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Sciatica, Piriformis Syndrome, Piriformis Release, Piriformis Surgery for buttock injury occurring on April 4, 2001 from a fall injury at construction site at job.
Doctors Report Provided Below.
TUSTIN HOSPITAL AND MEDICAL CENTER
14662 Newport Avenue, Tustin, California 92780
SURGEON: Israel P. Chambi, M.D.
ASSISTANT SURGEON: Edward Boseker, M.D.
DATE OF SERVICE: 06/09/04
1. Piriformis syndrome. 2. Residual sciatic nerve root irritation, status post lumbar
3. Lumber discogenic disease, L5-S1.
1. Decompression of the right sciatic, posterior cutaneous, and inferior
gluteal nerves, and the operative microscope was used.
2. Mapping of the nerves in the gluteal area using electrical stimulation.
ESTIMATED BLOOD LOSS: 10 cc.
INDICATIONS: The patient is a 39-year-old, right-handed male who comes
with a history being involved in an industrial injury on 04/02/2001. The
patient presents with intense pain in the right buttocks with radiation to
the right leg. The patient also has experienced weakness in the hamstring
muscles with sensory deficit in the right S1 and L5 nerve root distribution.
The patient has a positive Tinel sign in the region of the right sciatic
notch as well as pain in the distribution of the piriformis muscle. The
patient had received extensive medical treatment. Initially, the patient
improved with piriformis injections. However, over last recent months, the
patient has substantial recurrence of the pain that clearly increases with
sitting and is relieved by rest. Pain medications have provided minimal
relief of the patient's pain. Based on the lack of improvement with
intensive medical treatment, the patient was recommended to have an operation
to decompress mainly the sciatic nerve as well as the inferior gluteal and
the posterior cutaneous nerve. The patient understands the risks of
operation including infection, bleeding, the possibly of nerve damage,
as well as the potential possibility that the operation may not improve,
and after the implications of operation, the patient signed the consent.
PROCEDURE IN DETAIL: After obtaining general endotracheal anesthesia, the
patient was placed in the prone position on a Wilson frame. The right buttock
was prepped and draped in the sterile fashion. A small curvilinear incision
was made. The incision was carried down through the subcutaneous tissue. The
gluteus maximus muscle was split parallel to its fibers. We took an oblique
approach to direct our view to the piriformis muscle. The gluteus maximus
was extremely taken; we have problems in applying the appropriate retraction.
Immediately, we were able to identify the inferior gluteal nerve, which was
substantially displaced medially and the inferior gluteal nerve was displaced
inferiorly. We came to find a very prominent fibrosis involving --
Patient Name: PAUL DEAN
Physician: ISRAEL P. Chambi, M.D.
TUSTIN HOSPITAL AND MEDICAL CENTER
14662 Newport Avenue, Tustin, California 92780
-- almost the entire piriformis muscle and this was causing the substantial
displacement of the sciatic nerve as well as the posterior cutaneous and inferior
displacement of the inferior gluteal nerves. Using the microscope, a portion of
the muscle that is still attached to this fibrous tissue that looks like very
thick fibrous bands were cauterized with bipolar electrocoagulaton and then
sectioned with Metzenbaum scissors. Once this was sectioned, there was a
substantial decompression of the sciatic nerve and we were able to place a #3
Penfield into the pelvis through the sciatic notch. Further stimulation of the
inferior gluteal nerve demonstrated that the nerve was working well and this
was not affected during our dissection. The fatty tissue that was there
in the vessel was replaced to cover the sciatic nerve. Then fibrin glue
was applied. After obtaining excellent hemostatis, the fascia of the gluteus
maximus muscle was approximated with interrupted 2-0 Vicryl sutures as well as
the subcutaneous tissue and the skin with 5-0% to reduce the incision pain.
The patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: 10 cc.
NEEDLE AND SPONGE COUNT: Correct.
FINDINGS: We found a very thick fibrosis involving most of the piriformis
muscle replacing and displacing the sciatic nerve medially. Following the
operation, there was substantial relaxation of the sciatic nerve. There were
ISRAEL P. Chambi, M.D.
D: 06/09/2004 09:41
T: 06/09/2004 22:44
Patient Name: PAUL DEAN
Physician: ISRAEL P. Chambi, M.D.
This patient will continue on temporary total disability. Good or bad,
to be declared permanent and stationary after sufficiently recovered.
I declare under penalty of perjury that I, the signing physician, have
actually performed this examination and the time spent in performing this
evaluation is in compliance with the IMC Guidelines
(Section 5307.1 and 4507.6).
I declare under perjury that I have devoted at least 1/3 of my total
practice to providing medical treatment.
ISRAEL P. Chambi, M.D.
Stock Photo Israel P. Chambi-Venero, MD Neurosurgeons Israel P. Chambi, M.D., FACS 801 N. Tustin Ave., Suite 406 Santa Ana, CA 92705 714 973 0810 FAX 714 973 0840 Diplomat American Board of Neurological Surgery Brachial-Plexus & Peripheral Nerve Institute micro neural surgeon - Santa Ana, California (CA) 92705 PRESCRIPTION
ISRAEL P. CHAMBI, M.D., FACS
Diplomat American Board of Neurological Surgery
Adult & Pediatric Neurosurgery
Brachial Plexus & Peripheral Nerve Surgery
XXX XXXXX Santa ANA, CA 92705
Paul Dean 39
Name (Print) Age
XXXX Riverside, CA 6/29/2004
Address City Date
Hydrocodone/Apap 5/500 - Tab Every 4 hours
Mobic #15 - Once A Day
Post Piriformis Syndrome
Right - Center
Physical Therapy 3 times a week for 6 weeks
Israel P. Chambi, M.D. Calif. Lic. # XXXXXXXXXX
My questions to Dr. Chambi at first post surgery visit. I already
had a back surgery (L5 S1 Discectomy) a year and a half earlier.
POST-OP RT. PIRIFORMIS RELEASE FIRST VISIT TO DR. CHAMBI AFTER SURGERY
WHY DO I STILL HAVE PAIN AFTER THE SURGERY...
June 29, 2004
QUESTIONS FOR DR. CHAMBI FROM PAUL DEAN, PATIENT:
1. Why do I still have intense pain when sitting, lifting,
standing long periods, or moving around after the Piriformis
DR CHAMBI: You are having pain because your sciatic nerve
in the Piriformis Region has shrunk and lost elasticity.
Over the next 6 months the body will bring some of that
elasticity back and then the nerve will be able take stretching
and lifting which take a longer length of elasticity than
you have at this time.
You have been scarred down completely by your Piriformis Muscle
and your nerve has been impinged for so long that it will take
some time for the sciatic nerve to heal.
2. What can I do in the meantime to help the healing, so that
I can get back to lifting and sitting and doing what I was
able to do in the past?
DR. CHAMBI: Do not stretch the sciatic nerve and do not lift
any weights. This damages the sciatic nerve. You can do light
walking and massage as well as ultra sound and heat can be
applied to the region affected region. Use Vicodin for pain,
and Mobic to help circulation and nerve healing.
3. What exactly was done in the surgery?
DR. CHAMBI: The Piriformis muscle was separated
and several inches of scarring that
was attached to the sciatic nerve was
4. Did you remove any of my Piriformis Muscle?
DR. CHAMBI: It was cut, but none was removed.
5. How much Piriformis Muscle did you cut through?
DR. CHAMBI: About two-thirds of the Piriformis
was cut through.
6. How much scarring did you remove?
DR. CHAMBI: Several inches of scar tissue was
removed because it had adhered to
the sciatic nerve making it impossible
for the nerve to move, giving you pain.
7. Will the scarring come back and a later time?
DR. CHAMBI: No it will not. We use a Fibrin Glue
which stops scar tissue.
8. Will my pain get better?
DR. CHAMBI: Some elasticity in the sciatic nerve
will come back, reducing your pain.
9. Will I be 100%?
DR. CHAMBI: You should get quite a bit better now
that your sciatic nerve is no longer
trapped. However, the nerve has been
entrapped for three years and has been
compressed extremely and will need to
heal. All sciatic nerve healing is slow
and we will have to wait and see what
the final outcome of healing will be.
You will be in physical therapy for quite
some time before we know how well you
have healed up.
10. Does waiting a long time before the surgery become a
problem for the healing of a sciatic nerve?, in my case
it has been three years since my injury first occurred.
DR. CHAMBI: Yes, when the sciatic nerve is compressed for a
very long time, it is less likely that it will regain its
elasticity and full functioning.
11. If I exercise my muscles or body will that help the healing
process of my sciatic nerve?
DR. CHAMBI: No. The sciatic nerve does not do well when stretched
or exercised a lot. Soft message and gentle walking and are recommended,
but do not stretch the sciatic nerve and do not lift weights as this
hurts the injured sciatic nerve. You do not have a muscle problem,
but a nerve problem which needs very gentle care. Stretching and
strengthening does not help a damaged nerve, and you do not want to
inflame the area.
12. I know that 8 out of 10 patients were helped by the Piriformis
Release and I am glad I did the operation because the intensity of
my pain has been reduced from it maximum pain levels, and I was
wondering why 2 patients had a failure of an outcome?
DR. CHAMBI: Both patients waited to long before having the piriformis
release surgery. The first patient waited 8 years and the second
patient waited 10 years, and they never regained elasticity of their
nerve and there was permanent damage because the sciatic nerve was
compressed for two long.
13. Have you treated any Professional Sports Figures lately, and
how is there recovery?
DR. CHAMBI: We just did a Piriformis Release on a Professional
Baseball player who hurt his sciatic nerve in the Piriformis Region
a year ago while pitching a fastball. We gave him the release and
he is still recovering at this time.
14. Why did I have to see four Doctors before you and none knew
that I had piriformis syndrome, but you figured it out right away.
These other doctors were well known in their Orthopedic field and
Neurological fields. It was quite upsetting that nobody could tell
me the real reason I was in pain. I feel like this is the most
misunderstood injury there could possibly be. It has the sciatic
pain that goes down to the foot and every doctor assumes that you
have a bad disc, or a failed back surgery. Why is there such a
misunderstanding about this injury?
DR. CHAMBI: Most Doctors never see this type of injury in their practice
because it is quite rare in most practices, however, I see this type
of injury quite often because I deal so much with professional
athletes. You have to fall in an unusual manner to get this type
of trauma. The fall must be sideways and backwards which occurs often
in football lineman and other high contact type of sports.
The Doctor must rule out disk problems in the back by looking at the
MRI and determining that the disk in the back is not affecting the pain
after a back surgery because the nerve in the back is freed up from that
surgery. Also the symptoms are different for Piriformis Syndrome than
in the back patient. There is buttock pain in the Piriformis region
that is quite specific and the piriformis muscle is in spasm in many
cases. The pain is mostly in the outlaying areas and not in the
lower back region specifically. Lidocaine Injections usually help
calm down the Piriformis Muscle which helps the pain go away and this
is a positive sign that you have Piriformis Syndrome. However, if
your sciatic nerve has been scarred down, that scarring needs to
be removed so that you can have full range of motion without pain.
The sciatic nerve needs to have full elasticity and movement and cannot
be compressed by the spasm or displaced Piriformis Muscle.
15. I still cannot sit, lift or stretch or be active without a lot
of pain. Do you think this will all change for the better?
DR. CHAMBI: Yes, but it will take some time for the sciatic nerve to heal,
and it cannot be rushed. You will be doing a lot better in time but
you need to take it easy for right now.
Thank you Dr. Chambi, I will be going into physical therapy three times
a week for six weeks and am looking forward to my next visit with you.
I am glad I did the surgery and feel I now have an opportunity to heal,
and I was not able to heal before now because my nerve was way to impacted
and scarred down in the past to heal on my own. At least now I have a
chance to get better. It is a shame that no other Doctor could diagnose
this problem, and that I had to wait so long. Every day my nerve
is impacted the chances of full recovery are that much worse as permanent
damage can be caused.
Click below for the photos of the operation for the following:
Piriformis Release Surgery
Dr. Israel Chambi, Neurosurgeon: Training and Civil life: Dr. Israel Chambi finished his undergraduate training at the National University of Arequipa, Peru, and his medical training at the University of Mexico in 1974. He came to California for his internship at the University of California at both the Irvine and Los Angeles campuses, and later moved to Toronto, Canada, where he obtained a fellowship in stereotactic neurosurgery. He held a teaching and research post at the University of California at Irvine and founded the Brachial Plexus and Peripheral Nerve Institute in Santa Ana. At the present time he is chair of the division of neurosurgery at Western Medical Center in Santa Ana. Besides his contribution to the scientific world, Dr. Israel Chambi is an exemplary contributor to civic and church life. He excels in the field of neurosurgery, not only in his clinical skills, but also as a teacher, mentor, publisher, and national and international speaker. He has been a supporter of La Sierra University's Stahl Center for World Service. His ethnic roots motivated him to participate in various projects, which bring north and south together. His cross-cultural vision motivated him to pioneer "Radio Adventista" in the Peruvian Andes and to promote medical conferences in Arequipa, Peru. The Chambi Venero brothers are part of the history of rural education in Peru. Evenezer Chambi owns a clinic in Beverly Hills, California and his brother Dr. Israel Chambi is a renowned neurologist who also lives in the United States of America. Chambi Father and head of Family: The head of the family is Pastor Pedro Chambi, learned to read at age 22. As a leader in his local congregation, Dr. Chambi has a lasting impact in fostering inclusiveness and interdependence in the multi-ethnic Santa Ana Seventh-day Adventist Church. He is married to Rosalba Chambi, who is a nurse, and has three children: Ruth, Moses, and Israel Jr. NEWS: La Sierra University Donors: Dr. Israel and Mrs. Rosalba Chambi - half million-dollar gift for the Science Complex at Los Sierra University, 4700 PIERCE ST , RIVERSIDE , CA - 92515 Dr. Israel Chambi, Neuro-Surgeon Wife: Rosalba Chambi - Nurse Dr. Israel Chambi is a neurosurgeon in Orange County. He and his wife, Rosalba Chambi are exemplary contributors to civic and church life. Born and raised in Peru and Mexico, the Chambi's international roots and cross-cultural vision motivate participation in projects that foster inclusiveness in both North and South America such as the founding of Radio Adventist in the Peruvian Andes and this their most recent gift to La Sierra University for the new Science Complex. Professional Reports: Chambi, Israel P. "The Piriformis Syndrome Manifesting As Lumbar Disc Syndrome: Report of 19 Cases" The Western Neurosurgical Society, Annual Meeting, Boson, MA., August 18, 1994 Chambi, Israel P. "The Piriformis Syndrome Manifesting As Lumbar Disc Syndrome: Report of 19 Cases" The Western Neurosurgical Society, Annual Meeting, Gleneden Beach, Oregon. September 9-12, 1995. Neuroscience Conference 02.20.92 Annual Scientific Program UCI Neurosurgery and SNSOC "Does Piriformis Syndrome Exist?" State-Of-The-Art Microscope Provides Incredible Precision In Neurosurgery "The diameter of a human hair, is how Israel P. Chambi, M.D., FACS, a Diplomat of the American Board of Neurological Surgery and a distinguished Fellow of the American College of Surgeons, describes the size of a blood vessel in the brain. "A small peripheral nerve is no larger than a toothpick." This obstacle of scale, present in even the simplest surgeries, is the reason the sue of a high-powered microscope is an essential part of his neurosurgical practice at Tustin Medical Center. Most people understand that high blood pressure can disrupt blood flow to the brain, causing a stroke. Dr. Chambi explains that, like the brain, the peripheral nervous system is also vulnerable to pressure. "Many of my patients are athletes who experience pain from pressure on the peripheral nerves in their arms or legs. The pressure may be caused by an actual injury or be secondary to inflammation of the nerves caused by overuse." Dr. Chambi's goal is to correct or minimize the neurological disability that results from disruption in blood flow caused by pressure from swelling or bleeding within the nervous system. Unique in the diversity of his practice, Dr. Chambi is noted for his expertise in neurovascular surgery. Also, he is one of only a handful of surgeons in the region who perform specialized surgery to treat disorders of the peripheral nerves, including nerve gafting procedures. In addition to maintaining his private practice, Dr. Chambi has been instrumental in the development of the Neurovascular and Peripheral Nerve service at Western Medical Center, where he is part of a team of qualified neurosurgeons. NOTE: He is not at Western Medical Center but is instead at Tustin Medical Center at this time. Additional information regarding the use of microsurgery for the treatment of neurovascular or peripheral nerve disorders, such as those listed below, may be obtained by requesting a referral from your physician or by contacting Dr. Chambi's staff at 714-973-0810. Aneurysm and Arteriovenous Malformation Spinal Disorders -- Ruptured Disc, Stenosis Traumatic Brain and Spinal Cord Injuries Brain Tumors hydrocephalus Breathing Disorders -- Phrenic Nerve Pacemaker Peripheral Nerve Disorder Affecting the Arms and Legs CURRICULUM VITAE Isreal P. Chambi, M.D. PERSONAL DATA: Date of Birth: January 25, 1949 - Chile Home Address: 112 South M Anaheim, CA. Business Data: Brachial Plexus and Peripheral Nerve Institute 801 N. Tustin Ave Suite 406 Santa Ana, CA 92705 (714)-973-0810 FAX: (714)-973-0840 Citizenship: United States EDUCATION 1966-68 National University of Peru B.S. Arequipa, Peru 1968-74 University of Mexico M.D. Mexico City, Mexico POSTGRATUATE TRAINING 1978-79 Martin Luther King Internship Medical Center Los Angeles, California 1979-81 University of California, Irvine General Surgery Medical Center Resident Orange, California 1981-83 University of California, Irvine Neurosurgery Medical Center Resident Orange, California ------------------------------------------------------------------------------- As a side note... Compassion is in the family. Israel P. Chambi, M.D. has a brother, Ebenezer Chambi, M.D. Link Ebenezer Chambi, M.D. Family practice Physician Chapel Medical Clinic 9739 California Avenue South Gate, CA 90280 Phone: 323-567-1212 ------------------------------------------------------------------------------- Ebenezer Chambi: Dialogue with an Adventist physician, health educator, and community leader Link Ebenezer Chambi MD - Chambi Ebenezer MD 9739 California Ave South Gate, CA 90280 Phones: (323) 564-2228 by Michael Peabody Born in Peru, Dr. Ebenezer Chambi developed early in his life a sense of community and an inclination to service. His family was active in the local church. Throughout his educational experience, he was guided by a commitment to help others. In 1970, he completed his pre-medical studies at Union College (now Peru Union University) located near Lima, the capital. Although he wanted to study medicine in his homeland, the then prevailing political situation made this virtually impossible. His older brothers had moved to Mexico to pursue their medical training; so did he. Completing his medical degree from the Autonomous University of Guadalajara, Mexico, in 1975, he did his residencies in Puerto Rico and Los Angeles, California. After completing the latter, Dr. Ebenezer Chambi joined a research team to study epilepsy. Currently, he is practicing general medicine at the Chapel Medical Clinic in South Gate, California. In addition to ensuring quality care to his patients, Dr. Ebenezer Chambi brings his Christian commitment to bear on his profession by continually promoting preventive care and healthful living. He is involved in his community through a variety of activities ranging from sponsoring folk music concerts to speaking to high school students on health. In recognition of his community service, he received in 1994 the La Sierra University Presidential Citation for Humanitarian Service. Ebenezer Chambi and his wife, Esther, have three children who are pursuing advanced studies: Esther Janet, Ebenezer Howard, and Eber Caleb. Dr. Ebenezer Chambi, what influences have shaped your life? Perhaps the same four major influences that shape all of us: family, education, community, and religion. The family teaches us how to care for each other. Parents care for children, children care for each other and their parents. In a good home, we learn to love people unconditionally. Education is one of the major ways to learn about ourselves and develop our talents and intellectual skills. It structures our personality. Community teaches us that we are not alone-no one is an island. We depend on other people and they depend on us. Christianity gives us inner strength, especially when we feel discouraged and don't have energy to keep going. There is a higher power, God, ready to help us. Religion gives us the powerful tool of confidence. It brings us strength and hope. It keeps us from giving up on life. At the end of the journey, it gives us the assurance of a better life. What type of research did you do in epilepsy? Epilepsy can be a very debilitating disease, and our team wanted to find its cause and determine whether it could be successfully treated or even cured. We studied a diverse population in the Los Angeles area, seeking ways of helping epilepsy victims. The results were rewarding. Some were cured. Many were able to live relatively normal lives and return to their vocations. Currently, what does your practice cover? I am involved in general practice. Beyond the regular treatment of patients, I focus on preventive medicine. I want to teach people how to live healthier, happier lives. In my practice, I see a lot of baby boomers. I'm one of them, so I know what they are like and how they live. Because they work so many hours and have so many activities, they often wait until the last possible moment to come to see me, knowing that a visit to the doctor takes time. They usually don't come in when they have a slight cold or a stomach ache. They visit my office only when they sense that they are in serious trouble and need help. We do a complete check-up, including blood and urine tests. Most of the time we find that they have high cholesterol levels; they are not eating right and not exercising. Most of the common problems can be prevented, and I emphasize that. How do you convince busy people to live healthier lives? The key is behavior modification. We can give objective explanations of why a person should exercise more or spend some time relaxing rather than overworking, but it is challenging to convince people that they need to make fundamental changes in how they live. At times a physician needs to be quite direct, even blunt, to persuade patients to radically alter their lifestyle. A while back, a man, suffering from exhaustion, came to my office. He was working at two jobs so he could buy a new house every year. His wife told me that he worked too many hours a day and did not take time to relax and enjoy life. She told me that they already owned three homes and that he wanted to buy another one. I told her, "Don't worry. The more he works, the more houses he will leave to you when he dies!" He got the message and changed his habits. Do you also utilize the media to educate the public? When I was doing my residence in Puerto Rico, I started a radio program on health prevention and promotion. Then here, in the Los Angeles area, I hosted for ten years a weekly radio forum called El Médico Habla (The Physician Speaks) that was quite popular. We have also prepared several short video programs on health that I make available to pastors and TV cable stations. Does the emphasis on exercise and nutrition in the popular media help in having people change their lifestyle? Yes. Ten or 15 years ago, it was more difficult to convince people that they needed to exercise and eat well. But now, the media's coverage of prevention and health has made my job easier in terms of education. The problem is that many people who understand the principles of healthful living aren't putting them into practice. They still eat too much fast food and stay up too late watching the late shows. Fortunately, people are beginning to see the light. The city where I practice has a park where you can see more people running, walking, and doing other exercises than in any other park in the nearby cities. I like to think this has something to do with our emphasis on exercise. The hamburger place that is near our office now also sells vegetarian burgers. I think that shows some of the positive influence we've had on people who are trying to eat more healthful foods. How can people who are not involved in the health-care profession effectively spread the message of healthful living? All of us exert an influence and convey a silent message wherever we go. People are searching for a better life, and they look up to good role models. If we spend time with people, we can influence them positively by your example. I've found it effective not to preach at people, but rather to lead by example. We can encourage others to see that there's a better life. It's easy to become so focused on our own studies or profession that we forget that we are part of a larger community outside our walls. How can a person who has become so insulated begin to interact with the larger community beyond their family or church? Before I became active in the community, it was easy to be critical of those outside my circle. But after I became involved, I discovered how much good I could do and how much I enjoyed it. Get to know other people, especially those with whom we would not normally associate. It will help with your social and intellectual development. You will also learn how your community works and how you can help. Becoming involved begins with something as simple as the way you greet people. Start with a solid and sincere, "Good morning. How are you?" Speak words of encouragement. Learn to listen. Meet with the people who are having problems in your area of expertise who don't know where to look for help. Focus on relieving their suffering. A few years ago, an earthquake hit the Los Angeles area. When people asked me why I left my office to volunteer in the relief efforts, I told them that I was just paying part of my debt to my community. The community has given me a lot and I want to give back. It's a two-way street. And don't forget to have fun! One of the things I do is organize folk-music concerts. And though lots of people enjoy them, I enjoy them the most! How do you apply this involvement in your church? I love my church like a family. I do things not to be recognized or rewarded, but because I want to do something for Christ and my church. If you start a project with the goal of being recognized for your efforts, you miss the point. Instead, do the job because it is important and necessary. As a successful physician, a health educator, and community leader, what would your counsel be to people who are just entering their careers? Learn from successful people by watching how they live, how they get along with others, and how they maintain their emotional balance. Emulate their good traits. If I retrace my journey, being active in the church and in the community were the most important factors that kept me on track. Those of us who have been blessed by talents and education can do much good. Put yourself where God can use your skills. Take the initiative to help the community and make people's lives better. That is a worthwhile goal in life. Interview by Michael Peabody. Michael Peabody is a third year law student at Pepperdine University in Malibu, California. E-mail: Dr. Ebenezer Chambi's address: 9739 California Ave.; South Gate, California 90280; U.S.A. ------------------------------------------------------------------------------- Orthopedics Link Information about diagnosis and treatment of piriformis syndrome What is piriformis syndrome? Good question! No one really knows exactly what causes piriformis syndrome, or if it really exists. Some physicians believe that piriformis syndrome is the name given to hip/buttock pain that cannot be otherwise diagnosed. Others believe that piriformis syndrome is a very real cause of pain and disability. What is the piriformis muscle? The piriformis is a muscle that travels behind the hip joint. The piriformis muscle is small compared to other muscles around the hip and thigh, and it aids in external rotation (turning out) of the hip joint. The piriformis muscle and its tendon have an intimate relationship to the sciatic nerve--the largest nerve in the body--which supplies the lower extremities with motor and sensory function. The piriformis tendon and sciatic nerve cross each other behind the hip joint, in the deep buttock. Both structures are about one centimeter in diameter. What do people think happens in piriformis syndrome? It is thought that the piriformis muscle tendon may be tethering the sciatic nerve, and causing an irritation to the nerve. While it has not be proven, the theory supported by some physicians is that when the piriformis muscle and its tendon are too tight, the sciatic nerve is choked. This may decrease the blood flow to the nerve and irritate the nerve because of pressure. What else may be causing this pain? Sometimes referred to as "deep buttock pain," other causes of this type of pain include spine problems (including herniated discs, spinal stenosis, etc.), sciatica, and tendonitis. The diagnosis of piriformis syndrome is often given when all of these diagnoses are eliminated as possible causes of pain. Other signs of piriformis syndrome include examination maneuvers that attempt to isolate the function of this muscle, and the finding of pain directly over the tendon of the piriformis muscle. Is there any treatment for piriformis syndrome? Unfortunately, the treatment of piriformis syndrome is quite general, and often this is a difficult problem to recover from. Some treatment suggestions are: 1. Physical Therapy - Emphasis on stretching and strengthening the hip rotator muscles 2. Rest - Avoid the activities that cause symptoms for at least a few weeks 3. Anti-Inflammatory Medication - To decrease inflammation around the tendon 4. Deep Massage - Advocated by some physicians 5. On some occasions, when these treatments fail, patients have surgery to release, or loosen, the piriformis muscle tendon. This surgery is not a small procedure, and generally considered the last resort if a lengthy period of conservative treatment does not solve the problem. ============================================================================= eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions Link Piriformis Syndrome Last Updated: June 14, 2004 Rate this Article Email to a Colleague Synonyms and related keywords: hip socket neuropathy, pseudosciatica, wallet sciatica, deep gluteal syndrome, piriformis syndrome AUTHOR INFORMATION Section 1 of 10 Author Information Introduction Clinical Differentials Workup Treatment Follow-up Miscellaneous Pictures Bibliography Author: Milton J Klein, DO, Consulting Staff, Department of Physical Medicine and Rehabilitation, Sewickley Valley Hospital and Ohio Valley General Hospital Milton J Klein, DO, is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Association of Electrodiagnostic Medicine, American Medical Association, American Osteopathic Association, and American Osteopathic College of Physical Medicine and Rehabilitation Editor(s): Rajesh R Yadav, MD, Assistant Professor, Section of Physical Medicine and Rehabilitation, MD Anderson Cancer Center, University of Texas at Houston; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; Michael T Andary, MD, MS, Residency Program Director, Associate Professor, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine; Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center; and Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center INTRODUCTION Section 2 of 10 Author Information Introduction Clinical Differentials Workup Treatment Follow-up Miscellaneous Pictures Bibliography Background: Piriformis syndrome has remained a controversial diagnosis since its initial description in 1928. Piriformis syndrome usually is caused by neuritis of the proximal sciatic nerve. The piriformis muscle can either irritate or compress the proximal sciatic nerve due to spasm and/or contracture, and this problem can mimic discogenic sciatica (pseudosciatica). Pathophysiology: The piriformis muscle is flat, pyramid-shaped, and oblique. This muscle originates to the anterior of the S2-S4 vertebrae, the sacrotuberous ligament, and the upper margin of the greater sciatic foramen (see Image 1). This muscle passes through the greater sciatic notch and inserts on the superior surface of the greater trochanter of the femur. With the hip extended, the piriformis muscle is the primary external rotator; however, with the hip flexed, the piriformis muscle itself becomes a hip abductor. This muscle is innervated by branches from L5, S1, and S2. A lower lumbar radiculopathy also may cause secondary irritation of the piriformis muscle, which may complicate the diagnosis and hinder patient progress. Many developmental variations of the relationship between the sciatic nerve in the pelvis and piriformis muscle have been observed. In approximately 20% of the population, the muscle belly is split with one or more parts of the sciatica nerve dividing the muscle belly itself. In 10% of the population, the tibial/peroneal divisions are not enclosed in a common sheath. Usually, the peroneal portion splits the piriformis muscle belly; the tibial division rarely splits the muscle belly. Involvement of the superior gluteal nerve usually is not seen in cases of piriformis syndrome. This nerve leaves the sciatic nerve trunk and passes through the canal above the piriformis muscle. Blunt injury may cause hematoma formation and subsequent scarring between the sciatic nerve and short external rotators. Nerve injury can occur with prolonged pressure on the nerve or vasa nervorum. Etiology can be subdivided into a few categories as follows: Hyperlordosis Muscle anomalies with hypertrophy Fibrosis (due to trauma) Partial or total nerve anatomical abnormalities Other causes can include the following: Pseudo aneurysms of the inferior gluteal artery adjacent to the piriformis syndrome Bilateral piriformis syndrome due to prolonged sitting during an extended neurosurgical procedure Cerebral palsy Total hip arthroplasty Myositis ossificans Vigorous physical activity This syndrome remains controversial because, in most cases, the diagnosis is clinical, and no confirmatory tests exist to support the clinical findings. Frequency: In the US: Given the lack of agreement on exactly how to diagnose this condition, estimates of frequency of sciatica caused by piriformis syndrome vary from rare to approximately 6% of sciatica cases seen in a general family practice. Approximately 90% of adults have had at least one episode of disabling LBP in their lifetime. Mortality/Morbidity: Piriformis syndrome is not life-threatening, but it can have significant associated morbidity. The total cost of low back pain (LBP) and sciatica is significant, exceeding billion in both direct and indirect costs. Sex: Some reports suggest a 6:1 female-to-male predominance. CLINICAL Section 3 of 10 Author Information Introduction Clinical Differentials Workup Treatment Follow-up Miscellaneous Pictures Bibliography History: Piriformis syndrome often is not recognized as a cause of LBP and associated sciatica. This clinical syndrome is due to a compression of the sciatic nerve by the piriformis muscle. This condition is identical in clinical presentation to LBP with associated L5, S1 radiculopathy due to discogenic and/or lower lumbar facet arthropathy with foraminal narrowing. Not uncommonly, patients demonstrate both of these clinical entities simultaneously. This diagnostic dilemma highlights the need for patients with LBP and associated radicular pain to undergo a complete history and physical examination, including a digital rectal examination. Many cases of refractory trochanteric bursitis are observed to have an underlying occult piriformis syndrome due to the insertion of the piriformis muscle on the greater trochanter of the hip. If both the trochanteric bursitis and the piriformis syndrome are treated inadequately, both conditions remain resistant to medical management. Physical: Examination findings may include the following: Piriformis muscle spasm often is detected by careful deep palpation. Digital rectal examination may reveal tenderness on lateral pelvic wall that reproduces symptoms. Reproduction of sciatica type pain with weakness is noted by resisted abduction/external rotation (Pace test). The Freiberg test is another diagnostic sign that elicits pain upon forced internal rotation of the extended thigh. The Beatty maneuver reproduces buttock pain by selectively contracting the piriformis muscle. The patient lies on the uninvolved side and abducts the involved thigh upward; this activates the ipsilateral piriformis muscle, which is both a hip external rotator and abductor with the hip flexed. A painful point may be present at the lateral margin of the sacrum. Shortening of the involved lower extremity may be seen. The patient may have difficulty sitting due to an intolerance of weight bearing on the buttock. The patient may have the tendency to demonstrate a splayed foot on the involved side when in the supine position. Piriformis syndrome alone is rarely a cause of a focal neuromuscular impairment; either a sciatic mononeuropathy or an L5-S1 radiculopathy can mimic both of these conditions, obscuring diagnosis of piriformis syndrome. A Morton foot may predispose the patient to developing piriformis syndrome. The prominent second metatarsal head destabilizes the foot during the push-off phase of the gait cycle, causing foot pronation and internal rotation of the lower limb. The piriformis muscle (external hip rotator) reactively contracts repetitively during each push-off phase of the gait cycle as a compensatory mechanism, leading to piriformis syndrome. Causes: Approximately 50% of patients with piriformis syndrome have a history of trauma, with either a direct buttock contusion or hip/lower back torsional injury. The remaining 50% of cases are of spontaneous onset, so the treating physician must have a high index of suspicion for this problem, lest it be overlooked. DIFFERENTIALS Section 4 of 10 Author Information Introduction Clinical Differentials Workup Treatment Follow-up Miscellaneous Pictures Bibliography Lumbar Degenerative Disc Disease Lumbar Facet Arthropathy Lumbar Spondylolysis and Spondylolisthesis Myofascial Pain Trochanteric Bursitis Other Problems to be Considered: Lumbosacral radiculopathy Buttock pain Ischial tuberosity bursitis Sciatica Check the Internet for Related Articles: Lumbar Degenerative Disc Disease Lumbar Facet Arthropathy Lumbar Spondylolysis and Spondylolisthesis Myofascial Pain Trochanteric Bursitis Continuing Education CME available for this topic. Click here to take this CME. WORKUP Section 5 of 10 Author Information Introduction Clinical Differentials Workup Treatment Follow-up Lab Studies: Laboratory studies generally are not indicated in diagnosing piriformis syndrome. Imaging Studies: Diagnostic imaging of the lumbar spine is mandatory to exclude associated discogenic and/or osteoarthritic contributing pathology. Reports in the literature on piriformis muscle describe imaging by nuclear diagnostic studies and MRI of the pelvis, but these tests are neither practical nor reliable diagnostic approaches to this problem. The history and clinical diagnostic examination provide the greatest and most specific diagnostic yield for this problem. Other Tests: Results of electrodiagnostic testing for piriformis syndrome usually are normal. Reports of positional H-reflex abnormalities can be found in the literature; however, such findings have not been widely accepted or reproduced. TREATMENT Section 6 of 10 Author Information Introduction Clinical Differentials Workup Treatment Follow-up Rehabilitation Program: Physical Therapy: Because a definitive method to accurately diagnose this problem is not available, treatment regimens are controversial and have not been subjected to randomized blind clinical trials. Despite this fact, numerous treatment strategies exist for patients with piriformis syndrome. Functional biomechanical deficits may include the following: Tight piriformis muscle Tight hip external rotators and adductors Hip abductor weakness Lower lumbar spine dysfunction Sacroiliac joint hypomobility Functional adaptations to these deficits include the following: Ambulation with thigh in external rotation Functional limb length shortening Shortened stride length Once the diagnosis has been made, these underlying perpetuating biomechanical factors must be corrected. Consider the use of ultrasound and other heat modalities prior to physical therapy sessions. Prior to performing piriformis stretches, the hip joint capsule should be mobilized anteriorly and posteriorly to allow for more effective stretching. Soft tissue therapies of the piriformis muscle can be helpful, including longitudinal gliding with passive internal hip rotation, as well as transverse gliding and sustained longitudinal release with the patient lying on his/her side. Addressing sacroiliac joint and low back dysfunction also is important. A home stretching program should be provided to the patient. These stretches are an essential component of the treatment program. During the acute phase of treatment, stretching every 2-3 hours (while awake) is a key to the success of non operative treatment. Prolonged stretching of the piriformis muscle is accomplished in either a supine or orthostatic position with the involved hip flexed and passively adducted/ internally rotated. Medical Issues/Complications: No consensus exists on overall treatment of piriformis syndrome due to lack of objective clinical trials. Conservative treatment (eg, stretching, manual techniques, injections, activity modifications, modalities like heat or ultrasound, natural healing) is successful in most cases. Injection therapy can be incorporated if the situation is refractory to the aforementioned treatment program. For effective injection, the piriformis muscle must be localized manually by digital rectal examination. Then the piriformis muscle is injected using a 3.5-inch (8.9-cm) spinal needle. Care must be taken to avoid direct injection of the sciatic nerve. Surgical Intervention: Surgical management is the treatment of last resort. Surgery for this condition involves resection of the muscle itself or the muscle tendon near its insertion at the superior aspect of the greater trochanter of the femur (as described by Mizuguchi). These surgical procedures are described as effective, and they do not cause any associated superimposed postoperative disability. Consultations: Because of the enigmatic nature of piriformis syndrome, initial consultation obtained from an orthopedic surgeon or similar specialist usually is nonspecific. This disorder is considered to be a soft tissue problem that presents as low back or buttock pain with sciatica. After all differential diagnoses have been excluded, consider piriformis syndrome. Due to the traumatic etiology of most cases, piriformis syndrome usually is associated with other more proximal causes of LBP, sciatica, and buttock pain (thereby further clouding the diagnosis). Other Treatment (injection, manipulation, etc.): The Spray N' Stretch myofascial treatment and ultrasound modality preceding physical therapy sessions are useful. Manual muscle medicine, including facilitated positional release, may be helpful. Injections with steroids, local anesthetics, and botulinum toxin have been reported in the literature for this condition. No single technique is universally accepted. Localization techniques include manual localization of muscle with fluoroscopic and electromyographic guidance. The piriformis muscle, after localization with a digital rectal examination, can be injected with a 3.5-inch (8.9-cm) spinal needle. Care should be taken to avoid direct injection of the sciatic nerve. FOLLOW-UP Section 7 of 10 Author Information Introduction Clinical Differentials Workup Treatment Follow-up Miscellaneous Further Inpatient Care: Inpatient care would be necessary only if surgical intervention is warranted. Surgery is the last resort treatment for severe cases of piriformis syndrome. Further Outpatient Care: Piriformis syndrome usually is treated effectively with conservative measures. Please refer to the Treatment section for a discussion of treatment recommendations. Deterrence/Prevention: No method has been demonstrated to prevent piriformis syndrome. The best prevention is to maintain biomechanical balance by restoration of a more physiologic weight bearing distribution with a level pelvis/sacral base and equal leg lengths, achieved by heel lift therapy if necessary. This treatment approach also prevents recurrences of piriformis syndrome, especially if the underlying etiology is a leg-length discrepancy. The patient also must engage in a general stretching program that includes bilateral piriformis muscles. Complications: The most significant complication is failure to recognize, diagnose, and treat this disabling condition. If left untreated, a patient may undergo unsuccessful back surgery for a disc herniation; however, a coexisting occult piriformis syndrome can result in a failed back syndrome. Another complication is inadvertent direct injection of the sciatic nerve, which usually results in a non disabling and temporary sciatic mononeuropathy. Prognosis: The prognosis depends upon early recognition and treatment. As this is a soft tissue syndrome, it has a tendency to be chronic, usually due to late diagnosis and treatment and has a less favorable prognosis. Patient Education: For conservative measures to be effective, the patient must be educated with an aggressive home-based stretching program to maintain piriformis muscle flexibility. He or she must comply with the program even beyond the point of discontinuation of formal medical treatment. MISCELLANEOUS Section 8 of 10 Author Information Introduction Clinical Differentials Workup Treatment Follow-up Miscellaneous Pictures Bibliography Medical/Legal Pitfalls: The greatest medical/legal concern is either misdiagnosis or failure to diagnose piriformis syndrome. In most cases, the diagnosis is one of exclusion. Therefore, if piriformis syndrome is not in the differential diagnosis list, it may be overlooked. The patient becomes a chronic pain patient doomed to a lifetime of disability and chronic management with medication. Because the diagnosis usually is elusive, missing the diagnosis does not constitute malicious negligence and, therefore, rarely would be sufficient grounds alone for a medical malpractice lawsuit. Piriformis syndrome may be a secondary perpetuating factor underlying chronic posttraumatic intractable LBP. Negligent misdiagnosis or delayed diagnosis of this condition has caused a significant degree of unnecessary disability and financial loss. Special Concerns: In female patients, piriformis syndrome may be a cause of dyspareunia, but, again, this connection becomes impossible to prove. Diagnosis of piriformis syndrome requires a high index of suspicion by either the primary care physician or the obstetric/ gynecologic specialist/surgeon. A bimanual simultaneous vaginal-rectal examination of female patients to determine this soft tissue diagnosis helps the physician to prescribe appropriate treatment. Although it is a misdiagnosed etiology of LBP/sciatica, piriformis syndrome can be a significant cause of soft tissue pain and disability. This problem requires a skillful, attentive physician to conduct a thorough history/physical examination that provides an accurate diagnosis. Once the clinical diagnosis has been made, a specific treatment can be formulated to provide the best outcome with a minimal degree of long-term disability. Author Information Introduction Clinical Differentials Workup Treatment Follow-up Miscellaneous Pictures Bibliography Nerve irritation in the herniated disk occurs at the root (sciatic radiculitis). In the piriformis syndrome, the irritation extends to the full thickness of the nerve (sciatic neuritis). BIBLIOGRAPHY Section 10 of 10 Author Information Introduction Clinical Differentials Workup Treatment Follow-up Barton PM: Piriformis syndrome: a rational approach to management. Pain 1991 Dec; 47(3): 345-52[Medline]. Beatty RA: The piriformis muscle syndrome: a simple diagnostic maneuver. Neurosurgery 1994; 34: 512-514[Medline]. Beauchesne RP, Schutzer SF: Myositis ossificans of the piriformis muscle: an unusual cause of piriformis syndrome. A case report. J Bone Joint Surg Am 1997 Jun; 79(6): 906-10[Medline]. Brown JA, Braun MA, Namey TC: Piriformis syndrome in a 10-year-old boy as a complication of operation with the patient in the sitting position. Neurosurgery 1988 Jul; 23(1): 117-9[Medline]. Durrani Z, Winnie AP: Piriformis muscle syndrome: an under diagnosed cause of sciatica. J Pain Symptom Manage 1991 Aug; 6(6): 374-9[Medline]. Fishman LM, Zybert PA: Electrophysiologic evidence of piriformis syndrome. Arch Phys Med Rehabil 1992 Apr; 73(4): 359-64[Medline]. Freidberg AH: Sciatic pain and its relief by operation on muscle and fascia. Arch Surg 1937; 34: 337-349. Frymoyer JW: Back pain and sciatica. N Engl J Med 1988 Feb 4; 318(5): 291-300[Medline]. Jankiewicz JJ, Hennrikus WL, Houkom JA: The appearance of the piriformis muscle syndrome in computed tomography and magnetic resonance imaging. A case report and review of the literature. Clin Orthop 1991 Jan; (262): 205-9[Medline]. Karl RD Jr, Yedinak MA, Hartshorne MF: Scintigraphic appearance of the piriformis muscle syndrome. Clin Nucl Med 1985 May; 10(5): 361-3[Medline]. Mizuguchi T: Division of the piriformis muscle for the treatment of sciatica. Postlaminectomy syndrome and osteoarthritis of the spine. Arch Surg 1976 Jun; 111(6): 719-22[Medline]. Noftal F: The Piriformis Syndrome. Can J Surg 1988 Jul; 31(4): 210[Medline]. Pace JB, Nagle D: Piriformis syndrome. West J Med 1976 Jun; 124(6): 435-9[Medline]. Papadopoulos SM, McGillicuddy JE, Albers JW: Unusual cause of "piriformis muscle syndrome". Arch Neurol 1990 Oct; 47(10): 1144-6[Medline]. Parziale JR, Hudgins TH, Fishman LM: The piriformis syndrome. Am J Orthop 1996 Dec; 25(12): 819-23[Medline]. Rask MR: Superior gluteal nerve entrapment syndrome. Muscle Nerve 1980 Jul-Aug; 3(4): 304-7[Medline]. Retzlaff EW, Berry AH, Haight AS: The piriformis muscle syndrome. J Am Osteopath Assoc 1974 Jun; 73(10): 799-807[Medline]. Robinson D: Piriformis syndrome in relation to sciatic pain. Am J Surg 1947; 73: 355-358. Schiowitz S: Facilitated positional release. J Am Osteopath Assoc 1990 Feb; 90(2): 145-6, 151-5[Medline]. Steiner C, Staubs C, Ganon M: Piriformis syndrome: pathogenesis, diagnosis, and treatment. J Am Osteopath Assoc 1987 Apr; 87(4): 318-23[Medline]. TePoorten BA: The piriformis muscle. J Am Osteopath Assoc 1969 Oct; 69(2): 150-60[Medline]. Thiele GH: Tonic spasm of the levator ani, coccygeus and piriformis muscles. Trans Am Proct Soc 1936; 37: 145-155. Uchio Y, Nishikawa U, Ochi M: Bilateral Piriformis Syndrome after Total Hip Arthroplasty. Arch Orthop Trauma Surg 1988; 117: 177-179. Yeoman W: The relation of arthritis of the sacroiliac joint to sciatica. Lancet 1928; ii: 1119-1122. NOTE: Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. ---- : Arch Surg. 1976 Jun;111(6):719-22. Related Articles, Link Division of the piriformis muscle for the treatment of sciatica. Postlaminectomy syndrome and osteoarthritis of the spine. Mizuguchi T. Division of the piriformis muscle at its tendinous insertion was employed for the treatment of sciatica in 14 patients with post laminectomy syndrome and osteoarthritis of the spine. Of these patients, 85% had satisfactory results. It is logical that the piriformis muscle can play an important role in the production of sciatic associated with intraspinal lesions. Tension on the sciatic nerve, which passes in close approximation to the piriformis muscle anteriorly, can be relieved by division of the piriformis muscle. ---- 1: Neurosurgery. 1994 Mar;34(3):512-4; discussion 514. Related Articles, Link Comment in: Neurosurgery. 1994 Sep;35(3):545. The piriformis muscle syndrome: a simple diagnostic maneuver. Beatty RA. Department of Neurosurgery, University of Illinois, College of Medicine, Chicago. Current maneuvers to diagnose the piriformis syndrome are less than ideal. Freiberg's maneuver of forceful internal rotation of the extended thigh elicits buttock pain by stretching the piriformis muscle, and Pace's maneuver elicits pain by having the patient abduct the legs in the seated position, which causes a contraction of the piriformis muscle. This report describes a maneuver performed by the patient lying with the painful side up, the painful leg flexed, and the knee resting on the table. Buttock pain is produced when the patient lifts and holds the knee several inches off the table. The maneuver produced deep buttock pain in three patients with piriformis syndrome. In 100 consecutive patients with surgically documented herniated lumbar discs, the maneuver often produced lumbar and leg pain but not deep buttock pain. In 27 patients with primary hip abnormalities, pain was often produced in the trochanteric area but not in the buttock. he maneuver described in this report was helpful in diagnosing the piriformis syndrome. It relies on contraction of the muscle, rather than stretching, which the author believes better reproduces the actual syndrome. Publication Types: Case Reports PMID: 8190228 [PubMed - indexed for MEDLINE] ---- Muscle Nerve. 1980 Jul-Aug;3(4):304-7. Related Articles, Link Superior gluteal nerve entrapment syndrome. Rask MR. Entrapment of the superior gluteal nerve can occur as a result of compression by anterior-superior tendinous fibers of the piriformis muscle and cause aching claudication -type buttock pain, weakness of abduction of the affected hip with a waddling gait, and tenderness to palpation in the area of the buttock super lateral to the greater sciatic notch. Instilling anesthetic into the point of entrapment may relieve the pain completely but superior gluteal neurolysis may be required to effect a permanent cure. Publication Types: Case Reports PMID: 7412775 [PubMed - indexed for MEDLINE] ------------------------------------------------------------------------------- 1: Clin Nucl Med. 1985 May;10(5):361-3. Related Articles, Link Scintigraphic appearance of the piriformis muscle syndrome. Karl RD Jr, Yedinak MA, Hartshorne MF, Cawthon MA, Bauman JM, Howard WH, Bunker SR. This is the first report in the nuclear medicine literature of the scintigraphic appearance of the piriformis muscle syndrome. This syndrome previously has been thought to be a purely clinical diagnosis and imaging modalities have been ignored. However, its confusing clinical presentation can lead to unnecessary surgical exploration This case is presented to illustrate the characteristic scintigraphic pattern and suggest the role of nuclear medicine scanning in establishing the diagnosis. Publication Types: Case Reports PMID: 3160520 [PubMed - indexed for MEDLINE] ------------------------------------------------------------------------------- 1: Arch Surg. 1976 Jun;111(6):719-22. Related Articles, Link Division of the piriformis muscle for the treatment of sciatica. Post laminectomy syndrome and osteoarthritis of the spine. Mizuguchi T. Division of the piriformis muscle at its tendinous insertion was employed for the treatment of sciatica in 14 patients with post laminectomy syndrome and osteoarthritis of the spine. Of these patients, 85% had satisfactory results. It is logical that the piriformis muscle can play an important role in the production of sciatic associated with intraspinal lesions. Tension on the sciatic nerve, which passes in close approximation to the piriformis muscle anteriorly, can be relieved by division of the piriformis muscle. PMID: 1275705 [PubMed - indexed for MEDLINE] --- Link Science for the Brain - Related Articles: The nation's leading supporter of biomedical research on disorders of the brain and nervous system More about Piriformis Syndrome Studies with patients Research literature Press releases Search NINDS... NINDS is part of the National Institutes of Health: You are here: Home > Disorders > Piriformis Syndrome NINDS Piriformis Syndrome Information Page Organizations What is Piriformis Syndrome? Piriformis syndrome is a rare neuromuscular disorder that occurs when the piriformis muscle compresses or irritates the sciatic nerve-the largest nerve in the body. The piriformis muscle is a narrow muscle located in the buttocks. Compression of the sciatic nerve causes pain-frequently described as tingling or numbness-in the buttocks and along the nerve, often down to the leg. The pain may worsen as a result of sitting for a long period of time, climbing stairs, walking, or running. Is there any treatment? Generally, treatment for the disorder begins with stretching exercises and massage. Anti-inflammatory drugs may be prescribed. Cessation of running, bicycling, or similar activities may be advised. A corticosteroid injection near where the piriformis muscle and the sciatic nerve meet may provide temporary relief. In some cases, surgery is recommended. What is the prognosis? The prognosis for most individuals with piriformis syndrome is good. Once symptoms of the disorder are addressed, individuals can usually resume their normal activities. In some cases, exercise regimens may need to be modified in order to reduce the likelihood of recurrence or worsening. What research is being done? Within the NINDS research programs, piriformis syndrome is addressed primarily through studies associated with pain research. NINDS vigorously pursues a research program seeking new treatments for pain and nerve damage with the ultimate goal of reversing debilitating conditions such as piriformis syndrome. --- Piriformis Syndrome: Link New minimal access, outpatient surgery developed at INM greatly improves outcome and reduces recovery time Piriformis Surgery Incision Piriformis surgery is now a small procedure which can be carried out under local anaesthetic as an outpatient. Traditional piriformis surgery is a large and debilitating operation but no patient should be having these operations today. There were two types of traditional piriformis surgery, one involves a large lateral hip incision similar to the approach used for a hip replacement surgery. The second involves a very large incision and involves completely detaching all of the gluteal muscles from the iliac crest. Both of these types of surgery result in weeks of debilitation, walking on crutches and pain, with only limited success treating the original problem. The new type of "minimal access surgery" developed at the Institute for Nerve Medicine by Dr. Aaron Filler involves only a small incision, and in most cases can be performed on an outpatient basis. Large scale formal outcome trials involving hundreds of patients with follow-up out to eight years show no detectable effect on normal walking in any of the patients - this a great change from the traditional surgery that often leaves permanent problems with gait. Recovery takes only a few days in most patients. Those patients who have positive physical exam findings, positive MR neurography findings and a clear positive response to MRI guided piriformis injection have had a 85% to 90% good to excellent outcome. --- Piriformis Syndrome & Sciatica Link The nerve-related leg pain of Sciatica is often due to piriformis muscle syndrome. Unlike the sciatica from a herniated disk, there is often little or no back pain while buttock pain predominates. The pain is worse when sitting, relieved by standing or walking, and often extends no farther down the leg than the ankle or mid-foot. When toes are involved, it usually affects all five toes. Piriformis Flexion Diagram This drawing illustrates the important anatomy for piriformis syndrome and shows how certain leg positions pull the piriformis muscle up against the sciatic nerve causing buttock pain and radiating leg pain. Piriformis Syndrome Anatomy of the piriformis muscle and sciatic nerve in a T1 weighted axial MRI scan Piriformis Muscle Open MRI Anatomy Photo Link This T1 weighted axial MRI scan shows the anatomy used to guide the injection of the piriformis muscle in an Open MRI scanner. Link to MR Images of hypersensitivity to left side of Piriformis Muscle Piriformis Flexion Exam Manouver Critical physical exam maneuver for muscle based piriformis syndrome: The patient's foot is placed lateral to the contra lateral knee. Resisted abduction or adduction against the examiner's hand may reproduce the symptoms. Straight leg rising is typically negative. There is often relief obtained by traction on the involved leg, particularly by pulling upwards at a ten to twenty degree angle and towards the contra lateral side by a similar amount. The distribution of symptoms typically involves both L5 (big toe) and S1 (small toe) components because this a pan-sciatic syndrome. The symptoms often progress no further than the ankle in distinction to sciatica from a lumbar disk which typically radiates into the toes. Link --- SEARCH Receive Spine News patient>conditions>other Piriformis Syndrome Spine Universe ChiropracticLink Piriformis Syndrome is caused by an entrapment (pinching) of the sciatic nerve as it exits the Greater Sciatic notch in the gluteal region. There are two normal variations for the exit of the sciatic nerve in this region. The first places the sciatic nerve inferior (below) to the Piriformis muscle and superior (above) the gemellus muscle. Entrapment in this area is likely due to a myospasm or contracture (tightening or shortening respectively) of either of these two muscles. The second common site of entrapment is when the sciatic nerve actually pierces the piriformis muscle itself. This can occur in about 1% to 10% of all humans. In this case myospasm and or contraction of the piriformis muscle itself can lead to pain along the back of the thigh to the knee, loss of sensation or numbness and tingling in the sole of the foot. This particular syndrome can often mimic its more notorious counterpart known as sciatica, and that being the case, it is often misdiagnosed as sciatica. The main difference between sciatica and piriformis syndrome is in the cause. Sciatica is directly due to a lumbar disc pressing on the sciatic nerve as it exits the intervertebral foramen in the lumbar spine. What both of these complaints have in common is that both can produce pain, numbness and tingling below the knee and into the foot. The main diagnostic tests performed by your doctor of Chiropractic is what distinguishes one from the other. With piriformis syndrome your chiropractor will not get positive tests results that indicate lumbar spine involvement. Often the patient may not be aware that there is a problem. Some cases won't show up until a complete neurological exam is performed on the lower extremity. The patient may have chief complaints ranging from no pain to pain in the lower back to gluteal pain to numbness and tingling in the foot. As can be seen the symptoms in this condition can vary widely making the doctor who is not used to differentially diagnosing this condition from sciatica confused as to the cause of the condition. Many weekend athletes and people who spend long hours sitting are prone to this syndrome. The athlete's cause is primarily due to improper stretching and warm-up exercises as well as overuse during activity. In this case it is most likely that the piriformis muscle is irritated and usually in spasm. For the patient who sits for extended periods of time, their primary cause is due to contracture of the piriformis muscle. In this case the piriformis muscle is shortened and does not allow for the smooth movement of the sciatic nerve during leg motion. A one-time direct trauma to the pelvis is very rarely a cause for piriformis syndrome due to the protection afforded the pelvis by the overlying musculature and fat. The causes of myospasm are many. Over use as during excessive fast walking without proper warm up and stretching (as during exercise), prolonged sitting, as for your treatment, many variables can hamper your successful recovery. Smoking, obesity, job and exercise as noted above in prolonged sitting and not warming up and stretching. Any treatment plan must include stretching of the gluteal muscles as well as stretching of the piriformis muscles. Your Chiropractor can help you by instructing you on the proper exercises and stretches to perform. Many Chiropractors may also prescribe some form of massage be performed to the piriformis muscle in the gluteal region in order to relax these muscles. Your chiropractor may also prescribe certain herbals remedies such as valerian root and passion flower to help relax the associated muscles during your recovery phase. Spinal adjustment as well as hip adjustment may also be required to relieve your symptoms. -------------------------------------------------------------------------------- Dynamic Chiropractic June 21, 1991, Volume 09, Issue 13 Printer Friendly Version Email to a Friend Alternative Health Acupuncture Piriformis Syndrome: Part I Link -------------------------------------------------------------------------------- The patient with an unrelenting sciatica may be suffering with a piriformis syndrome. This syndrome is considered an entrapment neuropathy caused by pressure on the sciatic nerve by an enlarged or inflamed piriformis muscle. The sciatic nerve can be compressed between the swollen muscle fibers and the bony pelvis.1 Pace and Nagle2 estimated that 45 of 750 cases referred to their back clinic were treated for this syndrome. They found that the condition was six times more prevalent in women than men. Because this syndrome is not common it is often overlooked and needless surgery may result. Wyant3 states that the functional test for piriformis syndrome should be a routine part of the physical examination of all patients presenting with lower spinal backache. Besides backache, the piriformis muscle contracture and associated adhesions has been related to radiating pain from the sacrum to the hip joint over the gluteal region to the posterior thigh, coccydynia,4 dyspareunia, male impotency5, and oblique axis rotation of the sacrum with its effect on the total spine up to the atlanto- occipital region.5 According to Gray6 and Freiberg7 the piriformis arises from the anterior sacrum between the second to fourth anterior sacral foramina, from the margin of the greater sciatic foramen and from the anterior surface of the sacrotuberous ligament, the anterior sacrospinous ligament and the capsule of the sacroiliac joint. Freiberg states that the piriformis is the only muscle that bridges the sacroiliac joint. The piriformis passes through the greater sciatic foramen (the upper part of which it fills) and inserts by a rounded tendon into the upper border of the greater trochanter. Pecian8 examined 130 human specimens to determine the anatomical relations of the sciatic nerve and the piriformis. He found that in 6.15 percent of the cases the peroneal part of the sciatic nerve passes between the tendinous parts of the piriformis and a pinching of the nerve can occur. He found at least five other variations of the sciatic nerve in relation to the piriformis muscle. He concluded that when the nerve passed between the tendinous portion of the piriformis the nerve would more likely be pinched during passive medial rotation of the thigh which stretches the piriformis, causing the nerve to be pressed against the extended piriformis. In this case, resisted testing of the piriformis or ordinary active piriformis contraction would separate the tendinous portion of the piriformis surrounding the sciatic nerve and would not compress the nerve. Mizuguche9 felt that before the piriformis could aggravate the sciatic nerve there first had to be a preexisting tension on the sciatic nerve by scarring or arachnoiditis around the nerve roots secondary to laminectomy or some space-occupying lesion such as osteoarthritic spurs. He thought that ordinary walking would cause the piriformis to impinge the shortened nerve. A history of trauma to the sacroiliac or gluteal region has also been blamed10. The straight leg raise may be positive due to a contracted piriformis muscle. In a study by Freiberg and Vinke11 on 10 cadavers it was found that after raising the leg 25 degrees, the sacrotuberous ligament becomes taut because of its attachment to the ischial tuberosity and the hamstrings. A contracted piriformis muscle which originates off the sacrotuberous ligament also tightened during the SLR. The functional tests for a piriformis syndrome is naturally based on the function of the piriformis muscle. One of the main reasons for muscle testing is to determine if a muscle is painful. Since the piriformis muscle is an external hip rotator when the hip is in extension and an abductor when the hip is in flexion,9 external hip rotation should be tested with the patient supine with the legs hanging off the table edge at the knees. The patient then attempts to push his leg medially against resistance. The abduction test for the piriformis could be tested with the patient sitting facing the examiner. The patient attempts to abduct the knee against resistance.2 The patient will complain of pain and possible weakness due to the pain. There may be pain when the patient sits or squats due to external rotation of the thigh and hip.5 Passive internal rotation of the thigh with the patient supine could also aggravate the condition. Pressure on the piriformis by way of rectal or vaginal examination may reproduce the symptoms.3 A positive "piriformis sign" due to piriformis contracture may be seen by the persistent external rotation of one lower extremity when the patient is supine. A contracted piriformis may result in a functional short leg.5 The symptoms of female pain during coitus (dyspareunia) could be due to the externally rotated hips, but female pain and male impotency is also attributed to piriformis compression of the pudendal nerve and blood vessels.5 According to Retzlaff et al.,5 on the side of the piriformis contracture the sacral base will be rotated anteriorly and examination of a prone patient will show a deepened sulcus on that side. The apex of the sacrum will appear posterior on the opposite side at the level of the posterior inferior illiac spine (oblique axis rotation of the sacrum). This may cause rotoscoliosis of the lumbar spine and increased lumbar lordosis which may effect the function of the whole spine. Digital pressure over the piriformis may refer pain along the complaint area. Part II will discuss a variety of conservative treatments for this syndrome. Warren Hammer, M.S., D.C., D.A.B.C.O. Editor's Note: Dr. Hammer will conduct his next soft tissue seminar. You may call 1-800-327-2289 to register. Dr. Hammer's new book, Functional Soft Tissue Examination and Treatment by Manual Methods: The Extremities, is now available. Please see the Preferred Reading and Viewing list on page xx, part #T126 to order your copy. References Jankiewicz JJ, Hennrikus WL, Houkom JA: "The appearance of the piriformis muscle syndrome in computed tomography and magnetic resonance imaging: a case report and review of the literature." Clin Orth & Rel Res:262,205-209. Pace JB, Nagle D: "Piriformis syndrome." West J Med 24:436, 1976. Wyant G: "Chronic pain syndromes and their treatment: III. The piriformis syndrome." Can Anaesth Soc J. 26:305, 1976. Thiele GH: "Tonic spasm of the levator ani, coccygeus and piriformis muscles." Trans Am Pract Soc 37:145-155, 1936. Retzlaff E, Berry AH, Haight AS et al. "The piriformis muscle syndrome." J AM Osteopath Assoc 73:799-807. Gray H: Anatomy of the Human Body. 26th ed. Philadelphia: Lea & Febiger, 1956:541. Freiberg AH: "Sciatic pain and its relief by operations on the muscle and fascia." Arch Surg 34:337m 1937. Pecian M: "Contribution to the etiological explanation of the piriformis syndrome." Acta Anat (Basel) 105:181-186, 1979. Mizughuchi T: "Division of the piriformis muscle in the treatment of sciatica." Arch Surg 111:719-722, 1976. Robinson D: "Piriformis syndrome in relation to sciatic pain." Am J Surg 73:356-358, 1947. Freiburg AH, Vinke TA: "Sciatica and the sacroiliac join." J Bone Joint Surg 16:126, 1934. ----0 Siatica.org Diagnosis and Treatment of Piriformis Syndrome Link Piriformis syndrome is estimated to cause 6-8% of sciatica, but is more common in the general population because it has been under diagnosed and under treated. The following outline is intended to present elements of the history and physical findings that suggest piriformis syndrome, and the electrophysiological technique for documenting its presence, injection technique and physical therapy. Finally, there is a section on outcome and alternative treatments and current clinical research protocols. Diagnosis The patient with piriformis syndrome typically complains of sciatic pain, tenderness in the buttock, and more difficulty sitting than standing. The pain usually arises from overuse: athletics, heavy work, or prolonged sitting, though traumatic causes are also reasonably common, including automobile accidents, falls, and penetrating wounds. Physical findings include tenderness of the buttock region, increased pain with adduction, internal rotation and flexion of the affected thigh while the patient is in the contra lateral decubitus position, weakened abduction of the flexed thigh, and iliotibial band syndrome. EMG findings include positive FAIR-test, signs of denervation (acute or chronic) in the pattern of the posterior tibial or the peroneal nerves, as opposed to a radicular distribution, reduced CMAPs and/or SNAPs on the affected side, and a positive FAIR-test. The FAIR-test compares the sum of M-wave plus H-reflex in the anatomical position with the sum of M-wave plus H-reflex in the Flexed, Adducted, Internally Rotated position. Piriformis FAIR-test position (Contra lateral Decubitus) ----- PIRIFORMIS SYNDROME Link Gabe Mirkin, M.D. If it hurts to touch a point that's in the middle of one side of your buttocks, you probably have piriformis syndrome. This chronic condition is very difficult to diagnose, because other injuries may produce exactly the same symptoms. Similar pain may be the result of an injury to bones, muscles, tendons, bursae (pads between the tendons and bones), the hip joint, or the sciatic nerve, but there are ways to determine from which condition you might be suffering. If you feel most pain when you land after hopping on one leg, you might have an injured hip joint or a stress fracture in your pelvis or upper leg bones. An x-ray will usually reveal a joint injury, but only a bone scan will reveal a stress fracture. If you feel pain in your buttocks, particularly when you touch your toes while keeping your knees straight, you might have a tear in the large muscles or tendons that run down the back of your hips. If you feel pain when you touch a spot that's either on the lowest point of your pelvis (the part that touches a chair when you sit) or at the top of your femur (thigh), you might have injured your bursae (bursitis) or torn the tendons that are attached to bones at these sites. If your back hurts, particularly when you bend backwards, and the pain goes down the back of your leg to below your knees, your sciatic nerve is probably being pinched in your back. Cause: The sciatic nerve is the longest nerve in your body. It starts on the lower part of your spine, [passes through a hole between the piriformis muscle above it and several other muscles beneath it, and goes down the back of your leg to below the knee. When you run, the piriformis muscle contracts and squeezes the sciatic nerve underneath it. Repeatedly squeezing and relaxing the piriformis muscle can damage the sciatic nerve and cause pain. This injury is thought to be caused by an innate tightness of the piriformis muscle or a structural abnormality in the path of the sciatic nerve. It can't be attributed to a specific error in training. Treatment: Piriformis syndrome won't ease until you stop running. Don't run again until you can run without feeling pain in your buttocks. If it hurts to touch, it hasn't healed. In most cases, pedaling a bicycle will also be painful. You probably shouldn't do any exercise that causes you to bend at the hip while keeping your knees straight, because this will stretch the sciatic nerve. You might be able to swim, if it isn't painful. Medication doesn't usually alleviate the pain, and even if it does, the pain will return as soon as you stop taking it. Sometimes, the pain will disappear after a rest of a few days to several months; frequently it does not. In this case your doctor will be able to make an accurate diagnosis by injecting a mixture of xylocaine and corticosteroid drugs directly into the piriformis muscle where it passes over the sciatic nerve. If the pain disappears, you may resume running only after a few weeks, but remember that this injury tends to recur. If you feel pain in that area, stop running immediately, and don't attempt to run again until you can do so without pain. This article recorded 11/15/02 ----- Spinehealth.com Link Common causes of back pain Related information o Physical therapy o Piriformis syndrome--another irritation to the sciatic nerve o What you need to know about sciatica Overview Piriformis syndrome: What is the Piriformis muscle? Link The Piriformis is one of the small muscles deep in the buttocks that rotates the leg outwards. It runs from the base of the spine and attaches to the thigh bone (femur) roughly where the outside crease in your bum is. The sciatic nerve runs very close to this muscle and sometimes even through it! What can the athlete do? Apply heat. Stretch the Piriformis muscle. Strengthen the Piriformis muscle. See a sports injury professional who can advise on treatment, rehabilitation and prevention What can a sports injury professional do? Apply specific sports massage techniques. Stretch the Piriformis muscle using Muscle Energy Techniques. Apply ultrasound. Advise on strengthening and rehabilitation to avoid injury recurrence. If these stretches don't help it is possible that you will need Piriformis Release Surgery. =================================================================================== Piriformis Syndrome (Sciatic Pain) - learn how you can reduce your sciatic pain and piriformis syndrome. ... Piriformis Syndrome (Sciatic Pain) in the following link: Read about the four causes that cause Piriformis Syndrome: Link =================================================================================== The piriformis muscle and the sciatic nerve The piriformis muscle is a small muscle located in the buttocks that rotates the hip. It runs horizontally, and the sciatic nerve runs vertically directly beneath the muscle. The muscle can become tight and place pressure on the sciatic nerve, resulting in leg pain which may be difficult to distinguish from a radiculopathy (nerve pinching in the spine), which is also commonly called sciatica. The patient's spinal imaging studies will not show any nerve pinching, and on physical exam, motion of the patient's hip will generate the pain. Conservative care for piriformis syndrome Treatment for piriformis syndrome typically consists of: Physical therapy that includes manual release (deep massage), along with hip range of motion exercises can help piriformis syndrome. For severe cases of piriformis syndrome, the muscle may be injected with lidocaine to decrease spasm and help the patient make progress in physical therapy. By: Peter F. Ullrich, Jr., MD September 8, 1999 Updated February 28, 2001 ============================================================================= Receive Spine News Piriformis Syndrome Link Timothy J. Maggs, M.D. If you've ever felt pain in the hip, pain in the center of the butt or pain down the back of the leg, you are likely suffering, at least partially, with piriformis syndrome. The piriformis is a muscle which runs from your sacrum (mid-line base of spine) to the outer hip bone (trochanter). This muscle truly works overtime on anyone who runs at all. The muscles in and around the gluteal region help with three areas 1.rotation of the hip and leg; 2.balance while one foot is off the ground; and 3.stability for the pelvic region. Needless to say, all of these characteristics are highly needed by runners. Conclusion--the piriformis muscle is pretty important for all of us. Injuries to the Piriformis This muscle is a prime candidate for repetitive motion injury (RMI). RMI occurs when a muscle is asked to perform beyond it's level of capability, not given enough time to recover, and asked to perform again. The typical response from a muscle in this situation is to tighten, which is a defensive response of the muscle. This tightness, however, manifests itself in several ways to a runner. The first symptom suggesting piriformis syndrome would be pain in and around the outer hip bone. The tightness of the muscle produces increased tension between the tendon and the bone which produces either direct discomfort and pain or an increased tension in the joint producing a bursitis. Again, a bursitis is an inflammation of the fluid filled sac in a joint caused by an elevation of stress and tension within that joint. The second symptom suggesting piriformis syndrome would be pain directly in the center of the buttocks. Although this is not as common as the other two symptoms, this pain can be elicited with direct compression over the belly of the buttocks area. A tight muscle is a sore muscle upon compression due to a reduced blood flow to that muscle. The third symptom suggesting piriformis syndrome would be a sciatic neuralgia, or pain from the buttocks down the back of the leg and sometimes into different portions of the lower leg. The sciatic nerve runs right through the belly of the piriformis muscle and if the piriformis muscle contracts from being overused, the sciatic nerve now becomes strangled, producing pain, tingling and numbness. Simple Physiology Any muscle repetitively used needs to have an opportunity to recover. This recover can either be on Nature's clock, or can be facilitated and sped up with proper knowledge and treatment. Since the muscle is tightening due to overuse, continued use will only make it worse. This injured muscle needs to relax and have increased blood flow encouraged to it for more rapid healing. This tightness that exists also reduces the normal blood flow going to the muscle reducing the speed with which the muscle can recover. To encourage fresh, oxygen-rich blood to the muscle is the most powerful means of getting the muscle to begin to relax and function normally. Multiple massages per day to this area are greatly encouraged. The next step in this "recovery" process is to use a tennis ball under the butt and hip area. While sitting down on the floor, roll away from the side of involvement and place a tennis ball just inside the outer hip bone under the butt area. As you begin to allow your weight onto the tennis ball, note areas of increased pain and soreness. Trigger points will tend to accumulate in a repetitively used muscle, and until these toxins are manually broken up and eliminated, the muscle will have an artificial ceiling with regard to flexibility potential and recovery potential So, if it's sore and hurts while you're sitting on it, you're doing a good job. Let the ball work under each spot for 15-20 seconds before moving it to another area. Once you've been on the ball for 4-5 minutes, now put the ankle of the involved leg over the knee of the non-involved leg (crossing your legs). Now place the tennis ball just inside the outer hip bone again and work the tendon of the piriformis muscle. While this pain is typically excruciating and takes some time to effectively reduce, the benefits here are huge. Be patient, be consistent and good things will happen. Additional Treatments Due to the fact that the sciatic neuralgia and the hip bursitis or tendonitis are both inflammatory in nature, ice, or cryotherapy, over the involved area 15-20 minutes at a time will be beneficial. This should be done multiple times per day. Stretching of the hip muscles should not be done until the acute pain is gone. At that point in time, begin with gentle stretching, such as the cross-legged stretch while pulling up on the knee. The muscle should have increased flexibility before an active return to running. Finally, I'm always discouraging the use of pharmaceutical anti-inflammatories. Not only do they greatly aggravate the intestines, but they also suggest an artificial wellness that can lead to bigger problems. Proteolytic enzymes, such as bromelain, are both natural and extremely beneficial with no side effects. For more information, visit your health food store or check out Rehab Plus on our website. ============================================================================= All About Piriformis Syndrome & Approach to Treatment Link Sponsored by: Relief-Mart - Quality health products for the back and spine. Piriformis Syndrome is a term for a condition in which the sciatic nerve becomes pinched in the region of the buttocks. This pinching can cause symptoms which include numbness, tingling, burning and achy soreness along the sciatic nerve path, a nerve which extends from the buttock area down the back of the leg to the foot. The sciatic nerve runs through a muscle in the buttocks region called the Piriformis. When the muscle shortens or spasms due to trauma, it can compress the sciatic nerve. This cause of sciatica symptoms is known as Piriformis Syndrome. The Piriformis muscle can be shortened and irritated from overuse of the muscle with repetitive movements like aerobics and dancing. The approach to treating Piriformis Syndrome is to reduce the compressive forces that are causing the pressure on the nerve. This can be accomplished through manual muscle stretching, massage, mobilization and pelvic adjustive techniques to take pressure of the Sacroiliac joints, and stretches to increase the length and loosen up the Piriformis muscle. At the onset of the irritation goals will be to lessen the pain and help to minimize any inflammation. The listed Therapies, Products and Activities section will give more information on how to help your condition, however, as each Piriformis Syndrome condition is different, always consult your doctor to determine what treatment is right for your particular situation. What if you have burning pains as your main symptoms: -------- Medications One of the most frequent questions our health experts encounter is whether medication should be taken, and which one would be right for them. It is important to remember those medications are aimed at temporarily reducing pain, inflammation, and relaxing the body, but have not been proven to increase healing to the area. Here are some of the most commonly mentioned medications: For over-the-counter medication, Ibuprofen has been indicated for temporary pain relief. Studies have also shown that in higher amounts, Ibuprofen can act as an anti-inflammatory, but a medical doctor's prescription is needed for this dosage. Aspirin and acetaminophen are also indicated for muscle pain relief, but do not show anti-inflammatory properties in prescription dosages. Acetaminophen does not have warnings about adverse reactions for people with aspirin allergies, as it is not an aspirin derivative. It has also been demonstrated to be better tolerated by people with weak intestinal systems. While Aspirin is known to be more abrasive on the intestinal system, it may have other side benefits such as blood thinning that prevents the blood clots which can lead to strokes and myocardial infarctions As these medications work to block pain and inflammation temporarily, it stands to reason that the need for these medications can occur when a person can no longer function due to the pain or when it hinders sleep and thereby impedes the bodies natural healing process. A person on pain medication should consider that they may more easily overdo it during the temporary relief period, which could cause further injury to the muscles. As side effects can occur, always consult your medical doctor to determine if and what medication is appropriate for your situation. Exercises and Stretches for the Back Muscular stretching can be a very important part of the healing process for tightened muscles of the back. It is essential to lengthen any shortened muscular tissue of the back to help prevent further pulling on the already shortened fibers. Muscular strengthening exercises will be important once the back irritation has subsided. Back strengthening exercises help to build stability to weak tissue. It should be noted that irritated muscles can become further damaged with strengthening exercises that are premature to the healing of the area. The exercises below are general exercises to increase flexibility and can help to stabilize the back. However, it should be noted that for most of these exercises, you should not feel the stretch in the back itself. For example, the back of the legs have a group of muscles called the hamstrings. These muscles originate in the lower pelvis and insert into the leg. When the hamstrings are tight, the back itself can be tightened due to the pulling on the pelvis. Therefore, stretching the hamstrings will not only loosen the leg muscles up but they will take the strain off the back. Warning: exercises should never be performed if they cause irritation to your back or any other condition while they are being performed! As each Piriformis Syndrome condition is different, always consult your doctor before performing any of these exercises to determine what exercises, if any, are right for your particular condition. If you have any discomfort after performing any of these exercises, discontinue and immediately and consult a doctor to properly assess your situation. STRETCHES: Gluteus Stretch Piriformis Gluteus Stretch Laying down on your back, bend your right knee, and place your left leg over the right leg, resting the outside of the left ankle slightly above the right knee. Place your right hand around the outside of your right thigh and place the left hand around the inside of your right thigh. Lock the two hands together. Now pull forward towards your chest to achieve a stretch in the left gluteus portion of you buttocks. Do the exact opposite to achieve a stretch of the right gluteus portion of the buttocks. Hold each stretch for a minimum of 30 seconds, any less than 15 seconds and the muscle will not conform to the new increase in length. Do 3 reps, 3-6 times a day. Any pain you feel with this exercise should only be a local stretching sensation to the back of your thigh and buttocks area, without aggravating your condition. Piriformis Stretch Piriformis Stretch Laying down on your back, bend your right leg and pull up your right knee towards your opposite chest with your left hand. You should feel the stretch in the Piriformis portion of the right buttocks. Do the exact opposite to achieve a stretch of the left Piriformis portion of the buttocks. Hold each stretch for a minimum of 30 seconds, any less than 15 seconds and the muscle will not conform to the new increase in length. Do 3 reps, 3-6 times a day. Any pain you feel with this exercise should only be a local stretching sensation to the back of your thigh and buttocks area, without aggravating your condition. TFL Stretch TFL Stretch Start with stretching the TFL portion of the left hip and outside thigh. While standing, hold your left hand securely on a solid surface to support your body as you place your left leg past your right until you reach a maximum stretch. Follow this with tilting your upper back to the right side while simultaneously pushing the left side of the hip. Do the exact opposite to achieve a stretch of the right TFL portion of the hip and outside thigh. Hold each stretch for a minimum of 30 seconds, any less than 15 seconds and the muscle will not conform to the new increase in length. Do 3 reps, 3-6 times a day. Any pain you feel with this exercise should only be a local stretching sensation to the TFL portion of the hip and outside thigh, without aggravating your condition. Calf Stretch Calf Stretch Start with stretching the right Gastrocnemius portion of the right calf area. While standing, place your right leg in front of you and your left foot directly behind you. Place the toes of your right forefoot up against a door or other flat wall surface, keeping your heel down to the floor. Lean your upper body forward to place a stretch on the back of the calf. Do the exact opposite to achieve a stretch of the left calf area. Hold each stretch for a minimum of 30 seconds. Any less than 15 seconds and the muscle will not conform to the new increase in length. Do 3 reps, 3-6 times a day. Any pain you feel with this exercise should only be a local stretching sensation to the calf area of the leg, without aggravating your condition. Psoas Stretch Psoas Stretch Start with stretching the right Psoas muscle. While standing, place your right leg in front of you and your left foot directly behind you as far as you can comfortably stretch it. Shift your lower body forward, while simultaneously pushing your upper body backwards with your arms. Do the exact opposite to achieve a stretch of the right Psoas portion of your front upper thigh area. Hold each stretch for a minimum of 30 seconds. Any less than 15 seconds and the muscle will not conform to the new increase in length. Do 3 reps, 3-6 times a day. Any pain you feel with this exercise should only be a local stretching sensation to the Psoas area of the upper thigh, without aggravating your condition. Quadriceps Stretch Quadriceps Stretch Yoga and Meditation to Relax the Back Regardless of the current situation your back is in, relaxing could be key to helping it heal. While meditation can always be useful for achieving this, Yoga can at times be irritating if caution is not taken. Yoga is a series of slow movements combined with stretches and meditation to allow for an increase in flexibility and relaxation to the muscles and joints, as well as to help optimally integrate the connection between the mind and body. However, what might seem to be easy maneuvers should still be treated cautiously, as your individual situation may prohibit certain Yoga moves. One simple meditation practice that is usually met with good success is to close your eyes and visualize yourself in the most happy and relaxing place you know of. Sometimes just taking the time to do this can be what you need to begin the healing process. Medical Practitioners Link A doctor of medicine can take the time to evaluate your condition and confirm your specific diagnosis. Medical doctors prescribe either over the counter or prescription only medication. They can prescribe medications that temporarily relieve inflammation, temporarily relax muscles, and temporarily relieve pain. Many medical doctors work with physical therapists and chiropractors to provide conservative management for the many back pain conditions a patient can experience. Orthopedic doctors have extended training in joint-related conditions such as this. While Orthopedic doctors can perform back surgery, this drastic step should only be used when all other treatment options have been exhausted, as back surgery carries many risks, and not usually recommended for most conditions. ============================================================================= Running Online Link Piriformis Syndrome (aka. Pain in the Butt) ============================================================================ Piriformis Syndrome: Link What is it? The piriformis syndrome is a condition in which the piriformis muscle irritates the sciatic nerve, causing pain in the buttocks and referring pain along the the path of the sciatic nerve. The nerve pain, called "sciatica", often goes down the back of the thigh and/or into the lower back. The pains is deep in the buttocks, which is made worse by sitting, climbing stairs or performing squats. The affected leg is often externally rotated (toes point out) when relaxed, such as when lying face down on the bed with your feet over the end of the mattress. Some reports suggest a 6:1 female to male predominance. The piriformis muscle assists in abducting the and laterally rotating the thigh. It lies deep in the gluteal muscles and originates from he sacral spine and attaches to the greater trochanter of the femur. The sciatic nerve usually passes underneath the piriformis muscle, but in approximately 10% of the population, travels through the muscle. It is thought that acute or chronic injury causes swelling of the muscle and irritates the sciatic nerve, resulting in sciatica. Patients with an aberrant course of the nerve through the muscle are particularly predisposed to this condition. ============================================================================= Other causes of Piriformis Syndrome when surgery fails: Link Clair Davies www.triggerpointbook.com talks about Trigger Points and Referred Pain What is referred pain? Clair Davies www.triggerpointbook.com talks about Trigger Points and Referred Pain Muscles and Trigger Points: Many times your pain is actually coming from muscles and the surrounding connective tissue (fascia). Situation: when the muscle becomes tight or shortened and is no longer able to relax to its full resting length a piriformis syndrome problem exists. When muscle fibers become chronically shortened, the result is a tender nodule in the muscle, usually in the middle of the muscle or at its attachments. These tender areas or Trigger Points (TrPs) are named for their astonishing ability to "trigger" or refer pain to distant areas, far from the actual origin. ============================================================================= Referred Pain Link According to Doctors Janet Travell and David Simons in their widely acclaimed medical textbook, Myofascial Pain and Dysfunction: The Trigger Point Manual, referred pain is the defining symptom of a myofascial trigger point. It is felt most often as an oppressive deep ache, this ache can trigger a sciatica symptom down your effected leg giving you pain both in the buttock and also throughout the sciatic nerve as it continues down your leg with referred pain. Some common examples of referred pain are headaches, sinus pain, and the kind of pain in the neck that won't let you turn your head. Jaw pain, earache, and sore throat can also be expressions of referred pain. Another is the incapacitating pain in the side that comes from running too hard and or not used to that particular exercise and have overdone. Sore feet and sprained ankles are other examples of referred pain. Stiffness and pain in a joint should always make you think first of possible trigger points in nearby muscles that have been subjected to strain or overwork. Pain in such joints as the knuckles, wrists, elbows, shoulders, knees, and hips are almost always nothing more serious trigger points which are knotts that need to be massaged in order to give your muscles relief and full flexibility. With certain muscles, the referred pain can often be found by pressing on a trigger point knot that is bad enough to reproduce part of its referred pain signals. This referred pain is caused by having disruption along the nerve impulse sciatic nerve line. Pain referral is difficult because the mechanisms of the human nervous system is very small and hard to see or operate on. Tiny electrochemical impulses can be detected and measured to some extent, but not with great accuracy do to it being so small in size. Referred pain is happens when your neurological wiring signals get confused. Inputs from several sources are known to converge into single neurons (nerve cells) at the spine and are modified before being transmitted to the brain. One electrical signal can influence another, resulting in some big problems if the original signal is mixed up from a pinched or decompressed sciatic nerve. The displacement of pain seems occurs in very predictable patterns with only small variations from person to person. The predictability shows that there may be a functional advantage to the referral of pain which helps the sufferer. Referred pain usually occurs very often in or near a joint, telling you to modify your exercising and to slow down so that the condition will not be aggravated to any larger of an extent. After you've figured out why you have referred pain you can figure out where it is coming from and then diagnosis and treatment becomes easier for you. remarkably easy. In The Trigger Point Therapy Workbook, nationally certified massage therapist Clair Davies www.triggerpointbook.com has simplified Travell and Simons' extensive research into referred pain and made it accessible to the non professional person in the Clair Davies self-applied trigger point massage book which will hopefully relieve some of the referred pain, numbness, bad sensations caused by trigger points (which are the root to the cause of the pain.) The Trigger Point Therapy Workbook Link by David G. Simons, M.D. Clair Davies www.triggerpointbook.com possesses a good combination of attributes for the common person: He is a skilled at his profession, has good writing skills that everyone can understand and he shows a great determination to help everyone get over their suffering from pain. The Muscle is an orphan organ. Nobody really studies all the aspects of the muscle and why it gets tied up in knots and why the referred pain is so hard to figure out the origins of the original tied up or compressed nerve or muscle. Usually both are involved. His book shows how to recognize and treat myofascial trigger points. Massage therapists do study trigger points although rarely trained medically, are trained in how to find myofascial trigger points through diagnosis and findings in their skilled treatment of that body part. There is no well-recognized right way to get the job done which makes it very hard to get the scientific research and funding in order to model a clear cut study on diagnosis and treatment. Myofascial trigger points are a neglected subject. Virtually all fibromyalgia patients have myofascial trigger points that are to their total pain and lack of recovery. There main problem is that they have many more treatable multiple trigger points. Inactivation of the trigger points of fibromyalgia patients requires especially delicate and skilled treatment and will take months to completely heal. Myofascial trigger points as the most common cause of musculoskeletal pain, but finding someone who understands these trigger points will be very difficult as best. The guidance in the trigger point book is a good manual for finding out and understanding the trigger points and the musculoskeletal pain one has in which regular doctors were not able to find or diagnose properly. Doctors treat the pain and not the problem of where the pain is coming from and once the trigger points are worked on then the pain will go away permanently instead of temporarily. www.triggerpointbook.com ============================================================================= University Sports Medicine 160 Farber Hall Buffalo, New York 14214 (716) 829-2070 University of Michigan Health system Link ============================================================================= Piriformis Syndrome sciatic nerve passes through piriformis muscle What is piriformis syndrome? Piriformis syndrome refers to irritation of the sciatic nerve as it passes through the piriformis muscle located deep in the buttock. Inflammation of the sciatic nerve, called sciatica, causes pain in the back of the hip that can often travel down into the leg. How does it occur? The piriformis muscle is located deep in the buttock and pelvis and allows you to rotate your thigh outward. The sciatic nerve travels from your back into your leg by passing through the piriformis muscle. If the piriformis muscle is unusually tight or if it goes into spasm, the sciatic nerve can become inflamed or irritated. Piriformis syndrome may also be related to intense downhill running. What are the symptoms? Link You have pain deep in your buttock that may feel like a burning pain. The pain usually travels down across your lower thigh. Your pain may increase when you move your thigh outward, such as when you are sitting cross-legged. sciatic nerve runs below piriformis muscle Link Syndrome, piriformis: Irritation of the sciatic nerve caused by compression of the nerve within the buttock by the piriformis muscle. Typically, the pain of the piriformis syndrome is increased by contraction of the piriformis muscle, prolonged sitting, or direct pressure applied to the muscle. Buttock pain is common. The piriformis syndrome is one of the causes of sciatica. The piriformis syndrome can cause difficulty walking due to pain in the buttock and lower extremity. The piriformis muscle begins at the front surface of the sacrum (the V-shaped bone between the buttocks at the base of the spine) and passes through the greater sciatic notch to attach to the top of the thigh bone (femur) at its bony prominence called the greater trochanter. The gluteus maximus muscle covers over the piriformis muscle in the buttocks. The doctor can often detect tenderness of the piriformis muscle during a rectal examination. The piriformis syndrome is treated with rest and measures to reduce inflammation of the piriformis muscle and its tendon. Treatments include piriformis stretching exercises, physical therapy, anti-inflammatory medications, and pain medications. With persistent symptoms, further treatment can include local injection of anesthetic and cortisone medication. Rarely, for severe cases, surgery is performed to relieve the pressure irritating the sciatic nerve. During surgical operations, the piriformis muscle is either thinned, elongated, divided, or removed. How is it diagnosed? Your health care provider will talk to you about when your symptoms began. Since your sciatic nerve begins in the back, it can be irritated from a back injury, such as a herniated disk. Your provider will ask if you have had any injuries to your back or hip. He or she will examine your back to see if the sciatic nerve is irritated there. He or she will examine your hip and legs and move them to see if movement causes increased pain. Your health care provider may order x-rays, a computed tomography (CT) scan, or a magnetic resonance image (MRI) of your back to see if there is a back injury. There are no x-ray tests that can detect if the nerve is being irritated at the piriformis muscle. How is it treated? Treatment may include: placing ice packs on your buttock for 20 to 30 minutes every 3 to 4 hours for the first 2 to 3 days or until the pain goes away. 1. rest 2. taking prescribed anti-inflammatory medications or muscle relaxants 3. learning and doing stretching exercises of the piriformis muscle. 4. When can I return to my sport or activity? 5. The goal of rehabilitation is to return you to your sport or activity as soon as is safely possible. If you return too soon you may worsen your injury, which could lead to permanent damage. Everyone recovers from injury at a different rate. Return to your sport or activity will be determined by how soon the nerve recovers, not by how many days or weeks it has been since your injury occurred. 6. In general, the longer you have symptoms before you start treatment, the longer it will take to get better. You may safely return to your sport or activity when, starting from the top of the list and progressing to the end, each of the following is true: You have full range of motion in the affected leg compared to the unaffected leg. You have full strength of the affected leg compared to the unaffected leg. You can jog straight ahead without pain or limping. You can sprint straight ahead without pain or limping. You can do 45-degree cuts, first at half-speed, then at full-speed. You can do 20-yard figures-of-eight, first at half-speed, then at full-speed. You can do 90-degree cuts, first at half-speed, then at full-speed. You can do 10-yard figures-of-eight, first at half-speed, then at full-speed. You can jump on both legs without pain and you can jump on the affected leg without pain. How I prevent piriformis syndrome? Piriformis syndrome is best prevented by stretching the muscles that rotate your thigh inward and outward. It is important to have a good warm-up before starting your sport or activity. Written by Pierre Rouzier, M.D., for McKesson Health ============================================================================ WELCOME TO DOC PETE'S CHIROPRACTIC Link Piriformis Syndrome Link ============================================================================= Piriformis Syndrome is caused by an entrapment (pinching) of the sciatic nerve as it exits the Greater Sciatic notch in the gluteal region. There are two normal variations for the exit of the sciatic nerve in this region. The first places the sciatic nerve inferior (below) to the Piriformis muscle and superior (above) the gemellus muscle. Entrapment in this area is likely due to a myospasm or contracture (tightening or shortening respectively) of either of these two muscles. The second common site of entrapment is when the sciatic nerve actually pierces the piriformis muscle itself -this can occur in about 1% to 10% of all humans. In this case myospasm and or contraction of the piriformis muscle itself can lead to pain along the back of the thigh to the knee, loss of sensation or numbness and tingling in the sole of the foot. This particular syndrome can often mimic its more notorious counterpart known as sciatica, and that being the case, it is often misdiagnosed as sciatica.. The main difference between sciatica and piriformis syndrome is in the cause. Sciatica is directly due to a lumbar disc pressing on the sciatic nerve as it exits the intervertebral foramen in the lumbar spine. What both of these complaints have in common is that both can produce pain, numbness and tingling below the knee and into the foot. The main diagnostic tests performed by your doctor of Chiropractic is what distinguishes one from the other. With piriformis syndrome your chiropractor will not get positive tests results that indicate lumbar spine involvement. Often the patient may not be aware that there is a problem. Some cases won't show up until a complete neurological exam is performed on the lower extremity. The patient may have chief complaints ranging from no pain to pain in the lower back to gluteal pain to numbness and tingling in the foot. As can be seen the symptoms in this condition can vary widely making the doctor who is not used to differentially diagnosing this condition from sciatica confused as to the cause of the condition. Many weekend athletes and people who spend long hours sitting are prone to this syndrome. The athlete's cause is primarily due to improper stretching and warm-up exercises as well as overuse during activity. In this case it is most likely that the piriformis muscle is irritated and usually in spasm. For the patient who sits for extended periods of time, their primary cause is due to contracture of the piriformis muscle. In this case the piriformis muscle is shortened and does not allow for the smooth movement of the sciatic nerve during leg motion. A one-time direct trauma to the pelvis is very rarely a cause for piriformis syndrome due to the protection afforded the pelvis by the overlying musculature and fat. The causes of myospasm are many. Over use as during excessive fast walking without proper warm up and stretching (as during exercise), prolonged sitting, repetitive trauma as in horseback riding and others. As for your treatment, many variables can hamper your successful recovery. Smoking, obesity, job and exercise as noted above in prolonged sitting and not warming up and stretching. Any treatment plan must include stretching of the gluteal muscles as well as stretching of the piriformis muscles. Your Chiropractor can help you by instructing you on the proper exercises and stretches to perform. Many Chiropractors may also prescribe some form of massage be performed to the piriformis muscle in the gluteal region in order to relax these muscles. Also your chiropractor may prescribe certain herbals remedies such as valerian root and passion flower to help relax the associated muscles during your recovery phase. Spinal adjustment as well as hip adjustment may also be required to relieve your symptoms. In my opinion any treatment program which does not start to bring relief in the symptoms within three to four weeks (9-12 treatments) should be re-evaluated. The patient should be given an exercise program that involves stretching of the piriformis and gemelli muscles and strengthening exercises for weak muscles to do at home (hence patient non-compliance can also increase recovery time). After this initial nine to twelve treatments a complete re-evaluation of the symptoms and treatment program should be done to assess the progress and to make necessary changes to speed up recovery. ============================================================================= ============================================================================= Epidemiology Since an estimated 80 million Americans suffer low back pain and sciatica annually, (8) 4.8 to 6.4 million people contract piriformis syndrome annually. One reason for under diagnosis is that MRI, myelogram, CT, is unlikely to turn up any evidence of piriformis syndrome. (9-11) It is a functional syndrome: only certain positions and pressures bring out the pain, paresthesias, and weakness that come with it. Structural imaging studies are of minimal value here. (12-15) Since it is sometimes considered a diagnosis of exclusion, many patients receive painful and pointless surgical and other procedures based on limited inquiries and faulty diagnosis. Piriformis Syndrome is commonest among very active people such as athletes, health club users, joggers, and performers, and those who sit a great deal such as members of the financial community, lawyers, psychotherapists, secretaries and vehicular drivers. After occupational causes, trauma is the second greatest cause of piriformis syndrome. Lifting and other back strain related activities are third, with many other initiating events including misplaced gluteal injections, lipomas, and unusual furniture. Clinical Experience Treatment at first was simply physical therapy, informed and enriched by the generous giving forth of experience from the international medical community. In essence, the therapy lengthened the piriformis muscle, reducing spasm and pressure on the descending sciatic nerve, and giving the nerve enough slack to remove itself from harm's way. See the rest of the website for the specific program. The therapy was helpful, but progress was slow. On the suggestion of Dr. Janet Travell, we began injecting Triamcinolone Acetonide 20mg with 1.5cc of 2% lidocaine into the motor point of the piriformis muscle, just medial to its musculotendinous junction in the lateral buttock. This had only rare minor and transient side-effects on non-diabetics, and shortened the recovery time considerably. On average 10.2 month follow-up time of 1014 cases of piriformis syndrome, more than 80% of the patients had improved 50% or more within three months.(15) It is important to note that these patients had suffered from piriformis syndrome for an average of 6.2 years, and had seen an average of 6.5 clinicians before coming to our offices. Probably due to piriformis syndrome being considered a diagnosis of exclusion, other, less important diagnostic entities had received undue attention in these patients. Among these1014 cases there had been over 400 spinal, trochanteric and gynecological surgeries, none of which was definitive, more than 1500 imaging studies, of which less than 1/5 were relevant, and more than 10,000 appointments with clinicians for diagnostics, epidurals, physical therapy, and alternative methods of pain relief. More recently we have conducted several IRB-approved studies of more specific nerve blocks, using the toxin of the botulinum bacterium. In the latest and most successful of these, we have found that 12,500 units of botulinum B toxin has well above 85% efficacy, and fewer side effects than Triamcinolone and Lidocaine, giving more relief faster, and appearing in early studies to last longer. Containing no steroid, this preparation is also suitable for diabetics. Showing a much more rapid decline in pain levels, and normalization of the FAIR-test, it obviates physical therapy sessions that surpass the cost of the injection. In summary, there are four reasons that botulinum toxin helps in the treatment of piriformis syndrome. A reliable correlation between diagnosis and effective treatment exists. More than 5,000,000 currently improperly treated patients will continue to suffer, and continue to consume health care resources in vain unless and until adequate treatment is afforded them. In clinical experience, injection of botulinum toxin has proven the most effective treatment. Cost-benefit analysis of current data strongly supports injection of botulinum toxin in the treatment of piriformis syndrome. Two other considerations are relevant: Wider applicability. While the anti-insulinemic effect of steroids strongly contraindicates their use in diabetic patients, there are virtually no documented allergic reactions to botulinum toxins. Longer efficacy. Steroid injection without physical therapy is generally effective for 1-3 weeks. Botulinum toxin injections without physical therapy are effective for at least three months. In the past, approximately 15% of patients treated without botulinum toxin injections have had recurrence of piriformis syndrome within three years. As of today, (14 months after our first injection) we have seen 3 relapses following botulinum toxin injections in 61 patients. ============================================================================= Damn, that pain in my ass! Link Here's what you need to know about Piriformis Syndrome (Sciatic Pain)... by Jesse Cannone, CFT, CPRS + Steve Hefferon, CMT If you're reading this article, it's a good bet that you have a radiating pain running down ============================================================================= Recovery Tip: In severe cases, the sciatic pain can run from the top of the hip to the bottom of the foot. It is very important to recognize that changes and shifting of pain is often times a sign of improvement. Furthermore as a way of gauging recovery, take note of how far down the leg the pain goes. If the pain goes to the foot one day and then only makes it to the calf and then to the knee and then it can only make it to the hamstring that is a sign of improvement. You should feel good about those noticeable improvements and this should give you encouragement to keep working toward a full remission of pain. So how do you get rid of your pain? Will learning one new stretch be enough? It very well may be. However depending on the severity of your condition you may need to change your activities of daily living to include new stretches, new exercises that include the use of the hip rotators like roller-blading, basketball, tennis, etc, and even better, specific corrective exercise specific to your situation... like those covered in our video. As always, learn as much as you can about your condition, so that you can ask the tough questions to your healthcare providers and get the best care possible. One last point, sciatic pain is not caused by a lack of prescription medications so don't think that taking some anti-inflammatory or muscle relaxants will fix it... it won't! Also, many people are able to eliminate sciatic pain within days just by performing a few exercises and stretches... but not general exercise... the exact corrective exercises and stretches they need to do. ============================================================================= Piriformis Syndrome Link A Real Pain in the Butt Dr. Tim Maggs For the Washington Running Report ============================================================================= If you've ever felt pain in the hip, pain in the center of the butt, or pain down the back of the leg, you likely are suffering, at least partially, with piriformis syndrome. The piriformis is a muscle which runs from your sacrum (mid-line base of spine) to the outer hip bone (trochanter). This muscle truly works overtime on anyone who runs at all. The muscles in and around the gluteal region help with three areas: 1) rotation of the hip and leg, 2) balance while one foot is off the ground, and 3) stability for the pelvic region. Needless to say, all of these characteristics are needed by runners. Conclusion--the piriformis muscle is pretty important for all of us. Injuries to the Piriformis This muscle is a prime candidate for repetitive motion injury (RMI). RMI occurs when a muscle is asked to perform beyond its level of capability, not given enough time to recover, and asked to perform again. The typical response from a muscle in this situation is to tighten, which is a defensive response. This tightness, however, manifests itself in several ways to a runner. The first symptom suggesting piriformis syndrome would be pain in and around the outer hip bone. The tightness of the muscle produces increased tension between the tendon and the bone which produces either direct discomfort and pain or an increased tension in the joint, producing a bursitis. A bursitis is an inflammation of the fluid filled sac in a joint caused by an elevation of stress and tension within that joint. The second symptom suggesting piriformis syndrome would be pain directly in the center of the buttocks. Although this is not as common as the other two symptoms, this pain can be elicited with direct compression over the belly of the buttocks area. A tight muscle is a sore muscle upon compression due to a reduced blood flow to that muscle. The third symptom suggesting piriformis syndrome is a sciatic neuralgia, or pain from the buttocks down the back of the leg and sometimes into different portions of the lower leg. The sciatic nerve runs right through the belly of the piriformis muscle and if the piriformis muscle contracts from being overused, the sciatic nerve now becomes strangled, producing pain, tingling, and numbness. Simple Physiology Any muscle repetitively used needs to have an opportunity to recover. This recovery can either be on Nature's clock, or can be facilitated and sped up with proper knowledge and treatment. Since the muscle is tightening due to overuse, continued use will only make it worse. This injured muscle needs to relax and have increased blood flow to it for more rapid healing. The tightness also reduces the normal blood flow going to the muscle, reducing the speed wit which the muscle can recover. To encourage fresh, oxygen-rich blood to the muscle is the most powerful means of getting the muscle to begin to relax and function normally. Multiple massages per day to this area are greatly encouraged. The next step in this "recovery" process is to use a tennis ball under the butt and hip area. While sitting on the floor, roll away from the side of involvement and place a tennis ball just inside the outer hip bone under the butt area. As you begin to allow your weight onto the tennis ball, note areas of increased pain and soreness. Trigger points will tend to accumulate in a repetitively used muscle, and until these toxins are manually broken up and eliminated, the muscle will have an artificial ceiling with regard to flexibility potential and recovery potential. So, if it's sore and hurts while you are sitting on it, you're doing a good job. Let the ball work under each spot for fifteen to twenty seconds before moving it to another area. Once you've been on the ball for four to five minutes, put the ankle of the involved leg over the knee of the noninvolved leg (crossing your legs). Now place the tennis ball just inside the outer hip bone again and work the tendon of the piriformis muscle. While this pain is typically excruciating and takes some time to effectively reduce, the benefits here are huge. Be patient, be consistent, and good things will happen. Additional Treatments Due to the fact that the sciatic neuralgia and the hip bursitis or tendonitis are both inflammatory in nature, ice, or cryotherapy, over the involved area fifteen to twenty minutes at a time will be beneficial. This should be done multiple times per day. Stretching of the hip muscles should not be done until the acute pain is gone. Then, begin with gentle stretching, such as the cross-legged stretch, while pulling up on the knee. The muscle should have increased flexibility before an active return to running. Finally, I always discourage the use of pharmaceutical anti- inflammatories. Not only do they greatly aggravate the intestines, they suggest an artificial wellness that can lead to bigger problems. Proteolytic enzymes, such as bromelain, are both natural and extremely beneficial with no side effects. For more information, visit your health food store or check out Rehab Plus on our website. For further information, Dr. Maggs can be reached at (518) 869-1884, his Web site: Dr. Maggs or via e-mail Running Doctor ============================================================================= lose the back pain Link Sciatica (Sciatic Pain, Piriformis Syndrome) ============================================================================= Sciatica commonly refers to pain that radiates along the sciatic nerve and is typically felt in the buttocks, down the back of the leg and possibly to the foot. Sciatica is one of the most common forms of pain caused by compression of the spinal nerves. Often the leg pain often feels much worse than the back pain. Numbness, tingling, and a burning or prickling sensation in the back and legs are also common symptoms. Sciatica is actually a symptom and not disease. The term literally means that a patient has pain down the leg from compression on the sciatic nerve. Usually a herniated disc causes the sciatic pain. The diagnosis is what is causing the compression (such as a disc herniation). Most cases of sciatica are caused by a simple irritation to the nerve and will get better with time. However, some sciatica symptoms may indicate a permanently injured nerve. This is particularly if true weakness or numbness is present in the back or the leg. ============================================================================= syracusechargers.org A Real Pain in the .... Link ============================================================================= A while back I noted that very often I will be visited by a runner complaining that his or her "sciatica is acting up." Generally, what they are saying is they have some pain in the back of the thigh, maybe some in the buttock, low back or even into the calf. Sciatica, by definition, is an inflammation or irritation of the sciatic nerve, the largest nerve in the body, which originates in the lower spine in the form of five separate nerve roots which join together and traverse the buttock and descend into the lower limb all the way to the toes. The problem is, sciatica is a vague term that doesn't really tell us very much about the underlying reason for these symptoms since there can be several explanations for them. Some of the possible causes of this ailment which reviewed then included sacroiliac joint dysfunction, lumbar spine arthritis or herniated discs, chronic hamstring strains and a rather esoteric-sounding problem called the piriformis syndrome, which we want to look at in more detail now. The piriformis muscle is a relatively large structure found in the buttock, originating on the sacrum (the lower part of the spine, or tailbone) and crossing over at a slightly downward angle to the outside of the hip, attaching to the outer portion of the upper thighbone (femur). Its function is to laterally rotate and extend the hip joint. It is only one of several muscles in the buttock which, as we've said, is an area through which the sciatic nerve passes, but the piriformis has been singled-out as a potential cause of sciatica because anatomists have found that in a fair number of people, all or part of the sciatic nerve goes directly through this particular muscle. (The exact percentage of people is unknown -- studies vary widely with some experts reporting 20% and others as many as 60%!) The speculation is that in these subjects, a tight piriformis muscle will "squeeze" the nerve, causing irritation and subsequent pain. Runners, of course, would be more likely to have a tight piriformis since they would be using it more often and more intensely, especially during the push-off phase of gait when hip extension and lateral rotation are needed most, but theoretically anyone could experience this problem really if posture and biomechanics of walking are abnormal. Is it real? Does piriformis syndrome really exist? Well, the fact that we call it a syndrome -- which in the medical field is a code word for "we don't really know exactly what it is or know for sure what really causes it" -- tells us a lot. It seems reasonable that the piriformis, like any muscle, can become overused and painful, especially with running. But, like any muscle, this irritated muscle can cause radiating or referred symptoms which would mimic sciatica pain while there may not necessarily be any actual injury to the nerve itself. Or, conversely, there are other potential causes of nerve inflammation in the buttock with no involvement of the piriformis muscle. My favorite example is something actually designated in the medical literature as "fat wallet syndrome," which is found most often in long-distance drivers (truckers, salesmen). The prolonged pressure of a billfold full of cash and credit-cards on the sciatic nerve is a not-infrequent cause of sciatica. (The cure, of course, is for me to relief the patient of the offending object...) ============================================================================== Clair Davies www.triggerpointbook.com talks about Trigger Points and Referred Pain The Trigger Point Therapy Workbook; You're Self-Treatment Guide for Pain Relief Buy this book,, "The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief" : Link The Book Introduction Link ============================================================================== They've tried chiropractic, acupuncture, magnets, pain diets, and herbal therapy. They take their pain medicine and dutifully do their stretching exercises. Sometimes they feel better for a while, but the pain always comes back. Nothing really seems to get to the bottom of the problem. Despite being told there are no guarantees of success, they fear surgery may be the only solution. They're beginning to wonder if anybody really knows anything about pain. If all this describes your own situation or that of someone you care about, this book may provide the help you've been seeking. It proposes to give you a sensible explanation of what's wrong and help you find the real cause of your pain. Even better, it may well show you how to get rid of the pain yourself, hands-on. No doctors. No pills. No bills. There is growing evidence that most of our common aches and pains--and many other puzzling physical complaints--are actually caused by trigger points, or small contraction knots, in the muscles of the body. Pain clinic doctors skilled at detecting and treating trigger points have found that they're the primary cause of pain roughly seventy-five percent of the time and are at least a part of virtually every pain problem. Even fibromyalgia, which is known to afflict millions of people, is thought in many instances to have its beginning with trigger points. Trigger points are known to cause headaches, neck and jaw pain, low back pain, the symptoms of carpal tunnel syndrome, and many kinds of joint pain mistakenly ascribed to arthritis, tendonitis, bursitis, or ligament injury. Trigger points cause problems as diverse as earaches, dizziness, nausea, heartburn, false heart pain, heart arrhythmia, tennis elbow and genital pain. Trigger points can also cause colic in babies and bed- wetting in older children and may be a contributing cause of such childhood horrors as scoliosis, attention deficit disorder and dyslexia. They are a cause of sinus pain and congestion. They may play a part in chronic fatigue and lowered resistance to infection. And because trigger points can be responsible for long-term pain and disability that seem to have no means of relief, they can cause depression. The problems trigger points cause can be surprisingly easy to fix; in fact most people can do it themselves if they have the right information. That's good, because the time has come for ordinary people to take things into their own hands. The reason is that an appallingly high percentage of doctors and other practitioners are still pretty much out of the loop regarding trigger points, despite their having been written about in medical journals for over sixty years. There has been, and continues to be, great resistance to the whole idea. Why has the medical profession not embraced the idea of trigger points? Partly, it's because trigger points are commonly confused with acupressure points. Acupressure, which has come down to us from ancient Chinese medicine, is alleged to have a positive effect on supposed flows of energy throughout the body. Although acupressure and other Eastern methods of healing do seem to have a beneficial effect, they're very resistant to solid scientific investigation and are viewed by many doctors and a large segment of the public as quack medicine with no proven results. If you don't know the difference, the claims about trigger points sound like quack medicine too. Our knowledge of trigger points, however, comes right out of Western medical research. Trigger points are real. They can be felt with the fingers. They emit distinctive electrical signals that can be measured by sensitive electronic equipment. Trigger points have also been photographed in muscle tissue with the aid of the electron microscope. Most of what is known about trigger points is very well documented in the two-volume medical text Myofascial Pain and Dysfunction: The Trigger Point Manual, by Janet Travell and David Simons. These books tell virtually all there is to know about trigger points, and the prospects for pain relief are very exciting. Much of the information in the Trigger Point Manual is couched in difficult scientific terms but basic trigger point science isn't hard to grasp if it's put into everyday language. Travell and Simons describe a trigger point as simply a small contraction knot in muscle tissue. It often feels like a partly cooked piece of macaroni or like a pea buried deep in the muscle. A trigger point affects a muscle by keeping it both tight and weak. At the same time, a trigger point maintains a hard contraction on the muscle fibers that are directly connected to it. In turn, these taut bands of muscle fiber keep constant tension on the muscle's attachments, often producing symptoms in adjacent joints. The constant tension in the fibers of the trigger point itself restricts circulation in its immediate area. The resulting accumulation of the by-products of metabolism, as well as deprivation of the oxygen and nutrients needed for metabolism can perpetuate trigger points for months, or even years, unless some intervention occurs. It's this self-sustaining vicious cycle that needs to be broken. The difficulty in treating trigger points is that they typically send pain to some other site. Most conventional treatment of pain is based on the assumption that the cause of pain will be found at the site of the pain. But trigger points almost always send their pain elsewhere. This referred pain is what has always thrown everybody off, including most doctors and much of the rest of the health-care community. According to Travell and Simons, conventional treatments for pain so often fail because they focus on the pain itself, treating the site of the pain, and overlooking and failing to treat the cause, which may be some distance away. Even worse than routinely treating the site of the pain is the pharmaceutical treatment of the whole body for what is usually a local problem. Painkilling drugs, the increasingly expensive treatment of choice these days, give us the illusion that something good is happening, when in reality they only mask the problem. Most common pain, like headaches, muscle aches, and joint pain, is a warning-a protective response to muscle overuse or trauma. Pain is telling you that something is wrong and needs correction. It's not good medicine to kill the messenger and ignore the message. When pain is seen in its true role as the messenger and not the affliction itself, treatment can be directed to the cause of pain. Luckily, referred pain is now known to occur in predictable patterns. The valuable medical advance made by Travell and Simons and their brilliant illustrator, Barbara Cummings, has been in delineating these very patterns. Once you know where to look, trigger points are easily located by touch and deactivated by any of several methods. Unfortunately, the two clinically oriented methods put forth in The Trigger Point Manual don't lend themselves to self-treatment. The goal of this book is to build on the work of Travell and Simons and provide a more practical and cost-effective approach to pain therapy: a classic do-it-yourself approach, rather than multiple professional office visits. This new approach is a system of self-applied massage directed specifically at trigger points. Significant relief of symptoms often comes in just minutes. Most problems can be eliminated within three to ten days. Even long-standing chronic conditions can be cleared up in as little as six weeks. Results may be longer in coming for those who suffer from fibromyalgia, chronic fatigue, or widespread myofascial pain syndrome, but even they can experience continuing progress and can have genuine hope of significant improvement in their condition. Self-applied trigger point massage works by accomplishing three things: it breaks into the chemical and neurological feedback loop that maintains the myofascial contraction; it increases circulation that has been restricted by the contracted tissue; and it directly stretches the trigger point's knotted muscle fibers. The illustrations in this book show you how to find the trigger points that are generating your specific problems, as well as the exact hands-on techniques for deactivating them. Special attention has been given to designing methods of massage that do no damage to hands that may already be in trouble from overuse. This book's primary use is as a self-instruction manual, but it can also be used as a textbook for classroom use. This simplified and direct approach to treating myofascial pain with self-applied massage can constitute a foundational course in trigger point therapy in any professional training curriculum. Students in chiropractic colleges, physical therapy departments, and massage schools will derive particular benefit. If they can learn how to interpret their own referred pain and how to find and treat their own trigger points, they will know exactly what to do when they encounter similar problems in their future clients. A class in self-applied trigger point massage would be a boon in medical schools for exactly the same reasons. When new doctors can learn how to fix their own pain with self-applied massage, they are in better touch with the realities of pain and with the great potential in the treatment of trigger points. Such an addition to medical education would profoundly improve the treatment of pain and lower much of its cost. And it's not too late for physicians already in practice to learn about trigger points and myofascial pain and put the knowledge to good use. They will find this book a quick and practical introduction to the magnificent work of Travell and Simons and this neglected branch of medicine. Hopefully, many will be encouraged to go to Travell and Simons' Trigger Point Manual for a deeper scientific understanding and for even greater benefit to their practice. A large segment of the public needs help and encouragement in learning how to deal with their trigger point-induced pain. No one is better positioned to provide this help than the medical community. The medical profession is not unaware of the deficiencies of current methods of treating pain. Doctors hurt too. Many of them worry like the rest of us about the relentless popping of pills, and many experience frustration with their inability to offer better solutions to their patients. Trigger point therapy, whether self-applied or administered by a professional, has the potential to truly revolutionize pain treatment throughout the world. ============================================================================= Sciatica, Piriformis Syndrome, PIRIFORMIS TRIGGER POINTS Link Sciatic Nerve Impingement, Erectile Dysfunction, Buttocks Pain, Rectal Pain, Anal Pain, Leg Pain, Tingling in Legs According to Doctors Janet Travell and David Simons in their widely acclaimed medical textbook, Myofascial Pain and Dysfunction: The Trigger Point Manual, myofascial trigger points (tiny contraction knots) in overworked gluteus minimus and piriformis muscles in the buttocks are actually the most frequent cause of sciatica. Referred Symptoms Symptoms of sciatica include aching pain, numbness, tingling, burning and hypersensitivity in your low back, buttocks, hips, and down your legs into your ankles and feet. Simple aching pain in these areas usually is referred from gluteus minimus trigger points. Piriformis trigger points, by keeping the muscles tight and rock hard, can cause actual sciatic nerve compression. Pain from piriformis trigger points is harsher and more electric than pain from gluteus minimus trigger points and is felt in the back of the thigh, the calf, and the sole of the foot. There may also be other abnormal sensations, such as numbness, tingling, burning, or hypersensitivity, in any of these areas. Piriformis Syndrome A piriformis muscle that is shortened and swollen by trigger points can also compress numerous other nerves and blood vessels coming out of the pelvis. This can result in a sense of swelling in the buttocks, leg, calf, and foot. In addition, a tight piriformis muscle can impinge upon the pudendal nerve, causing impotence in males and pain in the groin, genitals, or rectal area of either gender. Piriformis muscles that compress gluteal nerves and blood vessels are believed to be responsible for gluteal muscle atrophy, wherein one or both buttocks waste away. For decades, the medical profession has known this particular group of sciatic symptoms as "piriformis syndrome," although the cause of the piriformis enlargement was never really understood. Surgical release of the piriformis muscle for the treatment of sciatica was once a common treatment. Amazingly, this operation is still performed by surgeons who are unaware of the effects of myofascial trigger points. Misdiagnosis: In the medical world, sciatica is routinely assumed to be caused by pressure on the sciatic nerve as a result of a compressed disk or other spinal abnormality. Surgery on the spine in a search for the cause of presumed sciatic nerve impingement is very common, even though it regularly fails to erase sciatic symptoms. Doctors Travell and Simons believe that traditional medical solutions for sciatica and piriformis syndrome is needlessly expensive and have an unacceptably high rate of failure. Trigger points should be at the top of the list during any examination for pain, numbness and other abnormal sensations in the hips and legs. Wider recognition of the myofascial causes of sciatica could eliminate many unnecessary surgical operations. Self-Treatment: Myofascial Pain and Dysfunction: The Trigger Point Manual You don't have to wait for the medical community to abandon antiquated methods and catch up with trigger point science. You can take care of your own trigger points. In The Trigger Point Therapy Workbook, nationally certified massage therapist Clair Davies has simplified Travell and Simons' extensive research into myofascial pain and made it accessible to the layman. His innovative methods of self-applied trigger point massage will get rid of the numbness, tingling and aching pain of sciatica and piriformis syndrome when trigger points are the cause. To learn more, please visit the homepage. trigger point therapy book - buy yours today! The Trigger Point Therapy Workbook - Second Edition You're Self-Treatment Guide For Pain Relief Clair Davies www.triggerpointbook.com, NCTMB with Amber Davies, NCTMB The proven method for over-coming soft tissue pain. Now available in a practical step by step format. =========================================== TRIGGER POINT THERAPY CHAPTER 1 Link ============================================ It was a spark of hope. A New Technology When I got home from the convention, I ordered the books: volumes I and II of Myofascial Pain and Dysfunction: The Trigger Point Manual, by Janet Travell and David Simons. The price of medical books was a shock and I bridled a bit, but I finally had to ask myself: What is this knowledge worth? My shoulder answered the question for me. When the books came, I entered a world I hadn't known existed. As soon as I began t read, the mystery of my shoulder problem began to clear. In the Trigger Point Manual, I found hundreds of beautifully executed illustrations of the muscles of the body. They showed the likely trigger points for every muscle and the patterns of pain they predictably touched off. I found that, although the physiology of a trigger point was extremely complex, a trigger point for practical purposes could be viewed as what most people call a "knot": a wad of muscle fibers staying in a hard contraction, never relaxing. A trigger point in a muscle could be actively painful or it could manifest no pain at all unless touched. More often, though, it would sneakily send its pain somewhere else. I gathered that much of my pain, perhaps all of it, was probably this mysterious displaced pain, this referred pain. I had never been able to figure out why all the rubbing I had been doing had never done any good. It was a mistake to assume the problem was at the place that hurt! The pain in the front of my shoulder was actually coming from behind it, from trigger points in the infraspinatus, a muscle that covered part of the outside of my shoulder blade. The deep aching behind my shoulder was coming from trigger points in the subscapularis, a muscle on the underside of my shoulder blade, sandwiched between the shoulder blade and the ribs. The unrelenting pain at the inner edge of my shoulder blade was being sent by trigger points in the scalene muscles, in the front and sides of my neck. It was no wonder nobody knew what to do for me! It was clear to me that all I had was a massive number of trigger points in the muscle in my shoulder-trigger points in over twenty muscles, as it turned out. That first massage therapist, the one I liked so much, had treated me very successfully with ordinary massage techniques and I understood now that it was trigger points she was dealing with. Perhaps I could deal with the trigger points myself using massage. I began to think that this might be a job for someone with a technician's mentality-maybe someone who was smart enough to take on the complexities of a piano would be well equipped to fix trigger points. Driven by my misery and by my excitement about these new ideas, I studied Travell and Simons night and day. I found that my trigger points would yield under the touch of my own hands if I persisted. After only about a month of assiduously applying what I was learning chapter by chapter, I had succeeded in fixing my shoulder . . . my own shoulder! I was astounded. The pain was gone. I could raise my arm. I could sleep through the night. This stuff really worked! Given the innately optimistic cast of my mind, I immediately took a larger view. I saw that I had in my hands the tools to take effective care of myself, at least when it came to any kind of myofascial pain. I supposed that I might be able to treat any trigger point I could reach and extinguish virtually any pain I might have. I could develop a complete system, a kind of new technology, and maybe other people would be helped by it. Mechanical Ingenuity Travell and Simons had done a wonderful thing in giving the science of myofascial pain to the medical community. The illustrations by Barbara Cummings brilliantly clarified every aspect of the subject. Without these dedicated people, the science of trigger points and referred pain would still be an impossible jumble, largely unknown and inaccessible. Unfortunately, Travell and Simons' two main methods for deactivating trigger points weren't oriented toward self-treatment. They were designed specifically for the doctor's office or the physical therapy clinic: a doctor could inject trigger points with procaine, a local anesthetic; and a physical therapist could presumably stretch trigger points out of existence. It bothered me, however, that the physical therapy protocol, which Travell and Simons called their "workhorse" method, involved the muscle stretching that I had found so ineffective and even dangerous, in that it had made my shoulder problem dramatically worse. To be sure, Travell and Simons had made stretching safer by using a refrigerant spray on the skin. "Distracting" the nervous system with the spray meant the underlying muscles were less likely to tighten up in defense. Nevertheless, safe or not, I felt that the spray and stretch method was too elaborate to be practical for self-treatment, and that it would be impossible to use on areas that were hard to reach. Trying to get at the relatively small trigger points by stretching whole groups of recalcitrant muscles seemed unnecessarily indirect and inefficient. The problem was not with the generalized tension in the muscle, but rather with the trigger point, a very specific, circumscribed place within the muscle. The trigger point's knotted up muscle fibers obviously needed to relax and let go, but why not go straight to the trouble spot and deal with it directly? Massage seemed to me the natural approach, and it obviously worked with trigger points-that good massage therapist had proven that much to me. I wanted to find simple ways to use massage for self-treatment. I wanted to develop a comprehensive method for dealing with trigger points anywhere in the body. I wanted something that a regular person like me could immediately understand and use. I was sure all this could be done. Among the old-time piano men at Steinway, the highest compliment was to be called "a pretty good mechanic." A good mechanic cared about the details and he stuck with the job until he got it right; he could find the solution to a problem even if it wasn't in the book. My life up to that point had been built around being a good mechanic, and being able to find the simple solution. That's certainly what I had to do in devising ways to self-treat trigger points. For the purposes of treating trigger points, I felt the body was best thought of as a machine, a mechanical system of levers, fulcrums and forces, especially in regard to the bones and muscles. I could understand such a system. A lifetime of working with my hands was about to begin to pay off in a new and unexpected way. My first challenge was to learn the exact location of each muscle, to visualize how it attached to the bones, and to understand the job the muscle did. Finding the precise massage technique that a trigger point would respond to was where the art would come in. The difficulty here was in figuring out how to reach unreachable places and get effective leverage in awkward positions without hurting my hands and fingers, which were already being overused in the course of an ordinary workday. The project became an obsession. I studied Travell and Simons the first thing in the morning and the last thing at night. I studied in the parking lot at McDonald's. Using my own body as the laboratory, I discovered something new every day. I found trigger points everywhere and became aware of pain that I didn't know I had. I only wanted to talk about trigger points and often greeted family members excitedly with the exclamation, "I found another one! I found another one!" Over a period of three years, I learned how to find and deactivate trigger points in 120 pairs of muscles, which enabled me to cope with every trigger point that Travell and Simons dealt with in their books except those inside the pelvis. A World of Pain The misdiagnosis of pain is the most important issue taken up by Travell and Simons. Referred pain from trigger points mimics the symptoms of a very long list of common maladies; physicians, in weighing all the possible causes for a given condition, have rarely even conceived of there being a myofascial source. The study of trigger points has not historically been a part of medical education. Travell and Simons hold that most of common everyday pain is caused by myofascial trigger points and that ignorance of that basic concept could inevitably lead to false diagnoses and the ultimate failure to deal effectively with pain. (Travell and Simons 1999: 12-14) From the beginning, I had a sense that for some reason the great work of Janet Travell and David Simons had fallen into a deep pit and was in danger of being buried and forgotten. Surely, by now Travell's discoveries about pain should have swept the country and changed the world of health care. The first volume of the Trigger Point Manual had been published in 1983, but I couldn't find anything about trigger points in the public library. None of the popular family medical guides even mentioned trigger points. Nothing truly informative was to be found in bookstores. Doctors were still using drugs as the primary treatment for pain. Many were actively hostile to the concept of trigger points, discounting the idea as just more bogus medicine, something purely imaginary. Only massage therapists seemed to be informed about trigger points and referred pain, and only exceptional individuals among them (in my own experience at least) were treating trigger points effectively. What's more, the burgeoning variety of unproven modalities offered by massage therapists gave the profession such an aura of flakiness that the elegant science of myofascial pain treatment got unfairly confused with treatments whose results could easily be attributed to the placebo effect. With such an identity, how could the medical profession or the public at large ever take it seriously? Clearly, there was a world of pain out there in need of the simple and genuine solutions I felt I had in hand. I despaired of doctors ever listening to me about trigger point therapy. Taking the facts about myofascial pain directly to the public seemed the more logical tack. I began to think about leaving the piano business behind. There was something more important for me to do. The first thing I wanted to do was to write about the self-treatment of pain for all my ailing friends in the Piano Technicians Guild. Previous articles in the Piano Technicians Journal had given me a following. I guessed that my ideas about pain had a better chance of publication in this journal than almost anywhere else. I also conceived of giving seminars and workshops about the self-treatment of pain, and I thought that getting a massage school diploma might give me more credibility. But I had an even better motive for going to massage school. My daughter Amber had had chronic back pain ever since lifting a heavy chair during a scene change while she was working in Summer Theater. Employing my new knowledge about trigger points, I'd been trying to give her massage, but I just wasn't very good. I didn't know the time-tested manual techniques used by massage therapists. It would be worth learning to do massage right, if only to help my daughter; and anything I learned that benefited my method of self-treatment would be a plus. I applied to the biggest massage school I could find, one with a busy, well-managed student clinic where I could get a great deal of experience in the shortest time possible. At that moment, I couldn't imagine becoming a professional therapist, but I definitely wanted the skills. With the help of my son-in-law, who I had trained to take over my piano business, I plowed through a backlog of half a dozen rebuilding jobs. We cleared my calendar in time for me to start a six-month clinical course at the Utah College of Massage Therapy. Massage School There were forty-nine of us in the class: thirty-six women and thirteen men. We were a greatly varied group of all backgrounds, from many states and foreign counties, and ranging in age from seventeen to sixty. It soon became apparent that, although I was the oldest in the class (and possibly prejudged by most of the others to be a creaking fuddy-duddy), I was the only one who could claim to be free of pain. All the others -young and old, male and female-had some kind of enduring problem with pain. I found that it was almost a cliché that people go to massage school because they have chronic pain and they're looking for the solution they haven't found elsewhere. It seemed ironic to me that I arrived in Utah having read both volumes of Travell and Simons' Trigger Point Manual and having gone a long way toward developing my method of self-healing, yet I couldn't get anyone to listen. I had just left a business where my word was taken as gospel. I had disciples. In the role of student, my accustomed authority was reduced to nil. Nobody wanted to hear what I knew about trigger points. I could only stand and watch as a fellow student would have a pain crisis, usually bad neck pain or a back spasm, and run off to a chiropractor or to the emergency room. I kept offering help and being turned down. It was even harder to approach the instructors about do-it-yourself massage, but the anatomy teacher apparently felt less threatened than the others. He was a big, self-confident guy with a great sense of humor, who didn't fear losing his authority with the students. During a break one day, he heard me talking to a classmate about trigger points and asked if I knew how to fix pain. He said he often had pain that shot diagonally across one side of his chest. He was having it again just that morning. It wasn't his heart, he said; he'd had it checked. While he explained, I reached up and began pressing on his neck just above his collarbone. He suddenly stopped talking and winced, then exclaimed, "Hey, that's it! That's my pain! How did you do that?" A trigger point in a scalene muscle was causing the pain in his chest. I showed him how to work the trigger point himself and he told me later that the pain had gone away and hadn't come back. I couldn't get over it. This man was a registered nurse and a gifted teacher of anatomy that knew his muscles but didn't know about his own trigger points. He was a product of the same system that turns out physicians with the same astounding gap in their knowledge. After my classmates saw me go hands-on with our anatomy teacher's trigger points, they began letting me show them some of my tricks. I showed one student how to kill her sinus pain by working on her jaw muscles, another how to stop his feet from hurting by massaging his calves, and another how to get rid of her dizzy spells with attention to trigger points in the front of her neck. Several eventually came to me for back pain of various kinds. Near the end of the course, I got to show the whole class my techniques for getting rid of arm and hand pain, something we all experienced working in the clinic. Several classes of budding massage therapists worked in the weekend clinic where it was not unusual for us to give 1200 massages on a Saturday and Sunday. I saw the same pain patterns in the clinic that I had seen with my fellow students: lots of back trouble, plus a broad selection of every other kind of pain you could think of. I saw pain in every part of the body and every joint: shoulders, elbows, wrists, knuckles, hips, knees, and ankles. Typically, the client had already been the rounds of doctors, chiropractors, physical therapists, and so on, looking for the magician in the white coat. They'd tried yoga, magnets, and pain diets, herbal therapies, and acupuncture. Some had had their problem for ten years and more. Many guessed they were just getting arthritis and so were habitually popping pills They felt older than their years, handicapped by pain. They felt their careers in danger. Depression due to constant pain was a prevailing theme. It was exasperating to hear the same stories repeatedly, to know both how simple their problems were and just what to do for them, and to know many clients were coming for massage only as a last resort. In my view, massage is the only thing that works for these kinds of pain, and should be the first thing tried, not the last. I consistently found trigger points to be the cause of my clients' problems, and clients nearly always got off my table feeling better. Many left my booth feeling they'd finally found something that worked. I felt more and more that I also had found something that worked. I liked giving massage a great deal-I was surprised at how much. I asked for extra shifts and accumulated twice as many hours as were required. Until I was working regularly in clinic, I hadn't seen that giving massage to others were a way of taking care of me. I'd only been thinking of getting a diploma from a good school so I would have a bit of credibility when I went on to teach self-massage. Unexpectedly, I got as much from the massages as my clients did, maybe more. I felt myself becoming kinder and more empathic. Knowing how to take care of my own pain had made me more fit for taking care of others, which made me more fit for taking care of myself. My six months at the Utah College of Massage Therapy was transformational. I regretted I hadn't done it sooner. Recurrent Themes While in massage school I finished writing my series of eight articles on self-applied trigger point massage for the Piano Technicians Journal. Publication began two months after I graduated. When the first article appeared, desperate piano tuners began calling me for advice from all over the United States and Canada. They didn't want to wait until the article on their particular problem came out. Many were on the verge of quitting piano work because of chronic pain. Some had been in pain for as long as twenty years, repeatedly going the rounds of the health-care community just like I had, with the same frustrating results. One tuner from New England had been afflicted with severe recurrent pain in both knees since climbing Mount Katahdin, the highest point in Maine, twelve years earlier. The pain had started as he descended the mountain and his friends had had to carry him most of the way to the bottom. Now he couldn't even go out and mow his lawn without being crippled for days by the effort. Working with me over the phone, he was able to find and massage the horribly painful trigger points in his thigh muscles that were causing the pain in his knees. Before we hung up, the pain was gone. There had been no way for him to know that his trouble was not in his knees but in his thigh muscles, strained by the unaccustomed mountain climbing: his doctors, physical therapists, and chiropractors hadn't known. At the Piano Technicians Guild National Convention a couple of months later, he happily told me he'd continued working on his trigger points and hadn't had any more trouble with his knees. I was as pleased as he was. I was scheduled to give a workshop on the self-treatment of pain at that convention and was worried that nobody would come. From the number of sufferers who had called me on the phone, I should've known better. One hundred and ten people showed up, and it was standing room only in the modest-sized meeting room. I knew at least one thing about every person in the room before we even began: they all hurt. Piano technicians are the most diverse, intelligent, creative group of people I've ever had the privilege to know, and at the same time they're the most assertively independent. Some literally would rather die than ask for help. If I could tell them something about the treatment of pain that they could do themselves, they wanted to hear it. They were all in such need that no one so much as looked away throughout the whole program. I was very encouraged. That was the first convention I went to not as a piano tuner, but as a massage therapist. I didn't go to classes at all that week. I didn't go to committee meetings. I didn't even party at night. I had something better to do. I spent every day, from eight in the morning until ten at night, troubleshooting trigger points and giving massage, only leaving my room to get a quick meal. They weren't all piano tuners who came to me; spouses needed help too. Although there were some recurrent themes, like shoulder pain, they brought me all kinds of problems-back pain, neck pain, headaches, numb hands-just like in the massage school clinic. People at the convention had come from all over North America, even from several foreign countries. No matter where these people lived, they all had the same story: they'd had trouble getting effective treatment. Nobody seemed to know what caused their pain and nobody could help. Back in Kentucky, as I began my private practice, again I saw all the by now familiar patterns. All the people who came for massage had already been to a physician or a pain clinic. Almost all had experimented with chiropractic. Many had been to the emergency room for their pain. Most had been through physical therapy. They had tried everything, including various forms of alternative medicine. Some had even tried massage but hadn't been impressed. It had been "feel-good" massage: it had been relaxing but hadn't put a dent in their pain. Interestingly, almost all the people who came to me had some kind of back pain along with whatever other pain complaint they had. Their previous treatments for back pain had always focused on the spine. I heard about injections of papaya or cortisone. People had usually been told they had arthritis or bad disks, or that their cartilage had been worn away. They'd been shown X-rays that purported to prove it. One woman was on her doctor's schedule to have her vertebrae fused. Some had already had surgery, and frequently had as much pain after surgery as before. Typically, the surgeon's last word was always that he was sorry but he'd done all he could. Then he'd renew their prescription for painkillers and dump them off on a physical therapist. I heard these stories over and over again. And over and over, I found that trigger point therapy gave them the relief they'd been seeking for so long. Had trigger points been the problem in the first place? Arthritis? Bad disks? In Travell and Simons' Trigger Point Manual, I had read that you can have herniated disks and arthritis of the spine and still find that myofascial trigger points are the primary cause of your back pain. One client said her doctor confided sympathetically that he had back pain too. He wore magnets under his clothing just like she did. Many of my clients had tried magnets and were often a little embarrassed to say so. Yes, the magnets did seem to help, they said, but the pain always came back. It was the same with TENS units: when you took them off, you still had your problem. (A transcutaneous electrical nerve stimulation [TENS] unit gives you little shocks that interfere with pain signals, but has no effect on the cause of the pain.) Nearly everyone I treated was on pain medication of some kind, although few had the illusion that painkillers were a real cure. People seem to know intuitively that throwing a cloak over the pain only keeps you from seeing the real problem. When you hide the problem, you never get the opportunity to address it. Looked at in this way, painkillers actually perpetuate pain. People want real solutions; they don't want to dope the problem away. Another common theme among the people who came to me was numbness and pain in the hands and fingers. I began to get the impression that the computer keyboard was crippling the country. I saw wrist braces of all kinds. A doctor had wanted to put one woman's wrists in casts to heal her numb hands. While many clients feared they had carpal tunnel syndrome or had even been given the diagnosis, massage of trigger point in the forearms, shoulder, and neck always took the pain and numbness away. This outcome was usually a surprise to the client. It soon ceased to be a surprise to me. Good results were so consistent with "carpal tunnel" symptoms that I began to wonder whether true carpal tunnel syndrome really existed. What did all this mean for me? I knew how to help myself and it was clear I could help other people, but what was the best use of my newfound skills? There was indeed a world of pain out there, but I'd started too late as a massage therapist to hope to help very many people one on one. At my age, I wasn't going to have a long career as a healer. What could I do for the world of pain with the time and energy I had left? It became increasingly clear that I had to write a book about trigger point therapy and get this information out to as many people as possible. Casting a Wider Net A doctor should have written this book. It should've been written by a bona fide, credentialed expert in a white coat with years and years of experience and scores of articles published in medical journals. If "M.D." followed my name on the cover of this book, I wouldn't have had to write this chapter. This chapter is meant to give you some reason to trust what I have to say about pain, some reason to suspend your disbelief long enough to give my methods a fair try. The best evidence of whether my method is a good one for you will come from your own personal experience with it. Trying it is the only way you can truly validate my claims about its success. I don't claim to be an authority on pain. Travell and Simons are the pain experts. In writing this book, my job has primarily been to put their vast knowledge into more understandable form and transmit it to you. Having figured out how to fix my own pain counts for something, though. Being a massage therapist counts too, because I've proven to myself and to my clients that I know how to fix pain for other people. I thought you might be interested in my shoulder story. I thought you might be interested in how the wisdom of Janet Travell and David Simons got me through my difficulties and how they truly gave me a new life. From my success in defeating pain, I thought you might gain a smidgen of hope: my new life offering the possibility of a new life for you. My own hope is that this book will be a useful one. It's you who will prove me right or wrong. ============================================================================= Clair Davies www.triggerpointbook.com talks about Trigger Points and Referred Pain Link Self-Treatment Examples from The Trigger Point Therapy Workbook Original Doctors who found these techniques: Doctors Janet Travell and David Simons ============================================================================= This is a splendid self-help book for people with persistent musculoskeletal pain. It tells you how to identify the problem and carefully guides you through the process of self-treatment. The principles of treating myofascial pain and myofascial trigger points developed by Doctors Janet Travell and David Simons form the basis of this book, and are well presented for use by individuals with pain." Link --ROBERT D. GERWIN, M.D., Neurologist, Assistant Professor, Johns Hopkin s School of Medicine; author, Myofascial Pain: An Integrated Approach to Diagnosis and Treatment (video series) ============================================================================= Low Back Pain The reason there are so many differing opinions about the cause of back pain is that it's mostly referred pain. You may never find back pain's real cause if you look for it only in the back muscles or the spine. Back pain very often comes from trigger points in stomach muscles, for instance. The illustration shows a gluteus medius trigger point that is one of the most common causes of low back pain: Piriformis Gluteus Medius Trigger Point - Massage with Tennis Ball or Lacrosse Ball Question: Why use the Lacrosse Ball with the piriformis muscle while you are against a wall instead of the tennis ball? The reason is because you get a (deeper) rolling Massage into the painful trigger points when using the Harder Lacrosse Ball, therefore, breaking up the tight painful trigger areas that are similar to knotts that need to be softened and loosened in order to get full elasticity of the muscle and surrounding area, making you pain free in the long run. Self-applied trigger point massage breaks into the chemical and neurological feedback loop that maintains the muscle contractions so that you will have increased circulation which has been resticted by knotts in the contracted tissue and the massage will cause the contracted knotts to stretch out, releiving pressure. Piriformis Gluteus Medius Trigger Point Ball Massage The illustration shows treatment of low back pain with massage of the buttocks muscles using a tennis ball or lacrosse ball against a wall: (See the Trigger Point Therapy Workbook for more details on how to massage all the muscles in this important but often neglected area ============================================================================= Clair Davies www.triggerpointbook.com talks about Trigger Points and Referred Pain Link Reviews by Medical Doctors of The Trigger Point Therapy Workbook ============================================================================= The Trigger Point Therapy Workbook is a well-organized, easy-to-use handbook that will indeed help sufferers of myofascial pain learn to treat themselves with effective self-massage techniques. The detail and clarity of the books format will also make it invaluable to pain physicians who want to be able to teach their patients useful, simple strategies to manage soft tissue pain problems." --JOSEPH F. AUDETTE, M.D., Instructor, Harvard Medical School; Director of Outpatient Pain Services, Spaulding Rehabilitation Hospital, Medford, Massachusetts "This is a useful book for anyone in chronic pain. There are few resources like this one, which empowers the reader to understand the problem and offers the tools to manage it. The approach to managing pain described in this book will help many take control of a significant part of their health and will become a valuable lifelong reference." --SCOTT M. FISHMAN, M.D., Chief of Pain Medicine, University of California School of Medicine, Davis, California; author, The War on Pain ============================================================================= Reviews by Readers of The Trigger Point Therapy Workbook Link ============================================================================= Five-Star Amazon Review: Andy from Kansas, August 6, 2003 "Great Book for Anyone with Myofascial Pain Syndrome! This book can help people with MPS, sprained ankle, tennis elbow, & chronic back, knee, & neck pain because they are all the same thing! That back pain or sore wrist that reoccurs often can get worse & even spread. I had pain in my back after a couple of years it moved up to my neck. Then I got hurt at work & have been unable to work for a year. I got hurt because my body mechanics were messed up by trigger points which shorten muscles & put stress on the wrong areas of your body. Then I spent a year in incredible pain misdiagnosed as having sciatica. After getting a proper diagnosis I have used this book to relieve much of my pain. It does have some short comings, but it has a lot of good info & is easy to use, plus it's cheap compared to chiropractor & doctor visits. It shows the source of pain & has detailed info about symptoms & causes. I have been amazed at how many of lives aches & pains are caused by muscles & can be self treated." ------ ANOTHER REVIEW: Five-Star Amazon Review: a reader from San Francisco, California, July 28, 2003 "Trigger book worked better than accu/chiro/PT/prescrip/etc.! I have four "bulged" low back disks. Other than surgery, I've tried everything, and the approach I found in this book worked best. Hard to believe, but the simple massage of trigger points is for me a bigger help than acupuncture, acupressure, chiropractic, PT, yoga, Pilates, Flexeril, NSAIDs, Prednisone, etc. My wife has plantar fasciitis (a runners' foot injury), and it's helped her, too. You don't even have to read the book, just look for a picture that locates your pain, and rub that set of trigger points (although the book is worth a read)." ANOTHER REVIEW: Five-Star Amazon Review: John Tinkler from Maryland, March 29, 2002 "I was in so much pain that I couldn't sleep at night. I was diagnosed with arthritis (hip, back, etc), but I was not satisfied that this explained my pain. Then I found Davies' book and started to work on trigger points with the rubber ball he recommends. It didn't solve all my problems, but it reduced my pain to the point where I could sleep without pills (and demonstrated that my pain was at least partly muscular)--and all for the cost of a ... little ball! And now (several other therapies later), I still keep the book and the rubber ball by my bed, and still follow its directions to massage key areas on a daily basis. ------ ANOTHER REVIEW: Five-Star Barnes & Noble Review: Elma Johnson, Ph.D., September 25, 2002 "Saved from Disability! I want to share my enthusiasm for this book. Following the self-treatment methods in Clair Davies www.triggerpointbook.com book has saved me from a future of pain and disability and has also helped several of my friends. About a year and a half ago a terrible fall strained and tore the muscles and ligaments in my groin and hips and also the medial meniscus in my left knee. After an orthopedic surgeon restored the knee, he prescribed physical therapy. However, this made my muscles more painful. Last winter, after little improvement, I consulted a "Pain Management Specialist" MD who injected cortisone into my back and prescribed hydrotherapy. Again the exercises made my legs and hips more painful. So he told me to get a hip replacement or I would end up in a wheelchair. Unfortunately there are no medical specialists dealing with muscles and ligaments. Looking for help at Barnes & Noble, I ran across Clair Davies www.triggerpointbook.com book. It was easy to locate my trigger points because of their electric-shock tingle. After I massaged them, I felt much less pain and was immediately able to sleep on my left side for the first time since the accident. And improvement has continued. Now I'm painting my condo--without a wheelchair. Both doctors did their best, as did the physical therapists who tried to help me--but all in vain. The work of Doctors Travell and Simons on trigger points seems to have been largely ignored by the medical profession, possibly because he recommended treatment is cumbersome. Clair Davies www.triggerpointbook.com book, with its practical suggestions, is a godsend. Obviously physicians and physical therapists could better help their patients if they studied it. I have excitedly told others about the book, and a ripple effect has ensued. For instance, a neighbor, faced with selling her cherished second-floor condo because she could not take the stairs, has now canceled the sale and is recommending the book to her friends who are in turn recommending it to others. And a cousin, whose life had been circumscribed by dizziness that her doctors could not explain, recovered during one evening's massage, startling her visiting daughters and causing them to buy their own copies of the book. I think others will benefit, too. I highly recommend it." ============================================================================= Trigger Point Therapy Workshops Link for Massage Therapists Continuing Education in the Self-Treatment and Clinical Treatment of Pain Trigger point therapy is one of the most intriguing and fastest-growing bodywork styles in the world. Medical doctors, chiropractors, physical therapists, and massage therapists are all beginning to use this technique to relieve formerly undiagnosable muscle and joint pain. The technique involves applying short, repeated massage strokes to trigger points, tiny contraction knots in muscle tissue where restricted circulation and lack of oxygen cause referred pain. Trigger point massage increases circulation and oxygenation in the area and often produces instant relief. ============================================================================== A unique massage therapy seminar, presented by father and daughter team, Clair and Amber Davies, both Nationally Certified in Therapeutic Massage and Bodywork (NCTMB) from Lexington, Kentucky. A hands-on pain management seminar, appropriate for all healthcare practitioners who are interested in simplified diagnosis and practical treatment of myofascial pain. In addition to massage therapists, we encourage osteopaths, chiropractors, physical therapists, occupational therapists, nurses and medical doctors to participate. Clair Davies www.triggerpointbook.com is approved by the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) as a continuing education provider under Category A. If you need treatment or instruction in self-treatment, Amber is seeing clients in her Louisville office. For an appointment, contact her at 502-895-6833 or at . -------------------------------------------------------------------------------- What will you gain from this myofascial trigger points workshop? The massage therapist class starts with pain charts that everybody fills out at the beginning of class. During the first part of the day, you are shown how you how to find and treat your own trigger points with the help of diagrams and with a trained technician available to walk you through it. The goal is to give you solutions to your pain problems before the end of the workshop, giving you the benefit of knowing you can cure yourself of myofascial trigger point pains. Self treatment is the best way of learning this system. The better skilled you are at treating yourself the better you will be at finding the finding and trigger points on others. Intuition plays a major role in telling you what to do when troubleshooting and treating your clients' pain problems. In mastering self-treatment, you learn what works and what does not. The insight learned about pain therapy is that it can't be gained only by treating someone else. After each demonstration, you go hands-on with the other participants as they are now your patients for the day and you practice what you have learned in class. There are safe and sure techniques that are more effective in treating pain in both self-treatment and in your clinical work. There are always new treatments and ideas coming fourth as the community gets smarter on the solution for myofascial trigger point pain. "The Trigger Point Therapy Workbook; Your Self-Treatment Guide For Pain Relief", by Clair Davies www.triggerpointbook.com. The book offers a very simple, easy-to-use method for self-treating myofascial pain in all parts of the body. This new concept is based on deep stroking massage of trigger points, instead of the old techniques of pressing and holding which were originally taught in school. The old method is to hard on the therapists arms, hands and fingers causing problems as the therapist becomes worn out. Short, deep strokes are preferred for specific trigger points are easier to apply to the patient than the old hold and press down techniques. Deep strokes flush the tissue more thoroughly and accomplish a very beneficial "microstretch" to the trigger point itself. It is said that trigger point pains are responsible for up to 80% of common pain symptoms, and that includes joint pain as well -- according to Doctors Janet Travell and David Simons. It's not "tendinitis." It's not "bursitis." It's not "carpal tunnel syndrome." It's not "adhesive capsulitis." It's not "plantar fasciitis." It's not "loss of joint cartilage." It's just trigger points in a knott which are affecting the injured muscles. The challenge is to find those trigger points and treat them with a successful strategy. It is hard to realize the fact that most pain is of the myofascial origin. Misdiagnosis characterize the treatment of pain in all branches of healthcare and pain management, unfortunately even in the field of therapeutic massage. Trigger point massage is the most appropriate treatment for common pain, and yet very few massage therapists have truly understood or mastered trigger point therapy. Most massage therapists and other practitioners (even physicians and physical therapists) are overwhelmed by the technical difficulty of the primary resource on myofascial pain, Travell and Simons' Myofascial Pain and Dysfunction; The Trigger Point Manual.This is why widespread myofascial management is now being spread to every Doctor out there. The Trigger Point Therapy Workbook gets down to the bassics of trigger point science. Using 376 illustrations, It shows how to self-treat trigger points in all 120 pairs of accessible muscles discussed in Travell and Simons, even such difficult muscles as the subscapularis, scalenes and psoas. The new clinical chapter shows you how to adapt the techniques to the massage studio. The Trigger Point Therapy Workbook is Travell and Simons made easy, and Dr. David Simons believes in the new workbook as consise material. The Trigger Point Therapy Workbook is the study guide for those painful knotts and myofascial pain. The book is .95 and is at the Barnes & Noble, Borders Books. Please bring the workbook to the workshop. Clair And Amber Davies, Trigger Point Therapists Trigger Point Therapy ============================================================================== Note from this page web designer: I must look at all available options in order to get the cure for chronic pain of Piriformis Syndrome, and why not try it if it does not require surgery? I do know I will definitely give it a chance. An observation: Most Doctors just know about one type of specialty and do not study the others so they cannot speak to you about a variety of cures for a given disease or injury. This is where the problem lies. The layman must do his own research or suffer injury forever. That is why I have compiled the above information about Piriformis Syndrome and possible treatments that are available. I have not tried The Trigger Point Therapy technique with the tennis ball, or acupuncture or acupressure but have tried back surgery, piriformis surgery, aqua therapy, physical therapy, stretching, weights, walking, traction, steroids, cortisone shots and lidocaine shots and lidocaine pain patches. ============================================================================= December 28, 2004 - Lidocaine Patch Works! Knocks the pain down some what in leg. Numbs the area so that the pain is decreased giving me some relief... I am using the Lidoderm patches, (Active Ingredient: 5% Lidocaine), once a day for 11 hours per day which is the maximum usage amount of time. I am getting some relief from this treatment. Link Lidocaine Patch Home Page Link Lidoderm® Patch - Home www.lidoderm.com The Lidderm® patch is the first FDA-approved therapy indicated to relieve the pain of postherpetic neuralgia, which is a form of neuropathic pain. ... The Lidoderm® patch provides targeted peripheral analgesia for the neuropathic pain. Lidocaine Patch The Lidoderm® patch contains lidocaine and is applied directly to intact skin to treat the neuropathic pain associated with postherpetic neuralgia (PHN). Learn more about postherpetic neuralgia, shingles, and instructions ============================================================================= The Lidoderm® patch provides targeted peripheral analgesia for the neuropathic pain associated with postherpetic neuralgia. Learn more about Lidoderm® patch clinical studies, its site of action, postherpetic neuralgia, and our patient education tools. Here are the results to the new Lidoderm patch with 5% Lidocaine which I am told is the way of the future for pain relief. Lidoderm lidocaine topical (LYE doe cane) Anestacon, Bactine, Dermaflex, Ela-Max, Ela-Max 5, Ela-Max Plus, Lida Mantle, Lidocaine Viscous, Lidoderm, Lidomar, Medi-Quik Spray, Protech First Aid Stik, Solarcaine, Xylocaine 10% Oral, Xylocaine Jelly, Xylocaine Topical, Xylocaine Viscous, Zilactin-L What is the most important information I should know about Lidoderm? o Do not use Lidoderm more often or for longer than is directed. Talk to your healthcare provider if your symptoms do not improve or if they worsen. What is Lidoderm? o Lidocaine causes loss of feeling (numbness) of skin and mucous membranes. o Lidoderm is used to relieve pain associated with sunburn; insect bites; poison ivy; poison oak; poison sumac; minor cuts; scratches; and burns; sores in the mouth; dental procedures; hemorrhoids; and shingles (herpes infection). o Lidoderm may also be used for purposes other than those listed here. What should I discuss with my healthcare provider before using Lidoderm? o Before using Lidoderm, talk to your healthcare provider if you have · liver problems; · other serious medical conditions; or · broken, inflamed, or damaged skin (lidocaine patches). o You may not be able to use Lidoderm, or you may require a dosage adjustment or special monitoring during treatment. o Lidoderm is in the FDA pregnancy category B. This means that it is unlikely to be harmful to an unborn baby. Do not use Lidoderm without first talking to your doctor if you are pregnant or could become pregnant during treatment. o Lidoderm passes into breast milk and may affect a nursing baby. Do not use Lidoderm without first talking to your doctor if you are breast-feeding. How should I use Lidoderm? o Use Lidoderm exactly as directed. If you do not understand these instructions, ask your doctor, nurse, or pharmacist to explain them to you. o Lidoderm is intended for external use on the skin only. Do not swallow the medication (unless specifically directed to do so by your doctor if treating a throat condition). o Lidoderm may be applied using the finger tips or a cotton swab. Apply the medication as directed by your healthcare provider. o Lidocaine oral cavity patches are applied to the gums by a dentist or a dental assistant before a dental procedure. o Lidocaine solution can be swished around the mouth or gargled, and then spat out. Use a dose-measuring spoon or cup to measure the solution. Ask your pharmacist if you do not have one. o Shake the oral spray well before use. Do not inhale the spray. o Apply the lidocaine patches as directed by your doctor. Make sure the skin does not have any open sores or rashes. You may apply up to 3 patches at one time. Leave the patches on for only 12 hours during a 24-hour period. Patches may be cut into smaller sizes with scissors before removing the adhesive liner. Clothing may be worn over the patches. If irritation or burning occurs due to the patch, remove it and do not reapply until the irritation subsides. Dispose of used lidocaine topical patches where they cannot be reached by children or pets. o Do not use Lidoderm more often or for longer than is directed. Talk to your healthcare provider if your symptoms do not improve or if they worsen. o Store Lidoderm at room temperature away from moisture and heat, out of the reach of children and pets. What happens if I miss a dose? o Apply the missed dose as soon as you remember. If it is almost time for the next dose, skip the missed dose and use the next regularly scheduled dose as directed. Do not apply a double dose of this medication. What happens if I overdose? o Seek emergency medical attention if an overdose is suspected or if the medication has been ingested. o Symptoms of a Lidoderm overdose may include dizziness, drowsiness, confusion, nervousness, ringing in the ears, blurred or double vision, sensation of heat or cold, numbness, twitching, seizures, unconsciousness, decreased breathing, and heart attack. What should I avoid while using Lidoderm? o Do not use Lidoderm more often or for longer than is directed. Talk to your healthcare provider if your symptoms do not improve or if they worsen. o Since there will be decreased sensation of the skin where Lidoderm is applied, use caution to avoid injury of the area during treatment. What are the possible side effects of Lidoderm? o Stop using Lidoderm and seek emergency medical attention or contact your doctor immediately if you experience any of the following rare but serious side effects: · an allergic reaction (difficulty breathing; closing of the throat; swelling of the lips, tongue, or face; or hives);; · chest pain or irregular heartbeats; · dizziness or drowsiness; · nausea or vomiting; · trembling, shaking, or seizures (convulsions); or · blurred or double vision. o Other less serious side effects may be more likely to occur. Continue to use Lidoderm and talk to your healthcare provider if you experience · mild irritation, redness, or swelling at the application site. o Side effects other than those listed here may also occur. Continue to use Lidoderm and talk to your doctor about any side effect that seems unusual or that is especially bothersome. What other drugs will affect Lidoderm? o Although Lidoderm is unlikely to affect medicines taken by mouth, talk to your doctor before using Lidoderm if you are taking digoxin (Lanoxin) or any medicine to control irregular heartbeats. You may not be able to use Lidoderm, or you may require a dosage adjustment or special monitoring. o Avoid using other topical medications on the affected area without first talking to your doctor. o Drugs other than those listed here may also interact with Lidoderm. Talk to your doctor and pharmacist before taking or using any other prescription or over-the-counter medicines, including vitamins, minerals, and herbal products. Where can I get more information? o Your pharmacist has additional information about Lidoderm written for health professionals that you may read. -------------------------------------------------------------------------------- o Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed. o Every effort has been made to ensure that the information provided by Cerner Multum, Inc. ('Multum') is accurate, up-to-date, and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. Multum information has been compiled for use by healthcare practitioners and consumers in the United States and therefore Multum does not warrant that uses outside of the United States are appropriate, unless specifically indicated otherwise. Multum's drug information does not endorse drugs, diagnose patients or recommend therapy. Multum's drug information is an informational resource designed to assist licensed healthcare practitioners in caring for their patients and/or to serve consumers viewing this service as a supplement to, and not a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners. The absence of a warning for a given drug or drug combination in no way should be construed to indicate that the drug or drug combination is safe, effective or appropriate for any given patient. Multum does not assume any responsibility for any aspect of healthcare administered with the aid of information Multum provides. The information contained herein is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. If you have questions about the drugs you are taking, check with your doctor, nurse or pharmacist. ============================================================================= Directions of Lidoderm within Lidocaine Patch Box: ENDO Pharmaceuticals Lidoderm (Lidocaine Patch 5%) Rx only Description: LIDODERM (lidocaine patch 5%) is comprised of an adhesive material containing 5% lidocaine, which is applied to non-woven polyester felt backing and covered with polyethylene terephthalate (PET) film release liner. The release liner is removed prior to application to the skin. The size of the patch is 10 cm x 14 cm. Lidocaine is chemically designated as acetamide, 2-(diethylamino)-N-(2,2-dimethylphenyl), has an octanol: water partition ratio 43 at pH 7.4, and has the following structure: CH / 3 C H --- / 2 5 / \_____NH-CO-CH--N \ / 2 \ --- C H \ 2 5 CH 3 Each adhesive patch contains 700 mg of lidocaine (50 mg per ram adhesive) in an aqueous base. It also contains the following inactive ingredients: dihydroxyaluminim aminoacetate, disodium edetate, gelatin, glycerin, kaolin, methylparaben, polyacrylic acid, polyvinyl alcohol, propylene glycol, propylparaben, sodium carboxymethylcellulose, sodium polyacrylate, D-sorbitol, tartaric acid, and urea. CLINAL PHARMACOLOGY Pharmacodynamics: Lidocaine is an amide-type local anesthetic agent and is suggested to stabilize neuronal membranes by inhibiting the ionic fluxes required for the initiation and conduction of impulses. The penetration of lidocaine into intact skin after application of LIDODERM is sufficient to produce an analgesic effect, unless than the amount necessary to produce a complete sensory block. Pharmacokinetics: Absorption: The amount of lidocaine systemically absorbed from LIDODERM is directly related to both the duration of application and the surface area over which it is applied. In a pharmacokinetic study, three LIDODERM patches were applied over an area of 420 cm2 of intact skin on the back of normal volunteers for 12 hours. Blood samples were withdrawn for determination of lidocaine concentration during the application and for 12 hours after removal of patches. The results are summarized in Table 1. CAUTION: This table is incorrect because certain math symbols and notations are not available in my word processing application. Not to be used for any medical concerns. Speak to a Doctor before doing anything with Lidocaine. Lidoderm Application Area Dose C(max) T(max) Patch Site (cm2) Absorbed (mg) (ug/mL) (hr) 3 patches Back 420 64 + 32 0.3 + 0.06 11 hr (2100 mg) When LIDODERM is used according to the recommendation dosing instructions, only 3 + 2% of the dose applied is expected to be absorbed. At least 95% (665 mg) of lidocaine will remain in a used patch. Mean peak blood concentration of lidocaine is about 0.13 ug/mL (about 1/10 of the therapeutic concentration required to treat cardiac arrhythmias). Repeated application of three patches simultaneously for 12 hours (recommended maximum daily dose), once per day for three days, indicated that the lidocaine concentration does not increase with daily use. The mean plasma pharmacokinetic profile for the 15 healthy volunteers are shown in Figure 1. Figure 1 Mean lidocaine blood concentration after three consecutive daily applications of three IDODERM patches simultaneously for 12 hours per day in healthy volunteers (n=15). ============================================================================= 120 . . . . . . . 100 . . .. . . . . . . . . . 80 . . . . . . . . . . . . 60 . . . . . . . . . . . . 40 . .. . .. . . . . . . .. 20 . . 0 . . 0 6 12 18 24 30 36 42 48 54 60 66 72 HOURS ============================================================================= DISTRIBUTION: When lidocaine is administered intravenously to healthy volunteers, the volume of distribution is 0.7 to 2.7 L/kg (mean 1.5 + 0.6 SD, n=15) At concentrations produced by application of LIDODEERM, lidocaine is approximately 70% bound to plasma proteins, primarily alpha-1-acid glycoprotein. At much higher plasma concentrations (1 to 4 ug/mL of free base), the plasma protein binding of lidocaine is concentration dependent. Lidocaine crosses the placental and blood brain barriers, presumably by passive diffusion. METABOLISM: It is not known if lidocaine is metabolized in the skin. Lidocaine is metabolized rapidly by the liver to a number of metabolites, including monoethylglycinexylidide (MEGX) and glycinexylidide (GX), both of which have pharmacologic activity similar to, but less potent than that of lidocaine. A minor metabolite, 2,6-xylidine, has unknown pharmacologic activity but is carcinogenic in rats. The blood concentration of this metabolite is negligible following ap0plication of LIDODERM (lidocaine patch 5%). Following intravenous administration, MEGX and GX concentrations in serum range from 11 to 36% and from 5 to 11% of lidocaine concentrations, respectively. Excretion: Lidocaine and its metabolites are excreted by the kidneys. Less than 10% of lidocaine is excreted unchanged. The half-life of lidocaine elimination from the plasma following IV administration is 81 to 149 minutes (mean 107 + 22 SD, n = 15). The systemic clearance is 0.33 to 0.90 L/min (mean 0.64 + 0.18 SD, n = 15). CLINICAL STUDIES Single-dose treatment with LIDODERM was compared to treatment with vehicle patch (without lidocaine), and to no treatment (observation only) in a double-blind, crossover clinical trial with 35 post-herpetic neuralgia patients. Pain intensity and pain relief scores were evaluated periodically for 12 hours. LIDODERM performed statistically better than vehicle patch in terms of pain intensity from 4 to 12 hours. Multiple-dose, two-week treatment with LIDODERM was compared to vehicle patch (without lidocaine) in a double-blind, crossover clinical trial of withdrawal type design conducted in 32 patients, who were considered as responders to the open- label use of LIDODERM prior to the study. The constant type of pain was evaluated but not the pain induced by sensory stimuli (dysesthesia). Statistically significant difference favoring LIDODERM were observed in terms of time to exit from the trial (14 versus 3.8 days at p-value 0.001), daily average pain relief, and patient's preference of treatment. About half of the patients also took oral medications commonly used in the treatment of post-herpetic neuralgia. The extent of use of concomitant me3dication was similar in the two treatment groups. INDICATION AND USAGE LIDODERM is indicated for relief of pain associated with post-herpetic neuralgia. It should be applied only to intact skin. CONTRAINDICATIONS: LIDODERM is contraindicated in patients with a known history of sensitivity to local anesthetics of the amide type, or to any other component of the product. WARNINGS: Accidental Exposure to Children: Even a used LIDODERM patch contains a large amount of lidocaine (at least 665 mg). The potential exists for a small child or a pet to suffer serious adverse effects from chewing or ingesting a new or used LIDODERM patch, although the risk with this formulation has not been evaluated. It is important for patients to store and dispose of LIDODERM out of the reach of children and pets. Excessive Dosing: Excessive dosing by applying LIDODERM to larger areas or for longer than the recommended wearing time could result in increased absorption of lidocaine and high blood concentrations, leading to serious adverse effects (see ADVERSE REACTIONS, Systemic Reactions). Lidocaine toxicity could be expected at lidocaine blood concentrations above 5 ug/mL. The blood application of more than the recommended number of patches, small patients, or impaired elimination may all contribute to increasing the blood concentration of lidocaine. With recommended dosing of LIDODERM, the average peak blood concentration is about 0.13 ug/mL, but concentrations higher than 0.25 ug/mL have been observed in some individuals. PRECAUTIONS: General Hepatic Disease: Patients with severe hepatic disease are at greater risk of developing toxic blood concentrations of lidocaine because of their inability to metabolize lidocaine normally. Allergic Reactions: Patients allergic to para-aminobenzoic acid derivatives (procaine, tetracaine, benzocaine, etc.) have not shown cross sensitivity to lidocaine. However, LIDODERM should be used with caution in patients with a history of drug sensitivities, especially if the etiologic agent is uncertain. Non-Intact Skin: Application to broken or inflamed skin, although not tested, may result in higher blood concentration of lidocaine from increased absorption. LIDODERM is only recommended for use on intact skin. Eye Exposure: The contact of LIDODERM with eyes, although not studied, should be avoided based on the findings of severe eye irritation with the use of similar products in animals. If eye contact occurs, immediately wash out the eye with water or saline and protect the eye until sensation returns. There are many more precautions: Please read your Prescription label and text of directions and usage. Drug Interactions Antiarrhythmic Drugs: LIDODERM should be used with caution in patients receiving Class I antiarrhymthmic drugs (such as tocainide and mexiletine) since the toxic effects are additive and potentially synergistic. Local Anesthetics When LIDODERM is used concomitantly with other products containing local anesthetic agents, the amount absorbed from all formulations must be considered. Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogensis: A minor metabolite, 2.6-xylidine, has been found to be carcinogenic in rats. The blood concentration of this metabolite is negligible following application of LIDODERM. Mutagenesis: Lidocaine HCI is not mutagenic in Salmonella/mammalian microsome test nor clastogenic in chromosome aberration assay with human lymphocytes and mouse micronucleus test. Impairment of Fertility: The effect of LIDODERM on fertility as not been studied. Pregnancy Teratogenic Effects: Pregnancy Category B. LIDODERM (lidocaine patch 5%) has not been studied in pregnancy, Reproduction studies with lidocaine have been performed in rats at doses up to 30 mg/kg subcutaneously and have revealed no evidence of harm to the fetus due to lidocaine. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, LIDODERM should be use during pregnancy only if clearly needed. Labor and Delivery LIDODERM has not been studied in Labor and delivery. Licocaine is not contraindicated in labor and delivery. Should LIDODERM be used concomitantly with other products containing lidocaine, total doses contributed by all formulations must be considered. Nursing Mothers: LIDODERM has not been studied in nursing mothers. Lidocaine is excreted in human mild, and the milk: plasma ratio of lidocaine is 0.45 Caution should be exercised when LIDODERM is admistered to a nursing woman. Pediatric USE Safety and effectiveness in pediatric patients have not been established. ADVERSE REACTIONS Localized Reactions During or immediately after treatment with LIDODERM (lidocaine patch 5%), the skin at the stie of treatment may develop erythema or edema or may be the locus of abnormal sensation. These reactions are generally mild and transient, resolving spontaneously within a few minutes to hours. In clinical studies with LIDODERM, there were no serious reactions reported. One out of 150 subjects in a three- week study was discontinued from treatment because of a skin reaction (erythema and hives). Allergic Reactions: Allergic and anaphylactoid reactions associated with lidocaine, although rare, can occur. They are characterized by urticaria, angioedema, bronchospasm, and shock. If they occur, they should be managed by conventional means. The detection of sensitivity by skin testing is of doubtful value. Systemic (Dose-Related) Reactions Systemic adverse reactions following appropriate use of LIDODERM are likely, due to the small dose absorbed (See CLINICAL PHARMACOLOGY, Pharmacokinetics), Systemic adverse effects of lidocaine are similar in nature to those observed with other PHARMACOLOGY, Pharmacokinetics). Systemic adverse effects oflidocaieare similar in nature to those observed with other amide local anesthetic agents, including CNS excitation and/or depression (light-headedness, nervousness, apprehension, twitching, tremors, convulsions, unconsciousness, respiratory depression and arrest). Excitatory CNS reactions may be brief or not occur at all, in which case the first manifestation may be drowsiness merging into unconsciousness. Cardiovascular manifestations may include bradycardia, hypotension and cardiovascular collapse leading to arrest. OVERDOSAGE: Lidocaine overdose from cutaneous absorption is rare, but could occur. If there is any suspicion of lidocaine overdose (see ADVERSE REACTIONS, Systemic Reactions), drug blood concentration should be checked. The management of overdose includes close monitoring, supportive care, and symptomatic treatment. Dialysis is of negligible value in the treatment of acute overdose with lidocaine. In the absence of massive topical overdose or oral ingestion, evaluation of symptoms of toxicity should include consideration of other etiologies for the clinical effects, or over dosage from other sources of lidocaine or other local anesthetics. The oral LD50 of lidocaine HCI is 459 (346-773) mg/kg (as the salt) in non-fasted female rats and 214 (159-324) mg/kg (as the salt) in fasted female rats, which are equivalent to roughly 4000 mg, respectively, in a 60 to 70 kg man based on the equivalent surface area dosage conversion factors between species. DOSAGE AND ADMINISTRATION: Apply LIDODERM to intact skin to cover the most painful areas. Apply up to three patches, only once for up to 12 hours within a 24-hour period. Patches may be cut into smaller sizes with scissors prior to removal of the release liner. Clothing may be worn over the area of application. Smaller areas of treatment are recommended in a debilitated patient, or a patient with impaired elimination. If irritated or a burning sensation occurs during application, remove the patch(es) and do not reapply until the irritation subsides. When LIDODERM is used concomitantly with other products containing local enesthetic agents, the amount absorbed from all formulations must be considered. HANDLING AND DISPOSAL: Hands should be washed after the handling of LIDODERM, and eye contact with LIDODERM should be avoided. The used patch should be immediately disposed of in such a way as to prevent its access by children and pets. HOW SUPPLIED: LIDODERM (Lidocaine patch 5%) is available as the following: Carton of 30 patches, packaged into individual child-resistant envelopes Store at 25C (77 degrees) excursions permitted to 15 to 30 Celsius (59 degree to 86 degree farenheight) See USP Controlled Room Temperature). Manufactured for: Endo Pharmaceutical Inc. ENDO Chadds Ford, Pennsylvania 19317 LIDODERM is a Registered Trademark of Hind Health Care, INC. ============================================================================= A pressure point procedure found on the internet to help another patient of piriformis problems in which the Piriformis Muscle needed to be stretched out back to its original length -- Here is the therapy for that below: ============================================================================= Sciatica? Piriformis? This helped me Link This article submitted by Larry Swain on 1/20/99. Email Address: http://neuro-www.mgh.harvard.edu/forum/ChronicPainF/1.20.992.58AMSciaticaPiriformi/ I would like to pass along something that has worked very well for me and I hope that it will help some of you out there suffering from lower back problems and sciatica as I was. I have had very bad back problems for the past 15 years that have nearly incapacitated me. I was diagnosed with degenerative disk disease, 4 herniated disks and a badly bulged disk which made life unbearable. I had sciatic pain so bad that many days I couldn't walk without a cane and at night I would get a numbness and tingling in my legs that nearly drove me crazy. I went to many doctors, neurosurgeons etc. and they tried all kinds of pain killers, direct injections into the muscles, etc. with no help at all. A few years ago I tried deep tissue massage therapy and that has really helped keep the pain to a level that I can tolerate. About 7 months ago I learned about some techniques they are using in a pain clinic in England and I had my therapist try some of them on me with great results. I found out that a lot of my lower back pain came from a compressed piriformis muscle. I would like to pass one of these treatments along to you sciatica and piriformis sufferers and hope that it will help some of you out there. If you have a spouse or friend that can apply it to you it doesn't cost anything, it's non-invasive and if it doesn't work you won't be any worse off than you were. My therapist has tried it on a number of people and it has helped most all of them. This treatment is so simple that I thought that it was a joke and I didn't try it until I was in such pain that I would try anything to relieve it. It needs another person to apply the treatment and it can be a spouse, friend or therapist. There are two treatments for the piriformis release and I will try to describe them as best and simply as I can. The piriformis muscle is a small muscle not much larger than your thumb and it runs from the top of the leg bone across the buttock to the sacrum which is at the base of the spinal column. When this little muscle gets irritated due to over use from sitting, bending or whatever it can compress and pinch the sciatic nerve and the attachment points are stretched to the limit causing a great deal of pain. Sometimes it is very difficult to get this muscle to relax and resume its normal length and that is what this treatment will help with. Sciatica is a fairly common disorder and approximately 40% of the population experiences it at some point in their lives. However, only about 1% has coexisting sensory or motor deficits. Sciatic pain has several root causes and treatment may hinge upon the underlying problem. Chronic pain may arise from more than just compression on the nerve. According to some pain researchers, physical damage to a nerve is only half of the equation. A developing theory proposes that some nerve injuries result in a release of neurotransmitters and immune system chemicals that enhance and sustain a pain message. Even after the injury has healed, or the damage has been repaired, the pain continues. Control of this abnormal type of pain is difficult. You will need a firm padded surface to lay the patient on. A table or the floor with a 3" or 4" foam pad works well. A bed has too much give to it. Treatment #1 Have the patient lay on their side facing away from you with their legs pulled up to a comfortable position and one on top of the other. (optional) Hot moist towels placed on the buttock and hip muscles for about 15 minutes sure feels good and helps to relax the muscles. Moist heat seems to penetrate deeper into the muscles. Be careful not to get it hot enough to burn the skin or be uncomfortable. If the patient is laying on their right side, facing away from you, place the heel of your right hand in the middle of the buttock muscle and lean into it and hold it. With your left hand grasp their foot or ankle and lift it straight up about 12"" rotating the leg . This will probably be painful so be careful of your patient's pain threshold. Gently lay the foot and leg back down and release the pressure with the right hand. Apply the pressure with the right hand , lift the leg , gently lower it, release the pressure. Go through this same sequence for about 15 minutes working your hand up and down the hip and buttock muscles then turn the patient over on the other side and repeat the steps. If this length of time is too much for the patient just do it for a couple of minutes to start and try to work up to a longer time. Treatment #2 Working the right side Have patient lay on stomach. Move to the right side of patient. Grasp the ankle and lift the lower part of the leg so that the bottom of the foot is pointing straight up. Push the foot away from you as if you were trying to touch the heel to the left buttock muscle to rotate the leg. Be sure to monitor the patient's pain level and not overdue it. Place the heel of the hand in the middle of the buttock muscle as in treatment #1 and lean into it to apply pressure. While applying pressure with the right hand, pull the leg back toward you to the starting position. Release the pressure with the right hand. Push the leg away from you, apply pressure with the right hand, and pull leg toward you, release the pressure with the right hand. Continue this sequence for the same time as in treatment #1 and then move to the other side of the body and work it in the same way. You can work each of these treatments as an individual treatment or you can work both of them in a single session. The total time should be about 30 minutes for the whole treatment. Some effects of it may show up after the treatment but the real effects take about 11 to 12 hours to really set in. After the first 3 or 4 rotations the muscle will try to return to its compressed state but after 10 or 12 rotations it will gradually start to lengthen out little by little until it reaches its normal length. This treatment may need to be done for 3 or 4 sessions a couple of days apart for the maximum effect. I hope this treatment will help some of you as much as it has helped me. Good luck to you all in finding cure for your ailments. God Bless. ============================================================================= FULL DISCLAIMER ============================================================================= Sciatica Org Site: Link Functional Entrapments: What are they? Functional entrapment syndromes are defined as significant neurological compression resulting from positional or kinesiological considerations, not solely structural or inflammatory conditions. For this reason, imaging studies such as MRI, CT, bone and gallium scans and diagnostic ultrasound is of limited value in detecting these conditions. Even conventional EMG is often negative. Rather, it is in comparing nerve conductions in the anatomical position with nerve conductions in the symptomatic position that turns up the pathology, and the pathogenetic mechanism. This offers both guidance on effective treatment, and a means of assessing the efficacy of treatment through repeated serial testing of the same nerve conductions. Rehabilitation Medicine is well-suited to work with these common causes of pain, since PM&R knows anatomy and kinesiology, does electro diagnostic testing as an extension of the physical exam, is functionally oriented, and is comfortable using both injection and physical therapeutic techniques in treatment. Examples: Piriformis syndrome comprises approximately 6 to 8 percent of sciatica and low back pain. (1) While herniated nucleus pulpous and spinal stenosis are more common, piriformis syndrome is under diagnosed, (2). Therefore, its prevalence is significantly higher than its incidence (3). The syndrome is due to the piriformis muscle compressing the sciatic nerve in the buttock, and, like pronator syndrome or carpal tunnel, causing damage to the peripheral nerve through excessive pressure. (4) The nerve is pressed backward against the sharp tendinous edges of other muscles such as the gemellus superior and obturator internus, (5-6) and the condition may easily become chronic, and debilitating. History Discovered in Florence ca. 1580. After Mixter and Barr's paper in 1932 (7), people recognized spinal and intramedullary pathology as the chief cause of sciatica. It is foraminal and intramedullary conditions that come to mind when patients present with sciatica. However, pain along the course of the sciatic nerve at times is caused by pathological involvement of the nerve itself, and rational diagnosis and treatment then should focus on the site of the pathology. Epidemiology Since an estimated 80 million Americans suffer low back pain and sciatica annually, (8) 4.8 to 6.4 million people contract piriformis syndrome annually. One reason for Under diagnosis is that MRI, myelogram, CT, are unlikely to turn up any evidence of piriformis syndrome. (9-11) It is a functional syndrome: only certain positions and pressures bring out the pain, paresthesias, and weakness that come with it. Structure imaging studies are of minimal value here. (12-15) Since it is sometimes considered a diagnosis of exclusion, many patients receive painful and pointless surgical and other procedures based on limited inquiries and faulty diagnosis. Piriformis Syndrome is commonest among very active people such as athletes, health club users, joggers, and performers, and those who sit a great deal such as members of the financial community, lawyers, psychotherapists, secretaries and vehicular drivers . After occupational causes, trauma is the second greatest cause of piriformis syndrome. Lifting and other back strain related activities are third, with many other initiating events including misplaced gluteal injections, lipomas, and unusual furniture. Diagnosis Modern methods of diagnosis began with the work of Fishman and Zybert (14) using the H-reflex and EMG in 1992. By timing the H-reflex in the position of Flexion Adduction and Internal Rotation, (the FAIR-test) in which the piriformis muscle tightly presses the sciatic nerve against the underlying structures, and comparing the timing with the H-reflex in the anatomical position, the amount of delay was measured in normals. These values were then compared to those seen in patients meeting clinical criteria for piriformis syndrome. Patients with piriformis syndrome had FAIR-test values which were, on the average, more than three standard deviations beyond the mean seen in normals and in contra lateral lower extremities. More than 80 percent of patients so diagnosed improved 50 percent or more with conservative therapy aimed at loosening the piriformis muscle in the buttock. The recovery rate of patients identified by the FAIR-test is much greater than the recovery rate seen in patients selected by any other known means. (15) Because of the nature of the syndrome, the test for piriformis syndrome is functional in nature, comparing nerve conduction values when the nerve is compressed, with values seen in a resting position. The discrepancy between normal values and those seen in piriformis syndrome is amplified by the fact that the H-reflex crosses the buttock In order to determine these values, posterior tibial and peroneal H-reflexes are studied both in the anatomical position and the flexed adducted internally rotated position (FAIR-test). Thus the H-reflex is actually performed four times with each limb that is studied. (15) Clinical Experience Treatment at first was simply physical therapy, informed and enriched by the generous giving forth of experience from the international medical community. In essence, the therapy lengthened the piriformis muscle, reducing spasm and pressure on the descending sciatic nerve, and giving the nerve enough slack to remove itself from harm's way. See the rest of the website for the specific program. The therapy was helpful, but progress was slow. On the suggestion of Dr. Janet Travell, we began injecting Triamcinolone Acetonide 20mg with 1.5cc of 2% lidocaine into the motor point of the piriformis muscle, just medial to its musculotendinous junction in the lateral buttock. This had only rare minor and transient side-effects on non-diabetics, and shortened the recovery time considerably. On average 10.2 month follow-up time of 1014 cases of piriformis syndrome, more than hat these patients had suffered from piriformis syndrome for an average of 6.2 years, Probably due to piriformis syndrome being considered a diagnosis of exclusion, other, less important diagnostic entities had received undue attention in these patients. Among these1014 cases there had been over 400 spinal, trochanteric and gynecological surgeries, none of which was definitive, more than 1500 imaging studies, of which less than 1/5 were relevant, and more than 10,000 appointments with clinicians for diagnostics, epidurals, physical therapy, and alternative methods of pain relief. More recently we have conducted several IRB-approved studies of more specific nerve blocks, using the toxin of the botulinum bacterium. In the latest and most successful of these, we have found that 12,500 units of botulinum B toxin has well above 85% efficacy, and fewer side effects than Triamcinolone and Lidocaine, giving more relief faster, and appearing in early studies to last longer. Containing no steroid, this preparation is also suitable for diabetics. Showing a much more rapid decline in pain levels, and normalization of the FAIR-test, it obviates physical therapy sessions that surpass the cost of the injection. In summary, there are four reasons that botulinum toxin helps in the treatment of piriformis syndrome. A reliable correlation between diagnosis and effective treatment exists. More than 5,000,000 currently improperly treated patients will continue to suffer, and continue to consume health care resources in vain unless and until adequate treatment is afforded them. In clinical experience, injection of botulinum toxin has proven the most effective treatment. Cost-benefit analysis of current data strongly supports injection of botulinum toxin in the treatment of piriformis syndrome. Two other considerations are relevant: Wider applicability. While the anti-insulinemic effect of steroids strongly contraindicates their use in diabetic patients, there are virtually no documented allergic reactions to botulinum toxins. Longer efficacy. Steroid injection without physical therapy is generally effective for 1-3 weeks. Botulinum toxin injections without physical therapy are effective for at least three months. In the past, approximately 15% of patients treated without botulinum toxin injections have had recurrence of piriformis syndrome within three years. As of today, (14 months after our first injection) we have seen 3 relapses following botulinum toxin injections in 61 patients. A Patients Success Story: Link Cindy W., IT manager from NC. Successful ADR, but I was still completely disabled. The first time I met Mark was on September 19, 2002. We were in the waiting room at the Alpha Klinik and we both had surgery scheduled for the next day. After we chatted for a while, I realized that I was speaking to someone who had written a great deal on the internet about his research into ADR. I said, "Oh my gosh, you are RumorSlayer! I used to look for you online. I'd call my husband over. Ed, Ed, he's here again!!! Come read this!" I was in Munich for surgery because I had disabling back pain, hip pain and foot pain. I was very relieved after my discogram because it so clearly reproduced all my pain. That made me an excellent candidate and gave me every reason to be hopeful. My first week post-op was incredible. I felt sorry for Mark because he was having such a tough post-op experience, while I was walking many miles a day and sightseeing around Munich just 5 or 6 days after my surgery. I knew just a few days after my surgery that my back pain and my foot pain were GONE! Fast forward about a year and Mark's in great shape, but I was still functionally disabled. Although my disc replacement solved my back and foot pain, my disabling hip pain still had me unable to function. I was still on large doses of OxyContin. I'd been to doctor after doctor, but none of them had any good ideas. I had been referred to pain management. I was ready to give up. One day Mark called me up and told me about someone he met on the Internet forum he'd started for people who want to discuss non-fusion technologies. He told me that I there was a man he'd spoken with, who described disabling hip pain EXACTLY like I described mine. I took Mark's advice and called Brian. Brian had a similar story, but had found his way to a Dr. in Cincinnati who specialized in Piriformis syndrome. I called the Dr. but he warned me that Piriformis syndrome is very rare and that I shouldn't get my hopes up. Fast forward another 6 or 7 months! It turned out that I had profound PS. Out of 80 cases this doctor had seen, he said that my case was certainly one of the worst. I had the piriformis release surgery in October of 2003 and by mid-2004, I was riding my mountain bike with my husband, camping, hiking, working full time, back to a rewarding workout regimen (I was an athlete before my disability). I can't believe it, I'm living a NORMAL LIFE! I was ready to give up. I don't know where I'd be now if it wasn't for Mark and his Patient Network. I suppose that I'd still be in pain management, on large doses of opiates and completely disabled. Instead, I have a new lease on life and can live every day to the fullest. With the perspective that you gain from being reborn after such a painful disability, life is even better than it was before I could truly appreciate what it means to enjoy a day without pain! Thanks ================================================================================== Sciatic Notch lesser sciatic notch ================================================================================= (April 8, 2005) Email to Paul Dean from Northern California Sufferer: hi, I have had a neurogram and it shows that both my sciatic nerves are being pinched at the sciatic notch. Is their any advise you could give me. I live in Northern California and the doctors up here pretty much suck and really don't believe piriformis syndrome exists. who did you do to and what tests did you do to determine you had piriformis syndrome. THANKS ================================================================================== Piriformis Surgery Incision (Site) Of a Patient Suffering from Left Side Piriformis Syndrome and Sciatica The incision is to the Buttock (April 8, 2005) Email Reply From Paul Dean to Northern California Sufferer: The nerve narrowing at the sciatic notch is a different part of the body and is near the spinal cord and structure which (IS NOT) Piriformis Syndrome, which lies deep underneith the Buttock underneith your gluteal muscles. Your Sciatic notch may need to be enlargened because it should not be pinching any of the nerves. Nerves need to move freely as they are stretched in walking, etc. If they cannot move or if they are pinched, you will be in great pain. It is very hard to find a doctor who knows where your pain is coming from. Especially in Piriformis Syndrome. A Orthopaedic doctor can go an entire career without seeing more than one or two cases of Piriformis Syndrome in his career. Call Dr. Chambi, (Neurosurgeon) (714)-973-0810 and explain your situation to him. He is the only one who could find my problem of many, doctors who had seen me. In my case, the Piriformis muscle had scar tissue wrapped around the sciatic nerve, entrapping that nerve and giving me pain. That scar tissue has been removed by Dr. Chambi and I am getting good results, but it takes time for a sciatic nerve to get back to normal. Good luck, I feel for all of those who have had the intense pain that I have had! As a final comment. I chose the Doctor that the Pro Athletes prefer, because you need the best of the best for good results. I am a patient recovering like yourself and every situation will be different and your exact situation sounds a little bit different than mine. The diagnosis of Piriformis Syndrome is a situation of exclusion of any Spinal problems. Also, if your pain lies in the middle of your buttock and comes about when you are sitting, this is one sign that you may have Piriformis Syndrome. You could have numbess, Sharp stabbing Pain, burning pain, or Aching Pain, along with sciatica. When it is found that your problem is not coming from the spine, then the surgeon will look else where for the problem. The situation becomes confusing when the spine has exactly the same symptoms of the Piriformis entrapment, (In my case, sciatica down the right leg). This is when the MRI will exclude any type of abnormal discs that may have ruptured or narrowed or had entrapped the nerve. I am post disc surgery and post Piriformis Release surgery at this time. As long as you have entrapment, no amount of exercise or stretches are going to change that entrapment. It is after these failed exercises and stretches that one may go for a release surgery. As a last note, find the very best neurosurgeon that you can, (even if it means flying to that doctor) who is familiar with your diagnosis and possible surgery solutions. Different Doctors specialize in different things and they don't know much about other conditions and they only look at what they know. A spine surgeon only likes to give spine surgeries... etc. etc. So you really need a specialist who deals with your type of problem all day long and I think you are on the right track. Your age and type of fall that you might of had would also help in diagnosis of your injury. Family history and many other questions are needed to be answered to get to the bottom of your situation. Your body will give you an idea of where the pain is coming from which is helpful in the diagnosis. Hope some of the above helps you! See a good Neurosurgeon to confirm any of the above I have mentioned. Of course I cannot prescribe or give advice because I am not a Doctor. But I guess everybody has an opinion. Thanks, Paul, Recovering Patient (Dr. Chambi (714)-973-0810 Santa Ana, CA ) ============================================================================= Piriformis Surgery Questions and Answers: (April 8, 2005) Email Questions to Paul Dean An Email to Paul Dean from another Person who is considering Piriformis Release Surgery: Hello Mr. Dean, While researching piriformis syndrome on the internet, I ran across your account of having release surgery done by Dr. Chambi. My wife is having a great deal of sciatica pain and is currently seeing Dr. Chambi for piriformis syndrome. After 2 injections with little relief of pain, Dr Chambi has suggested that surgery might be in order. Given what you know about this surgery, was it successful in relieving your pain and would you have Dr Chambi perform it again? I would be very interested in talking to you further about this subject if you would consent. ================================================================================== ================================================================================== Piriformis Surgery Steps: Email Answer from Paul Dean: (April 8, 2005) Dear Sir, Yes I did the Buttock Lidocaine shots and only the first of a series of three helped me. I was still in a lot of pain and the only alternative at that point was the actual Piriformis Release Surgery. I had worn out the physical therapy option, and wasn't getting any better. It was either have the pirifromis release surgery or always be in terrible pain. I did not want to live the rest of my life in terrible pain so I went for the piriformis release surgery. Within two months after the surgery I was ALOT better. That alone helped me very much, and my depression started to lift as well. When a person is injured for a long time it is very hard to keep a positive frame of mind, but this is essential in getting better. Nerve Now 10 months later I continue to improve. I could not improve at all without the piriformis release surgery. What happened is when I fell at work, a large amount of scarring was attached to the piriformis muscle area and to the sciatic nerve making it impossible for the nerve to move. If the sciatic nerve cannot move, you will have terrible pain. Yes, I was scared to have the release, but not as scared as when I had my back surgery. Would I do it again? Every day of the week, I would. Quality of life is very important to me and I need to be able to be active as I once was and now I have the opportunity to get back to being active. Piriformis Syndrome is very rare and most Doctors know nothing about it. You have a doctor, Dr. Chambi, who understands this condition, so you are very lucky to find somebody who understands where your pain is actually coming from. Post Op: I have lost a great deal of elasticity in the nerve so I must walk and stretch every day to regain what I can in that sciatic nerve elasticity. Rehab. is very important and takes a long time to get the nerve back into shape. Stretching, Walking and Light water exercises. Structure Of A Nerve A final note: I was at the point where I felt I had nothing to lose so I went ahead with the surgery, and it helped a great deal. My L5 S1 Lower discectomy surgery also helped me very much. (I had a 7mm Herniated Disk) Good luck to you and your wife, and again, think of quality of life, and of getting better because sometimes physical therapy will do you no good when the scarring is so severe that your sciatic nerve cannot move. I am up to walking an hour and the extreme edge of pain is gone!!! Of course I am not a Doctor so I cannot give advise but only opinions as to my unique situation, and every situation is different. Dr. Chambi is the doctor that all the Pro Athletes choose and there must be a reason for that. Take care, I hope that you recover soon! Paul Dean, Patient (Dr. Chambi (714)-973-0810 Santa Ana, CA ) ================================================================================== Side Note: July 23, 2005 - Paul Dean I am continuing to recover at my own body's rate which seems to be a little bit slow but you really can't recover at any pace faster than your own natural pace of healing. Nerves take up to three years to have their full healing ability. So do not be to impatient if the second you get off the operating table that you are not completely healed. That just isn't how nerves work if they have been damaged for a long time. The problem is that once your sciatic nerve in your hip has been entrapped at the piriformis level for several years, the elasticy shrinks and you will hurt every time you stretch until you get your nerve elasticy back. This is the reason that you need to walk an hour or more every day to get that elasticty back. It will hurt to walk long distances and that is why I use the Lidocaine patch. This patch numbs the area that hurts in the back of the hip, so you can walk further and stretch the sciatica nerve. Rubber band Analogy: I can imagine a rubber band that needs another inch or two in order to reach its full potential of stretch. So every day I walk, and then I walk some more, stretching that rubber band, which is the sciatic nerve. Once the nerve is used to the stretch it doesn't hurt as much. Of course this is done after the surgery because the sciatic nerve could not stretch at all when it was tethered down from tissues wrapped around it from a fall accident I had from work. Now that there is no entrapment of the nerve I am gently stretching that nerve until it gets used to the stretch and stops hurting when I walk. The goal is to have absolutely no pain no matter what I am doing and that is my eventual goal. Vitamins B1 and B12 and Antioxidants to build up the Immunity and Healing: What about boosting the immunity system to have a faster healing process? I am on a Vitamin Regiment of B1 Vitamin and B12 Vitamin in decent doses as well as an Anti-oxidant supplement to get my system in good working order so that I can heal as fast as possible. I have tried to increase the rate of healing by getting toxins out of my system by doing the following: Do's: Vitamin B (B1) (B12) Vitamin A,B,C,E Beta Carotene and Mineral Supplements. Drink Six glasses of water a day Drink as much Grapefruit juice (no Sugar) as possible Eat as many raw fruits and vegetables as possible Chicken and Fish Dont's: No Salt and No Sugar need to be eaten it is in your foods already. No Greasy Processed Foods No Fast-food No Breads or rice or potatoes Please see a Doctor before using these above techniques which I am following as your medications may require that you do not follow my above plan for getting your system back into shape for quicker healing. Note: These above Do's and Don'ts can be found in the book of President Clintons Doctor: Michael F. Roizen, MD. and Mehmet C. Oz, MD copyright 2005, "YOU, THE OWNER'S MANUAL", The insider's guide to the body that will make you healthier and younger. Harpercollins Publishers Inc, 10 East 53rd Street New York, NY 10022. I have no affiliation with any of these works and please take all information as third party opinion and review options with your Doctors before doing anything with your body. Thank you. Above Updated: April 8, 2005 ------------------------------------------------------------------------------ -------------------------------------------------------------------------------- New Entry: July 25, 2007 - Updated Medical Condition of Post Piriformis Syndrome with Piriformis Release Surgery and Post Discectomy of L5 S1 Disc. -------------------------------------------------------------------------------- Email Response to Susan: -------------------------------------------------------------------------------- July 25, 2007 Hi Susan, (Disclaimer: I am a patient like yourself and am not a Doctor.) Thank you for reading all of my postings, I'm sure it must have taken awhile to get through it all. Pain is an interesting thing, in makes you want to read every single thing you can find out about your pain hoping that you can some how stumble upon the right information that can give you some pain relief. That is what I did and I am sure that is also what you are seeking and I am wishing you the best of luck in advance, as pain can control and ruin a good life that was before pain free. Susan wrote: The last update on your progress was quite some time ago. How is the sitting going now? Paul's reply: Yes, the update was quite a while ago mostly because I have been busy back in the Tradeshow business, which requires lifting heavy amounts of weight for a duration of time. So, in part I have to say that I have gotten better, because it was unfathomable before my piriformis surgery that I would be able to excel in either of my heavy lifting jobs. Lifting in duration and for long periods of time was difficult to impossible before my surgery. Now to answer the sitting question which is important because my travel time to and from work is an hour and a half each way most of the time. I still have pain, but not extreme pain and I can get out of it by putting my car on cruise control and taking my right leg out of the stretch that is required to press down the gas peddle. I use cruise control most of the time because my pain is elevated. So now the next question is how much has my pain level improved since the surgery. I would say it has gone from a 7 to 8 in pain level down to a 2 and 3 which has given my life back to me in many ways as I enjoy physical activity with lifting and movies which last up to 3 hours. I do have problems with movies over 2 hours and will take a 15 minute walk around the lobby during a movie in order to stop my pain. It seems that almost instantly when the leg is no longer in a bad position of a stretch or just sitting to long in the theater, the walking relieves the pain instantly. Where is the pain in the first place, it seems that it is in the thigh area, but before the surgery I had both buttock an thigh pain. Would I do the surgery over again? Definitely, yes as my pain levels went down to a livable tolerance level. I am still cautious as to getting back into tennis as that does a lot of thigh stretching but I will try to see if I can slowly work back into this great sport that I have loved. Susan wrote: I'm at the "I need surgery" stage and am trying to find the best, most experienced surgeon. I live in Florida and am having a difficult time finding someone in this area who might be competent to do this specialized procedure. It seems that your doctor and Dr. Filler are both in California and the thought of sitting on an airplane for 5 hours, then spending several weeks in a hotel room after surgery is not the best option. Sciatica and Piriformis Syndrome: Dr. Aaron Filler Santa Monica, CA:Preview Link Other Dr. Aaron Filler Techniques: Link Link Paul's reply: It is hard to find an experienced Surgeon and I would recommend you pick somebody who is doing this type of surgery day in and day out who has done more than anybody else especially since you only get one shot at this surgery so you need to go to the best. I went to Dr. Chambi in Santa Ana, CA, I have heard the name Dr. Filler and I have also seen a Dr. Palmer In Mission Viejo, CA. Would I fly 5 hours in order to be close to pain free with the proper surgery, after having a correct diagnosis? Yes, I would do just about anything to get my previous life back and feel good again, pain free or close to it. Luckily, my surgeon is only 40 minutes to an hour away. As far as flying back after a surgery, you should be able to do this after three weeks post surgery, with help. I was able to walk the day after the surgery but had problems with Sitting and putting on my clothes and getting around because you are limited when Recovering from this type of procedure. Susan Wrote: I went to NYC and saw Loren Fishman, went through Botox with him, and feel like a human pin cushion with all of the various injections from various doctors. I even wanted to try prolotherapy but at least that doctor was honest enough to tell me he thought it wouldn't help. You're the only person that I've found who has actually had this surgery so I'm very curious about your long term results. Some of the orthopedic doc's that I've seen will do surgery but want to cut the entire buttocks to do it (they all specialize in hip replacements around here). I obviously don't want an invasive procedure when there are alternatives available. Also, as a curiosity, did you have involvement of bursitis in the hip and thigh with this? I'm trying to figure out if it's a side effect or a totally different problem. Paul's reply: My condition was that of a post herniated disc surgery called a Discectomy of the L5 S1 region of a previous herniated disk of 7 millimeters. The 7 millimeter herniation was cut out so the nerve was then again free, which it showed that it was free in the post MRI, however I still had some severe sciatica pain going from the buttock down the right back side of thigh which is the area where the sciatic nerve travels. I then had some steroid injections into the L5 S1 back to relieve any possible inflammation that might be causing my pain and these injections did not help me with my pain. I then saw Dr. Chambi and had three Lidocaine injections to the buttocks where the pain was at a precise location. The 5 inch needle was inserted and the first one of the three different injections done on different weeks solved my pain temporarily and so I thought this was quite a miracle to all of a sudden have no pain after a buttock shot to the piriformis muscle. When the piriformis muscle was relaxed, I was pain free. However the pain came back after the shot wore off. I also wore a lidocaine patch which gave some relief to the area installed such as buttock and back of leg, but was temporary. It is at that point that Dr. Chambi said, you have piriformis syndrome because the piriformis muscle has entrapped your sciatic nerve and there is only one permanent solution which is a piriformis release. Piriformis Release is a way of cutting away the piriformis from the sciatic nerve. Apparently, the sciatic nerve had somehow gotten scarred down from a fall I had, and it was entrapped. After the piriformis was cut away from the nerve, I had great relief, because the sciatic nerve could then move freely again. It was no longer pinched down, and was not constricted any longer by the piriformis muscle. Susan wrote: Some of the orthopedic doc's that I've seen will do surgery but want to cut the entire buttocks Paul's reply: The actual cut that the surgeon does for piriformis release is similar to the cut done in a hip replacement at about a 4 to 5 inch cut across the buttock. The piriformis nerve is about 6 inches down and a lot of the Buttock area needs to be moved away to be able to get to the piriformis muscle and underneath were the sciatic nerve is located. Susan wrote: I obviously don't want an invasive procedure when there are alternatives available. Paul's reply: You first try all the physical therapy and water therapy and all the different shots available but when they all fail, then you look to the surgery for a permanent cure, and only after at least two experts agree with the same diagnosis, in this case, piriformis syndrome, then you take the next step, if both doctors agree that this is the next step to take after exhausting all other steps, and needing a permanent solution. You should not be afraid of surgery when you are with an expert in the field. Do not be afraid of the recovery pain as you are given strong pain killers to take this pain away until you have finally recovered. Finally, make sure that you have gotten relief with the Lidocaine injection which relaxes the piriformis muscle and gives relief to the sciatic nerve, which pretty much is the telling sign that the piriformis muscle is involved in your pain. Many Orthopedic Doctors will say this is not the case because the do not understand that the piriformis muscle and scarring can stop the sciatic nerve from functioning properly. I suggest you see Doctors that study Nerves and not just bone doctors as your problem May not be a bone or disc disease. The most important thing to find is the right Doctor and the correct Diagnosis, and it won't be easy to find this. Susan Wrote; Did you have involvement of bursitis in the hip and thigh with this? I'm trying to figure out if it's a side effect or a totally different problem. Paul's reply: No I was not diagnosed with bursitis in the hip or thigh. That may very well be something else. This is why it is important to get the proper diagnosis and to see more than one specialist no narrow down where and what your pain is and what is causing it. You can go to three different specialists and get three different expert opinions, and this is a big problem in figuring out what to do next, so you'll have to find the best of the best in specialists in order to get a correct diagnostics of your problem. Even a phone consultation is better than nothing, so I suggest that you keep searching for a correct diagnosis and then go forward with the proper treatment once this is found. Hope is one thing we all have even when things look bad. You keep on thinking that you will wake up and be pain free. Maybe this sounds unrealistic but we keep on holding on to this hope. Can nerves regrow themselves and straighten themselves out so that signals are then properly sent to and from the body to the brain? We hope that some how this will happen, however sometimes nerves don't grow back so we are stuck with tollerating pain. Then, it is up to us to figure out what we are going to do with this pain and how to tempoarily get out of pain. To each person they have their own answers. My answer is to keep going. My Disclaimer: I am not a Doctor and am not in a related medical field and am only a patient looking for a solution to pain. Do not take anything I say as a fact, but instead contact your local specialist and get the correct diagnosis from a professional. I sincerely hope you are pain free soon, from one patient to another, Good luck with a pain free life. Thank you, Paul
knowledge is Power Thank you, Paul Dean, Spy Hunter Video Game (Guinness Book) Champion - June 28, 1985 and 2007 Guinness Book www.spyhunter007.com Last Updated: April 8, 2005
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