piriformis syndrome can be caused by a variety of issues. The underlying mechanism is from irritation to the sciatic nerve. Below are some causes of irritation to the sciatic nerve as it passes the piriformis muscle:
1. Muscular problems
2. Postural
3. Traumatic
4. Partial or total nerve anatomical abnormalities
5. Other causes can include the following:
Ballet dancers are widely known for their superior body control in various challenging body positions. In fact it has been found in recent studies that ballet dancers have better postural control when compared to other elite athletes. However, what has not been examined is the effect of injury on postural balance in dancers. A recent study in The American Journal of Sports Medicine by Lin, et al, addresses this vary issue.
Postural balance requires a combination of several different sensory inputs: visual, vestibular (inner ear), and somatosensory (from the skin, joints, muscles, etc). Somatosensory input gives the brain information about where the body is in space; this is called proprioception. These sensors can be damaged with ligamentous and muscular injuries such as ankle sprains and in turn lead to a deficit in proprioception. Proprioceptive deficits can put a dancer at more risk for re-injury or new injury.
The recent study by Lin was the first study that evaluated stability in dancers in ballet specific postures following an injury. Three different groups were studied: healthy dancers, injured dancers (with sprained ankles), and health non-dancers. Postural stability was evaluated on a balance sensor that monitors subtle deviations in stability. This was done with the eyes open and then again with the eyes closed to further stress the proprioceptive component of balance. As expected the injured dancers had decreased control not only in ballet specific positions but also in a simple single leg standing position when compared to healthy dancers. Surprisingly the injured dancers had worse stability control than the non-dancers. Many dancers, and other athletes, that I have treated often assume that a skill such as balancing will come back without training, however this is not the case, and as the study indicated it regresses to the point that is worse than untrained people.
The postural deficits were most notable in side to side control with single leg standing and front to back control with first and fifth position. Compensation was noted at the knee and hip joints in an attempt to make up for the injured ankle. The en pointe position crated the most stability issues; injured dancers were inferior in all directions of stability. With lateral ankle sprains the most commonly damaged ligament is the anterior talofibular ligament. This ligament is stressed maximally when the ankle is plantar flexed, such as during en pointe positions. It is not surprising that when this ligament is damaged the proprioception during pointe is significantly disturbed.
This study brings to light the importance of a thorough rehabilitation program that includes proprioceptive training in ballet specific positions. Typically a sprained ankle takes 6-8 weeks to recover. During this time it is critical to begin proprioceptive training to ensure that the balance deficits do not lead to further injury. Additionally if a dancer has a past injury of ankle sprain without proper rehabilitation it is likely that postural stability still remains and there is an increased risk to further injury. If this is the case, dancers should begin a 3-4 week proprioceptive training plan that includes ballet specific posture.
Dance injuries and rehabilitation are unique and should be managed by a healthcare practitioner that is experienced with the subtleties of dance medicine. Proprioception training for ballet typically includes balance exercises on an unstable surface such as a Bosu ball or stability disc. These exercises should be done in normal stance position as well as ballet specific positions. Whole body vibration may additionally add value as a proprioceptive trainer especially early during rehab when range of motion is limited. KinesioTape or RockTape are also good taping methods that help protect the joint and provide increased proprioception when applied properly. Keep in mind that a training plan should be designed specifically for each injury and you should not attempt to manage the injury without the supervision of an experienced healthcare practitioner.
Backpacks are a practical way for students to carry schoolbooks and supplies. They are designed to distribute the weight of its contents among some of the body’s strongest muscles; however, in recent years, the weight of student backpacks has increased dramatically and has become a public health concern. Studies show that heavy backpacks can lead to both back pain and poor posture, notes the American Chiropractic Association (ACA). In fact, in 2001 backpacks were the cause of 7,000 emergency room visits and countless complaints of muscle spasms, neck and shoulder pain.
Here are some tips on purchasing a backpack, packing a backpack, and wearing a backpack to reduce the risk of injury.
Taking the time to make careful consideration regarding your child’s backpack use is important to prevent injury. If your child does develop back pain have him or her seen by a qualified health professional for proper diagnosis and treatment.
-Dr. Rose, DC
Dr. Rose is a San Diego Chiropractor located in Mission Valley. More information regarding the services he provides can be found at www.RoseChiropracticSD.com.
American Chiropractic Association. Backpack Misuse Leads to Chronic Back Pain, Doctors of Chiropractic Say. Accessed at acatoday.org
Admas, Chris. A Fitting Guide for a Child’s Backpack. 2006.
Howard County Public School System. Backpack Safety Guidelines
More and more young baseball players, especially pitchers, are coming down with “Little League elbow,” or “Little League shoulder.” Don’t let the names fool you; these are real medical diagnoses with real consequences. Among pitchers under 12-years-old, as many as 45 percent complain of chronic elbow pain, according to several published studies. At the high school level, nearly six in every 10 pitchers suffer chronic elbow pain. Most will heal with a combination of rehabilitation and prolonged rest while some will require surgery.
A broad recommendation is that pitchers base their number of pitches each week by multiplying their age by 10, so an 8-year-old would limit his pitches to 80 per week. A 12-year-old would throw no more than 120.
The American Academy of Orthopaedic Surgeons (AAOS) recommends limiting the number of pitches per game to 60 to 100, with no more than 30 to 40 in a single practice session, adding that innings pitched should be limited to about four per week, with a minimum of three days rest between starts.
Research studies have shown that cold muscles are more prone to injury. The AAOS suggests an active full body warm up followed by slow, gentle stretching, holding each stretch for 30 seconds. A knowledgeable coach or trainer should be able to guide your athlete in this area.
Poor throwing motions put undue stress on the elbow and shoulder. It is especially important that between the ages of 8 and 14 players receive skilled instruction in proper throwing mechanics. Pitching lessons should focus on gaining control, increasing velocity and developing a command of the strike zone.
One of the most important factors to preventing the development of serious injuries is early identification and treatment. Young players often ignore pain or are encouraged to play through it. This way of thinking can be extremely harmful and lead to more serious complications that may not heal without aggressive treatment and possible surgery. However, if caught early, most youth throwing injuries can be relieved with a combination of therapy, rest, and rehabilitative exercises.
Early signs of injury include decrease in ability to throw the ball as fast or as accurately, loss of enjoyment in playing baseball, elbow or shoulder pain with or after throwing. If any of these signs are present, the player should be evaluated by a healthcare professional. More significant signs include prolonged persistent pain after throwing, swelling at the elbow, and difficulty straightening the elbow.
Any persistent pain, loss of motion or joint should keep a player on the sidelines until the symptoms disappear or a doctor clears the players. Be sure to consult a health care professional familiar with the intricacies of baseball injuries if any of these signs are present.
-Dr. Kevin Rose, DC, CCSP®
Dr. Rose is a Certified Chiropractic Sports Practitioner® located in San Diego. As a former professional baseball player, having played three seasons in the minor leagues, Dr. Rose understands the unique characteristics of baseball injuries first hand.
The physical demands placed on the bodies of dancers have been shown to make them just as susceptible to injury as football players. For this reason, more emphasis should be placed on creating awareness of risk and preventing injuries in dancers. Most dancers begin dancing at a young age, the repetitive practice of movements that require extreme flexibility, strength, and endurance make them prime candidates for overuse injuries. In fact, there is little doubt that the vast majority of injuries are the result of overuse rather than trauma. These injuries tend to occur at the foot, ankle, lower leg, low back, and hip. These injuries show up with greater frequency in dancers as they age, so it is extremely important to emphasize what the young dancer can do to prevent future injuries.
Dancers are exposed to a wide range of risk factors for injury. The most common issues that cause dance injuries include:
Getting and keeping dancers free of injury in a fun environment is key to helping them enjoy a lifetime of physical activity and dance. With a few simple steps, and some teamwork among parents, teachers and health professionals, dancers can keep on their toes and in the studio with a healthy body.
Key Points
Dancers should remember a few key things to prevent injury:
Parental Oversight
Parents play a large role in injury prevention. First, they must be careful not to encourage their children to advance to higher levels of training at an unsafe rate. Specific to ballet, parents should ensure that the decision to begin pointe training is not made before the child’s feet and ankles develop enough strength. Age 12 is the generally accepted lower limit, but strength and maturity are more important than age.
Proper Instruction
The first line-of-defense to prevent injuries may be dance instructors. From the onset of instruction teachers should establish a class environment where students are not afraid to share that they are injured and need a break. Students should also be consistently instructed on the importance of warm-ups and cool-downs, proper equipment, and at what point, whether by age or maturity, it is appropriate to move on to the next level of dance.
Health Care and Screening
Health professionals play a significant role not only in treating and rehabilitating the injuries dancers incur, but also in preventing them. Dancers respond well to providers who respect both the aesthetics and intensity of dance. Experienced providers can initiate and facilitate screening sessions for dancers to help identify potential problems and prevent future injuries. They should be considered a natural part of a dancer’s career and sources of insight into staying healthy. A dancer should return after an injury only when clearance is granted by a health care professional.
REFERENCES
Clippinger, K. Dance Anatomy and Kinesiology. Champaign, IL: Human Kinetics, 2007.
Howse, J. Dance Technique and Injury Prevention. 3rd ed. London: A & C Black, 2000.
Solomon, R, J. Solomon, and SC Minton. Preventing Dance Injuries. 2nd ed. Champaign, IL: Human Kinetics, 2005.
www.stopsportinjuries.org
At Proform Sports Chiropractic, we help create lifelong musculoskeletal health, emphasizing physical activity and exercise throughout life. Our goal is to prevent injury and achieve optimal health, mobility, and quality of life throughout each person’s lifespan.
Our two primary areas of interest are musculoskeletal injury prevention and rehabilitation. Our offfice focuses on on injury prevention and on effective treatment and rehabilitation that are essential to putting the person back on the path to optimal health.
