Piriformis Test

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Definition/Description

The Piriformis test is a lower limb provocation test to evaluate the impact of the piriformis muscle on the sciatic nerve. 

Clinically Relevant Anatomy

Piriformis is a flat muscle and is one of the hip lateral rotators. The origin is on the facies pelvina (anterior side) of the Os sacrum and has a insertion at the superior aspect of the trochanter major of the femur. The piriformis muscle is running over the top of the sciatic nerve. This muscle has the function of external rotation, abduction and extension in the hip and it is also important to stabilize the joint of the hip. And is innervate by the direct branches from the sacral plexus (L5-S2). 

Sciatic nerve or also named as N. Ishiadicus ,passes behind the hip joint to the muscles lying underneath. Above the knee joint, the sciatic nerve splits into two branches: N. Tibialis and the N. Fibularis communis. The sciatic nerve passes over or under the piriformis muscle but it is also possible that the sciatic nerve passes, partially or whole, trough the piriformis muscle. This depends from person to person.

Purpose

The piriformis test is used to screen the piriformis muscle and to detect tightness of the muscle or other discomforts of the sciatic nerve as it passes through or under the Piriformis muscle. Because this is a muscle and neurological test.

Technique

The Piriformis test can be performed in two methods:

1. Piriformis test in side-lying position: For performing the test, the patient is positioned in side-lying on the unaffected side. The symptomatic leg is positioned in 60 to 90 degrees of flexion in the hip and 90 degrees flexion in the knee joint. The patient should be lying with the face directed towards the examiner, The examiner’s hand is placed on the pelvis to stabilize it, The other hand is placed on the lateral side of the knee. The examiner gives hand pressure on the lateral side of the knee and tries to stretch the part as far as possible. The examiner performs a horizontal adduction while putting pressure on the knee in the direction of the table. During the stretch the patient may feel pain or discomfort.This test is also named as the FAIR test (Flexion Adduction and Internal Rotation).
2. Seated Piriformis Test: The piriformis test can also be examined in seated position on the chair with back upright and feet resting on the ground. The test is performed by crossing the affected leg and placing the ankle of the affected leg on the unaffected knee. One hand of the examiner is at the ankle to stabilize the part while the other hand is placed on the lateral side of the knee. The patient is then asked to bend forwards to feel the stretch in the gluteal region or the examiner pulls the knee towards the chest.

Results of the test

The patient may complain of pain in the piriformis muscle region or the gluteal region, The pain may increase suddenly and there could be pain also in the posterior of thigh. This indicates that the pain is because of the piriformis muscle tightness and the sciatic nerve is not directly involved by the lumbar disc herniation. There could be pain in the buttock and throughout the course of sciatic nerve that is posterior part of thigh and leg then this indicates that the sciatic nerve has become pinched by the piriformis muscle. The positive result of the test indicates Piriformis syndrome. Although the pain could be because of both piriformis muscle and lumbar disc herniation which can be found by the Straight Leg Raising Test. The Freiburg sign also stretches the piriformis muscle where in supine lying position, the hip is passively medially rotated and extended.There is burning pain felt in the gluteal region and also throughout the course of the sciatic nerve signalling that the sciatic nerve has got irritated by the pinching of piriformis muscle. This also indicates of Piriformis syndrome. In this syndrome, we speak of pain or numbness in the buttock and posterior thigh with occasional radiation into the foot. Another possible cause for the clamping of the sciatic nerve are trigger points in the piriformis muscle.

Key Research

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A study was performed by Fishman et al. that determine the sensitivity and specificity of the piriformis test.

Sensitivity = .88²     -LR = .14

Specificity = .83²    +LR = 5.2

Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

1. Flynn, T, Cleland, J, Whitman, J. Users' Guide to the Musculoskeletal Examination. (2008) pg 238
2. Fishman, L, Dombi, G, Michaelson, C, Ringel, S. Piriformis syndrome: Diagnosis, treatment and outcome- a 10 year study. Arch Phys Med Rehabil 2002; 83:295-301.
3. Fishman, L, Zybert, P. Electrophysiologic evidence of piriformis syndrome. Arch Phys Med Rehabil 1992; 73:359-364.
4. Prentice, W.E. (2003) Arnheim's principles of athletic training: A competency based approach. 11th edition. McGraw-Hill Higher Education, New York.
5. David Magee. (2002) Orthopedic Physical Assessment. 2002. 4th edition. Published by WB Suanders.
6. ↑ VENU AKUTHOTA & STANLEY A. HERRING (Editors), 2009, Nerve and vascular injuries in sports medicine, Springer, New York, 203p.
7. ↑ SANDRA J. SHULTZ & PEGGY A. HOUGLUM & DAVID H. PERRIN, Third edition 2010, Examination of musculoskeletal injuries, Human Kinetics, Leeds, 698p.
8. ↑ Londers J, Van Melkebeek J. Hip arthroscopy: outcome and patient satisfaction after 5 to 10 years. Acta Orthop Belg. 2OO7;73(4): 478-83
9. ↑ SCHUNCKE M, SCHULTE E, SCHUMACHER U, VOLL M, WESKER K. Derde oplage 2008, Anatomische atlas Prometheus algemene anatomie en bewegingsapparaat, Bohn Stafleu van Loghum, Houten, p543
10. ↑ CURTIS W. SLIPMAN, DERBY R, FREDERICK A. SIMEONE & TOM G, 2008, Interventional Spine: An algorithmic approach, Saunders, Philadelphia, 1454p.
11. ↑ M. Lynn Palmer & Marcia E. EPLER, Second edition 1998, Fundamentals of Musculoskeletal Assessment Techniques,Lippincott Williams & Wilkins ,432p