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Piriformis Syndrome again

Originally published in Orthopaediciq, April 2013

The following  letter which demonstrates the difficulty some have in obtaining help from obdurate therapists.

 

Dear Doctor,

This is rather random, but I came across your contact details while trying
to find out where I could get the surgery to treat piriformis syndrome. I am
having great difficulty persuading my GP and spinal specialist that my
problem is piriformis syndrome as apparently it’s not seen as a legitimate
diagnosis in the UK. I am absolutely miserable with the daily pain and lack
of movement in my leg. I can’t enjoy life anymore and nobody will give me an
answer. I am supposed to be having an epidural in the spine which I know
will not work. I gave had the pain for nearly 2 years and its getting worse
as the range if movement decreases. I believe it is a result of falling on a
step wearing high heels on to me right buttock as that us when the sciatic
pain started and now I am in almost constant pain with ache and stiffness. I
guess I am just hoping you have an answer or more information. I just want
someone to release this muscle and give me my life back. I am only 26 and
feel like my life is over. I would be so grateful if you could reply. I
understand you are probably very busy.

 

Dear V,

I am sorry that you have received this rebuffing approach.
Further, could you tell me more about and where is your pain – does it extend down your leg? Is it aggravated by cough, sneeze and straining on the toilet? Do you have any difficulty in controlling your bladder or any sensation loss around the anus?

I find it curious that many qualified people “oppose” the diagnosis of the piriformis syndrome. What I find difficult to understand is that there is nothing “unconventional” about it. The anatomy is undeniable, and there are many ways of demonstrating its existence.

It might be that every sciatica is not attributable to the piriformis syndrome, but that is not invalidation.

The good news is that it can be conclusively diagnosed and equally conclusively treated. As is always the case diagnosis is the sine qua non. Therefore my current approach in establishing the diagnosis – if the clinical features support it – is to inject the muscle, under ultra-sound guidance, with local anaesthetic. This temporarily paralysis the muscle, reduces the spasm and as a sequel takes the constricting pressure off the underlying (and compressed) sciatic nerve. Some radiological skills are required and selection of a capable and interested radiologist (or orthopaedic surgeon) is advised

In your case there might be an accumulation of blood from the injury in the muscle which you sustained and CT scanning (or MRI) could be warranted. Once the local anaesthetic wears off, at the expected time, the pain would be expected to return. This is therefore a DIAGNOSTIC procedure. At times the benefit lasts, which is a great plus. But if it does not there are many other approaches to its management, sometimes by non-surgical methods.

It is ironic that you have been lined up for an epidural injection (of what?). Epidural injections for back and leg pain are “random walks”. A loosely empirical “therapeutic trial” with little basis regarding the mode of action, an absence of any diagnostic accuracy, no established certainty of its benefit and not inconsequential risks. Therefore your clinicians, in denying the concept of the piriformis syndrome are proposing a form of treatment which is, itself, totally lacking in “legitimacy”

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