OCS- 4-11 Psoas and piriformis syndromes

a sciatic neuritis

Muscle rapidly lengthens ‐ sensory “tells” CNS that OVERSTRETCH has occurred • Reflex contraction (increase Alpha and Gamma gain)
• Microtrauma ‐ pain sensory feedback

ischemia, overuse, local irritating factor, metabolic abnormality of muscle, viscerosomatic reflex

a. increase
b. increase
c. increase
d. pain cycle with positive feedback

A-delta
C-fibers

1. CNS sends impulses to neothalamus, and somatosensory cortex, which allows for localization and discrimination of type of pain
1. send impulses to a variety of locations: brainstem, midbrain nuclei, cortical limbic system- (key place for behavior modification conditioned behavior, learned avoidance

Results in larger than normal motor outputs to the autonomics and somatic systems
– This then is thought to set up the low‐threshold spinal reflexes Korr and Denslow talked about: THE FACILITATED SEGMENT

O: pelvic surface of the lateral part of the sacrum at the second through fourth sacral segmental levels, the greater sciatic foramen, and the sacrotuberous ligament

I: medial side of the upper margin of the greater trochanter

Action: Depends on whether the hip is flexed or extended.
• Straight lower extremity
– External rotation at the hip
– May contribute to thigh extension
• Lower extremity flexed 90 degrees at knee and hip
– Abduction at the hip
– May also internally rotate thigh

there are tons but...
upper border: superior gluteal nerve vessels
lower border- pudendal nerve, inferior gluteal nerve, posterior femoral cutaneous, nerves to short external rotator of femur

Pain- lower back pain with radiation down the thigh, hip or butt

Tenderness- over muscle, exacerbated by provocative testing
Paresthesiasis- along course of sciatic nerve
- abscence of true neuro deficit- deep tendon reflexes are ok

fibrosis/scarring
hematoma
mass (Sarcoma)

– Somatic dysfunction
– Herniated nucleus pulposes
– Foraminal stenosis
– Intraspinal lesions
– Pelvic mass

Mechanical:
• Somatic dysfunction
• Sacroiliac disease
• Facet syndrome
– Metabolic/Chemical:
• Diabetic neuropathy

1. Visualization/observation
2. palpation
3. • Osteopathic considerations
4. • Provocative tests
5. • Neurological testing
6. • Special tests

Tender points are exactly where it hurts (midcheek)
- Travell's trigger points cause painful radiation of pain distal to the trigger point (along nerve distribution)

– Addressed towards underlying functional/structural pathology
– Strain/Counterstrain: Indirect positioning and reduction of
tender point tenderness by 75%
– Myofascial release: Direct and indirect
– Muscle energy: Direct
– Spray and stretch: Uses a vapo‐coolant on the skin to down
regulate the muscle tightness/spasm.
– Injection of myofascial tender points.

Deep knee bends (3-6 q 2-3 hrs)
walk
bike exercises
sway exercises

- Warm baths

flex ext/rotation

1. Difficulty sitting or standing upright
2. Pain, Thoracolumbar, Lumbosacral, Sacroiliac, Gluteal pain down leg, stopping at knee
• Posture – Forward bent with one leg shortened and externally rotated
Position of comfort is supine with legs flexed up

• Flexion stress of lumbar spine (e.g. bending over table for prolonged period of time)
• Sit ups (constant)
• Trauma (blow to the abdomen)
• Chilling (warmed up not)
• Viscerosomatic reflexes (pelvis and abdomen) T12-L2
• Flat lumbar lordosis (predisposes)
• Emotional stress- often causes body to flex foward

extend very slowly

1. Bilateral spasm
2. Unilaterally Dominant Spasm
3. Sacral torsion
4. Piriformis spasm
5. Add Sciatica

Stage one- Lumbar Spine Flexed, Regionally: Nonneutral
• Pain Site: Belt Line
Exam:
– Flat Lordosis
– Unable to return from a flexed posture
– Positive Thomas Test
– Pain on thigh extension

Treatment: – OMT
– Passive exercise (rolled towel TID, muscle relaxants)
– Muscle relaxation exercises

Dysfunction (assuming R‐sided spasm): – L1 F RRSR (KEY LESION)
– Lumbar spine side bent right
– L2‐5 RLSR
• Pain Site:
– Right belt line, pain on sidebending to the left

Exam:
– Lumbar SB right
– Short leg on the right
– Right leg externally rotated

• Treatment:
– All previous treatments plus:
– L1 first
– L2‐5 next
– Psoas stretch
– NSAIDS

Dysfunction:
– All dysfunctions above
– Left on Right sacral torsion
– Left pelvic side shift
• Pain Site:
– Lumbosacral junction at side of sacral axis

– All of above
– Right sacral sulci deep
– Left ILA Posterior/Inferior
– Positive Spring test
treatment: – All of previous treatments plus treat torsion

Dysfunction:
– All of previous, plus left piriformis spasm
– Counterstrain point develops in Piriformis
• Pain Site:
–With pelvic side shift to the left, pain moves to left gluteal region, SI joint, and hip

• Exam:
– All of previous plus left foot externally rotated due to Piriformis spasm
• Treatment:
– All of the above
– Treat piriformis counterstrain
– Spray and Stretch
– Trigger point injection

Dysfunction:
– All of above plus left sciatic nerve irritation
• Pain Site:
– Left gluteal, left SI, left hip, radiating down left leg to knee

Exam:
– Paresthesias left leg (stop at knee)
– No neural deficits
– Muscle atrophy
– Negative EMG
– Positive left straight leg raise (30°)
• Treatment:
– All of the above plus low dose steroid

used for psoas syndrome...
Jones Counterstrain:
– Pt. Supine, lower extremities flexed, externally rotated, and lower thorax side bent toward side of
dysfunction
• Chronic spasm:
– Direct stretch and muscle energy

NSAIDs
OTC (Aleve, Motrin): NSAIDS (at lower OTC doses)
– Rx (Meloxicam (Mobic) Celecoxib (Celebrex) : NSAIDS (full strength dose)
Muscle relaxants (metaxalone (less sedative), cyclobenzaprine (fatigue, dry mouth, anti-cholinergic effects)

at high stage- avoid HVLA, instruct and medicate, counterstain/myofascial release
Dont delay, look for viscerosomatic reflex