Friday, February 12, 2016

Deep Burning Butt Ache review: Piriformis syndrome, sciatica, deep gluteal syndrome, sacroiliac syndrome, deep buttock syndrome ...

One of the more interesting aspects of being an older physician is that we get to experience first hand problems we’ve treated (or mis-treated) in other people. We learn experiential subspecialties like cancer, pain management, arthritis (yay), hypertension, obesity, heart disease and the like.

My experiential subspecialty is sports medicine, particularly anything related to tendons and, most recently, joints. I owe my experience to a combination of bad genes (thanks Mom) and a need to move. 

Experiential specialties teach even new physicians that the medical knowledge base is weird. It’s not simply that textbook descriptions and treatment plans are incomplete, it’s also that they vary a great deal, both between references and within them. Even books that do some things well may cover other things poorly. If you hang around for a while you also see the same “thing” get new names and explanations, even if the treatments don’t change as much. Insider experience exposes some “well known” disorders as Potemkin villages — on closer inspection they kind of fall apart. (Osteoarthritis? We know almost nothing. There really is something wrong with how we explore disease).

Deep Burning Butt Ache (DBBA) is all of the above. Actually, that’s my term, not the scientific name. It’s sometimes known as “Piriformis syndrome”, “deep gluteal syndrome”, “sciatica” (older name, now obsolete), “sacroiliac syndrome” (less often), and “deep buttock syndrome”. PITA, inevitably.

I’ve had DBBA three times in my life. Once it was related to carrying a wallet in my hip pocket (today it would be a phone). That one cleared up when I moved the wallet, but it still took many months to completely resolve (also typical). A second time was related to inline skating, and only slowly resolved when the season ended. This time it seems to have come from playing ice hockey, but it is a bugger during my broken-arthritic-old-man CrossFit workouts —  especially running, rope jumping, and, weirdly, kipping pull-ups but not squats or box jumps. (There may be a new arthritic component to the problem, but I can’t tell that.)

Having lived with this a few times I think I’m in a good position to do an informed review of the accessible online literature. These references matched my insider experience:

I think with this set of references you know about as much as anyone does - except what the stretches actually look like (see below).  All of the references are pretty recent, that’s because until a few years ago DDBA didn’t “exist”. We used the term “sciatica” to include both disk and bone pressure on the sciatic nerve and what most now call “piriformis syndrome”. Two very different problems with different courses (disk problems often resolve in 6 weeks) and different management (esp. stretching).

The use of “Piriformis Syndrome” came out of the internet community; this may be the first crowd-sourced medical syndrome. In truth we really don’t know that the Piriformis muscle is the root problem; it gets blamed because in many people (muscle anatomy varies) the Piriformis lies on top of the sciatic nerve and the symptoms resemble those caused by known injury to the sciatic nerve. Unfortunately, the muscle is hard to study — there’s too much on top of it. For that reason I prefer terms like “Deep Gluteal Syndrome” or “Deep Buttock Syndrome” or “Deep Burning Butt Ache” (DBBA). Similarly I prefer “shoulder pain syndrome” to “rotator cuff tendonitis”. Humility is a good idea.

I particularly liked Dr. Pribut’s description of the problem (excerpt and emphases mine):

Dr. Pribut on Piriformis Syndrome

Piriformis syndrome is difficult to diagnose and resistant to therapy. The existence of piriformis syndrome has been doubted for years, but with the power of the Internet the reality of this syndrome has finally reached a tipping point. Previously, it was not even considered as a diagnosis, in others it was quickly ruled out. In others the symptoms are ascribed to "sciatica" or some other cause, even if the piriformis is considered as a possible cause. Often the patient has considered the possibility before the physicians, trainers, therapists and others have.

Piriformis syndrome may overlap with a variety of other problems including what McCrory et. al. have called a "deep buttock" syndrome. This includes pain in the buttock region, possibly pain in the hamstrings, occasionally pain in the back of the leg that is difficult to locate.

… Scant information is available on the piriformis syndrome in lay publications, and only a little more in scientific publications. The functioning of the muscle has not been clearly defined and examined in the literature. The location of the muscle does not allow for surface EMG (electromyographical) study. It is quite difficult, if not impossible to place a deep electrode in the muscle for study purposes also.

The anatomical position of the muscle leads one to conclude that it functions in some ways similar to that of the gluteus medius

The sciatic nerve passes immediately below the piriformis muscle

…Like Achilles tendonitis and iliopsoas tendonitis this is a very difficult problem to eliminate…

Dr Pribut, like most medical types, skips over the details of conservative management. We usually outsource that to physical therapy! It’s surprisingly hard to find good descriptions online, this is best I could do (don’t forget - nothing in back pocket!):

  • Roll sore butt over foam roller, can be combined with the cross-over sit stretch as in this picture. (The other exercises on this site don’t make as much sense to me.)
  • Rubber (lacrosse) ball over piriformis/sore spot, roll over it. I have no idea why this seems to help, it sounds crazy. Should make things worse.
  • Google Image Search: Piriformis stretch: I gave up and outsourced to the Google AI. Pretty good set, lots of examples of variations on sitting with one ankle on other knee and leaning forward/pushing down. That’s the fundamental external rotation stretch.
  • ”External” Rotation banded Hip Driver - CrossFit St Paul: this is an aggressive version of the classic sitting leg external rotation piriformis stretch; it’s one of a series of stretches in a single YouTube “lower body mobility” set.

For my personal flavor of DBBA I’m doing several versions of hamstring stretches, seated and freestanding “chair sit" external rotation stretches, leg over leg to chest stretches, foam roller, lacrosse ball, and, my personal favorite, the banded ”External” RotationHip Driver - CrossFit St Paul. After 6-8 weeks of this I’m improved, but a few hours of hockey or running/jumping will set me right back.

Oh, I’m supposed to not do things that make it worse? Well, yes. That time will come. For now though I’m trying something counter-intuitive that I learned from my pretty-much-fixed long-term bad back problem (another experiential subspecialty of mine). I do the problem activity to produce mild to moderate burning discomfort, then I stretch it out, then I go back to the work. After I rest and recover I stretch some more. Experimenting, because we really don’t know much. Anyway, only 8 more hockey games left before it’s mountain biking (knee pain) season …

- fn -

[1]  Filler AG, Haynes J, Jordan SE, et al. Sciatica of non disc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment. J Neurosurg Spine 2005; 2:99–115.

I haven’t read the article, but looking the tumors they found (very rare in real world) I think they are a referral center …

“Piriformis syndrome: 68%

No diagnosis: 4%

Sciatic tumor: 1.7% (that’s 4 people in 239. I think this is referral center and small sample bias)

Lumbar stenosis: 0.8% (2 people)

Sacroiliac joint inflammation: 0.8% (2 people, surprised no sacroiliac arthritis)

Tumor in lumbosacral plexus: 0.4% (1 person, suspect referral bias.) 

Update 3/19/2016

Eight weeks after new painful burning pain in one butt or the other made me skip a week of CrossFit my piriformis pain is entirely gone. A 1.5 mile run and extended double-under session produced no symptoms at all.

So either the exercises worked or I just needed to run the clock. Eight weeks is actually a fairly short time to fix a tennis-elbow class problem at my age so I will credit the stretches. I had to substitute rowing for running, do burpees without a jump, use bands with my pull-ups, and make a few other accommodations but otherwise CrossFit Saint Paul was fine. It helped that despite our extreme temperatures we didn’t run much in Minnesota’s January and February.

Interestingly something I learned in my back pain days applied here. Once I was pain free with usual activities, I found I had to induce mild to moderate symptoms and then stretch them out in order to improve. So I’d run a bit, stretch both hamstring and piriformis/hip extenders until symptoms were clear, then run a bit more. It’s an approach that’s consistent with a PNBC marketing/research document:

Many, if not most, of our patients initial periods of discomfort as they vigorously exercised a weak and stiff lumbar spine. This discomfort was not unexpected, but it was amazing how many patients had been advised to continuously decrease their activity levels and to let pain guide their activity level. Such patients become conditioned to avoid pain. This causes more deconditioning and more dependence on the health care system…

I remember that aching and controlled discomfort feeling from my 8y ago PNBC therapy. There’s a hard to describe difference between real pain and therapeutic discomfort. I wonder if it’s a general principle in healing many soft tissue injuries … (or, for that matter, fractures…)

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