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Thread: Piriformis syndrome

  1. #1
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    Default Piriformis syndrome

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    Fellas, I would GREATLY appreciate your advice on this. My wife was diagnosed with Piriformis Syndrome last year. 2 months and $900 of PT brought relief for a couple months but no surprise the pain is back. Would you recommend the standard SS method/exercises for her or should I change something, add something, modify something? Thanks in advance and thanks for your motivation

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    Quote Originally Posted by Millerfarm View Post
    Fellas, I would GREATLY appreciate your advice on this. My wife was diagnosed with Piriformis Syndrome last year. 2 months and $900 of PT brought relief for a couple months but no surprise the pain is back. Would you recommend the standard SS method/exercises for her or should I change something, add something, modify something? Thanks in advance and thanks for your motivation
    I think you may be surprised to know that “piriformis syndrome” is an umbrella term that really doesn’t mean anything, which is supported by the fact that this PT was unable to assist with long lasting relief.

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    Quote Originally Posted by Will Morris View Post
    I think you may be surprised to know that “piriformis syndrome” is an umbrella term that really doesn’t mean anything, which is supported by the fact that this PT was unable to assist with long lasting relief.
    So what exactly does this umbrella term include? This diagnosis is actually pretty specific, unlike say....fibromyalgia The fact she didn’t get long term relief doesn’t prove anything. Soft tissue can be re-injured, muscle spasms can return even when effective treatments are utilized. I assume since you are giving medical advice that you are an MD. What is your specialty?

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    Quote Originally Posted by BostonFan9 View Post
    So what exactly does this umbrella term include? This diagnosis is actually pretty specific, unlike say....fibromyalgia The fact she didn’t get long term relief doesn’t prove anything. Soft tissue can be re-injured, muscle spasms can return even when effective treatments are utilized. I assume since you are giving medical advice that you are an MD. What is your specialty?
    Please point me to the “medical advice” I gave.

    That said, I do not have any obligation to tell you a damned thing about my credentials.

    You are completely wrong comparing piriformis syndrome, which by its very name is a “syndrome”, meaning a constellation of symptoms, to fibromyalgia. Fibromyalgia is a very specific diagnosis, with an internationally approved set of diagnostic criteria. Piriformis Syndrome is a bullshit diagnosis given by Physical Therapists when someone has radiating pain down the posterior thigh and it is not likely related to an impinged nerve root.
    Last edited by Will Morris; 08-21-2019 at 10:54 PM.

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    Wow, I didn’t say you were obligated to do anything. I asked a question. A bit of unnecessary hostility don’t you think? Sorry to ruffle your feathers miss. Surely someone of your intelligence could see the difference. And fibromyalgia is not a specific diagnosis. It is a relatively new diagnosis given when pretty much nothing else can explain the patients pain that often does not stay localized but seems to “travel” to different parts of the body. Sorry you have issue with the word “syndrome” in the diagnosis. But both you and I know we aren’t talking about a collection of diseases that aren’t correlated with each other. The verbiage of the diagnosis name doesn’t change the fact we are talking about abnormal functioning of a specific muscle effecting a specific nerve with an expected array of symptoms. Another thing, in most states PTs aren’t allowed to diagnose, the patients PTs see are referrals from MDs who show up for therapy already diagnosed. I’m not aware of a state where a pt can treat someone who walks into a clinic and get treated without an MD referral. I do know, however, that the “bullshit” diagnosis you have issue with was more than likely given by an MD and not a PT. Does a PT have the authority to change or challenge a diagnosis from an MD? But hell, what do I know, I’m only a neurologist who owns an interventional pain management clinic. I guess I’m also guilty of using the bullshit diagnosis of Piriformis Syndrome.

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    Quote Originally Posted by BostonFan9 View Post
    Wow, I didn’t say you were obligated to do anything. I asked a question. A bit of unnecessary hostility don’t you think? Sorry to ruffle your feathers miss. Surely someone of your intelligence could see the difference. And fibromyalgia is not a specific diagnosis. It is a relatively new diagnosis given when pretty much nothing else can explain the patients pain that often does not stay localized but seems to “travel” to different parts of the body. Sorry you have issue with the word “syndrome” in the diagnosis. But both you and I know we aren’t talking about a collection of diseases that aren’t correlated with each other. The verbiage of the diagnosis name doesn’t change the fact we are talking about abnormal functioning of a specific muscle effecting a specific nerve with an expected array of symptoms. Another thing, in most states PTs aren’t allowed to diagnose, the patients PTs see are referrals from MDs who show up for therapy already diagnosed. I’m not aware of a state where a pt can treat someone who walks into a clinic and get treated without an MD referral. I do know, however, that the “bullshit” diagnosis you have issue with was more than likely given by an MD and not a PT. Does a PT have the authority to change or challenge a diagnosis from an MD? But hell, what do I know, I’m only a neurologist who owns an interventional pain management clinic. I guess I’m also guilty of using the bullshit diagnosis of Piriformis Syndrome.
    The difference I was trying to point out between fibromyalgia and piriformis syndrome is that fibromyalgia has a set of internationally recognized diagnostic criteria. Piriformis syndrome does not have that. At best, piriformis syndrome is just like patellofemoral pain syndrome, greater trochanteric pain syndrome, and the like, where we are giving the patient’s symptoms a label, but we cannot be certain the true etiology of the pain. If nothing else, piriformis syndrome is essentially a diagnosis of exclusion, where the provider has assessed the sciatic nerve pain / deep gluteal pain is not coming from the lumbar spine. Hamstring Syndrome would also be a plausible assessment, but, yet, this is often overlooked.

    In the assessment of piriformis syndrome, pain with a piriformis stretch or a positive “sign of the buttock” is typically what is used, but those tests do not actually test for muscle dysfunction. They are simply pain provocation tests. You have the menu option to do more to assess the piriformis than other providers. You can’t compare your ability to diagnose or assess this to a GP/FP/IM/PA/NP. How many times has a patient been referred to you with a diagnosis from an intermediate provider and the diagnosis provided was way off base?

    Many states allow direct access for physical therapy without a referral from a MD/DO. The vast majority of patients referred to PT are going to have an umbrella diagnosis and the referral is going to say “evaluate and treat”, which, in my experience, the physicians are asking for a clarification of their original assessment.

    This is going to be much different for you. As a tertiary pain provider, you are the terminal provider for what you see in the clinic. At this point, the patient has likely already been through physical therapy. When referrals come from the GP/FP community, the diagnosis provided is the working hypothesis and a PT’s assessment is taken into account as a more specialized assessment.

    As far as the hostility, I apologize as I must have misinterpreted where you accused me of providing medical advice. Let’s assume this is, indeed, a case of sciatic nerve impingement originating at the piriformis. Let’s go further and say that this particular person is one of the approximately 30% of people where the piriformis is pierced by the sciatic nerve. Could we assume 2 months of physical therapy, augmented by a solid home exercise program, to achieve adaptive lengthening of the piriformis? Certainly, patient compliance may be an issue, but we have to make a big assumption to assume that.

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    Admittedly, I did not know the full extent, but currently only three states have an outright prohibition against a PT seeing someone without a referral. 27 states and the DC allow direct access with some minor limitation, and 20 states have complete, unimpeded direct access to PT services.

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    This is a weird thread. Where are the original posts?

    And I would guess that PTs see plenty of vague/nonspecific/catchall diagnoses from physicians who refer patients because they “need PT” and then give a diagnosis because the referral doesn’t happen without an ICD code.

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    Quote Originally Posted by jfsully View Post
    This is a weird thread. Where are the original posts?

    And I would guess that PTs see plenty of vague/nonspecific/catchall diagnoses from physicians who refer patients because they “need PT” and then give a diagnosis because the referral doesn’t happen without an ICD code.
    This is, in my apparently limited experience, extremely common, Dr. JFSully. But, with all fairness to Dr. BostonFan9, his experience is not an apples to apples comparison. His role as a tertiary pain management provider gives him a wide array of diagnostic tools that the typical Primary Care Provider does not have. While his diagnoses may be very specific, diagnoses coming to PT from PCPs tend to be vague and, many times, outright wrong. But, then again, they are sent to PT for an “evaluation and treatment” as very few physicians prescribe specific physical therapy interventions, and those that do have a very poor understanding of the literature regarding physical therapy treatments.

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    If I were able to be completely honest on a PT referral, they would all say something like “this guy is walking funny for no particular reason. Get him to walk better, or at least walk differently so it’s not bothering him.”

    That would be so much more satisfying than “astasia-abasia, low back pain, evaluate and treat.”

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