The Pyramidalis Muscle or also called Piriformis is a flat that is located on each side of the sacrum and extends to the upper part of the femur. Then it has functions related to the movement of the hip, so the appearance of Piriformis syndrome generates inconvenience and pain in this area.
It is also triangular in shape and lies in front of the lower part of the rectus abdominis muscle. Muscles begin to twitch ani. Muscle fibers are guided from the bottom up and intertwine in the white line of the abdomen. (Sometimes the muscle is absent) (SOURCE)
In the gluteal region, there are several muscles that are responsible for the mobility of the hip, thigh and knee. That is why they are important so that we can carry out activities of daily life, such as walking, standing, running and jumping.
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Where is the Pyramidalis muscle?
They are two long, but thin muscles that are located in the posterior part of the pelvis, specifically in the deep muscular plane, together with the obturator, Gemini, Gluteus minus and Quadratus muscles.
What are the origin and insertion of the Pyramidalis muscle?
The muscle fibers originate in the first three vertebrae of the sacrum, and then run horizontally toward the head of the femur, but first pass through the greater sciatic notch and then insert into the superior greater trochanter area.
What is the function of the Pyramidalis muscle?
It is a muscle that, due to its position in the gluteal area and its insertion in the femur, is responsible for contracting its fibers to produce an external rotation movement in the thigh, it also intervenes in the abduction of the hip, which consists in moving away the leg of the midline of the body.
Why does the Pyramidalis muscle hurt?
The most common injury to this muscle is the well-known Piriformis syndrome, which occurs when the tissue involves the sciatic nerve that originates in the lumbar spine and passes just below the pyramidal nerve. This compression of the sciatic nerve generates radicular pain in the buttock and in the back of the thigh, muscle weakness, tingling and limitation to move the affected leg.
When this type of pain is generated, it is necessary for the person to be evaluated by a doctor and by physical therapy, in order to reduce the associated symptoms and avoid sequelae due to damage to the sciatic nerve. In addition, the assessment is important since this syndrome is usually confused with sciatica, which is a different pathology that occurs due to compression of the nerve at its exit in the lumbar spine.
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How does Pyramidalis muscles work?
During a running cycle, the pyramidal muscle works in coordination with the rest of the hip muscles to:
- Stabilize the joint.
- Create a stable environment.
All of these are to use force at every step, seeking the maximum possible thrust.
Along with the Pyramidalis muscle, the gluteus medius, minimum and major also have an important stabilizing role. Therefore, when one of them is weak, it is the pyramidalis muscle, among others, the one that has to take on more tasks than it should. Thus generating an altered running cycle with the consequent end result, overload of the pyramidalis muscle and greater probabilities. Compression on the sciatic nerve.
Symptoms of Pyramidalis Syndrome
The pyramidalis syndrome presents with pain in the buttock. It can travel down the back of the thigh and calf and worsens with hip rotations. It does not normally present with weakness and paresthesia at the foot level. Sometimes it is also associated with tingling and burning sensation down the leg.
Causes of pyramidal sciatica
There are four reasons why the pyramidal muscle can cause sciatica.
- Due to traumas that occur either from falls or from repeated traumas such as those that occur to the Pyramidalis muscle when running, they can inflame the fascia (it is like a fabric that surrounds the Pyramidalis muscle). This inflammation causes the sciatic nerve to become irritated sciatica occurs
- Anatomical: Although at 80% of the cases the sciatic nerve passes below the pyramidal muscle in 20% of the cases it can cross it, when the muscle contracts when performing external rotation it clamps the nerve producing sciatica
- In people who, due to their work or the exercise they perform, present a hypertrophy of the pyramidal nerve, compression of the sciatic nerve may occur
- In patients who present pyramidal contractors due to trauma or fibrillar ruptures, pyramidal sciatica can occur
The diagnosis is eminently clinical. it is important to go to a specialist familiar with this pathology as it will be easier for them to distinguish sciatica:
- Caused by a Pyramidalis syndrome
- Caused by a herniated disc.
There are several maneuvers that allow us to know if a Pyramidalis is shortened or painful
- Direct palpation: The pyramidal muscle is an accessible muscle, when we press it, we will produce pain in the area.
- External rotation: Lying face up, patients with a shortened pyramidal will have their feet in external rotation. So, when we rotate both feet inwards we will cause pain in the affected pyramidal.
- Flexion and internal rotation: With the hip flexed to 90º we will adduct the hip accompanied by internal rotation. With this maneuver we seek to stretch the pyramidal muscle and reproduce the pain.
X-rays are not useful, ultrasound, although if it can provide information. But, it is difficult to perform due to the situation in which the Pyramidalis muscle is found. The test that provides the most information is the MRI. As, it can sometimes tell us that the Pyramidalis muscle is inflamed and hypertrophied. Sometimes it is also capable of detecting inflammation of the sciatic nerve.
MRI is also useful for differential diagnosis. As it allows us to rule out other origins of pain such as herniated discs or sacroiliac dysfunction
As we have been talking about, pyramidal sciatica usually goes unnoticed when it is confused with other pathologies, hence the importance of having the experience of a specialist in vertebral pathology.
Ischiogluteal bursitis: in this case the pain increases with the extension and palpation of the ischium, appears in people who spend a lot of time sitting.
Sacroiliac dysfunction: This time the pain is centered in the buttock and back of the thigh. Pelvic mobilization maneuvers are painful.
Pertrochanteric bursitis: The pain is centered on the lateral aspect of the leg, the pressure of the greater trochanter being very painful.
Radiculopathies: These are the classic citats. What occurs is the compression of a lumbar root due to a hernia or because the hole through which the lumbar root comes out is narrow
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Treatment of The Pyramidalis Syndrome
The treatment of Pyramidalis syndrome is eminently conservative. At first it is treated with anti-inflammatories, stretching and manual therapy by the physiotherapist. Conservative treatment is effective 79% of the time, according to Fishman. In the conservative treatment we must include not only visits to the physiotherapist.
But also daily stretching and postural hygiene to prevent the pyramidal from loading and correct biomechanical alterations such as:
In a second step we would have infiltrations with corticosteroids, Botox, or the performance of dry puncture or EPI
Finally, if all conservative treatments fail, the surgical option would be indicated. Surgery for sciatica caused by the pyramidal muscle consists of sectioning the pyramidal tendon, in this way we shorten the muscle and the sciatic is no longer compressed.
Surgery is not effective when the cause of sciatica is muscle contractures. Considering that surgery is only indicated for the worst cases, Benson et al. In 1999 obtained 11 excellent and 4 good results with a follow-up of 38 months. In contrast, Indrekvam et al. They obtained excellent results in 8 patients, good in 5 and bad in another 5 in 2002.
Sciatica caused by pyramidal syndrome:
It is a relatively frequent and little-known cause. Its diagnosis is made based on the symptoms and examination of the patients, where radiological tests are very important when reaching the definitive diagnosis and whose treatment is conservative, leaving the surgical option for the most painful cases that do not improve with any other treatment.
The Best Exercises For Pyramidalis Syndrome
To prevent this context, it is essential to strengthen the Pyramidalis muscle and the rest of the muscles involved, for which we propose 8 key exercises for the pyramidal syndrome based on what science says:
Start with the hip extension pattern, so necessary in the race.
- To correctly perform this exercise, lie supine (face up), bend your knees and keep your back neutral (maintaining its natural curvatures).
- You should not completely press the spine against the ground, as this will produce a compensation that can generate disc problems and instability in the trunk in the long run.
- From this position, the pelvis is raised upwards, to the maximum extension, without changing the neutrality of the trunk.
- Try to balance both hips and extend them in a coordinated way.
- You should exhale when you go up and inhale when you go down.
- You have different levels of intensity, add a rubber for greater difficulty and even do it on just one leg.
- It is very important to try to notice the muscle activation of the buttocks (buttocks area) and not the lumbar or hamstrings (back of the leg).
Another of the hip movement is abduction (separation of the leg from the body). The abductor muscles, including the gluteus medius, help control the so-called pelvic drop (pelvic drop during running). Therefore, your training is the key when it comes to stabilizing the pyramidal area.
Carrying out this exercise is simple, but you shouldn’t trust yourself because depending on the attention you pay for it, you will make it more or less effective.
- Lie on your side (on your side), bend both knees and bring them forward.
- From here, the movement must be performed only with the hip, separating the knee from above.
- Each person will have a certain range of motion.
- You will be able to know yours the moment you notice how the pelvis moves backwards, which will indicate how far you can go.
- Place your hand on top of the glute to feel its activation.
- Perform the indicated repetitions in a slow and controlled manner.
This is a well-known exercise, but always located in the oblique abdominal muscle training section. What is unknown is that it is a great activator of the gluteus medius.
Carrying out this exercise is simple, but you shouldn’t trust yourself because depending on the attention you pay to it, you will make it more or less effective.
- Lie on your side (on your side).
- Bend both knees and bring them forward.
- From here, the movement must be performed only with the hip, separating the knee from above.
- Get into lateral decubitus (side) and support one leg extended over the other.
- The exercise consists of lifting the body and maintaining only the support of the foot located below, the elbow and the forearm.
- Try to keep your body as aligned as possible, don’t forget your neck and head.
For this exercise you can progress or return in difficulty. To make it more difficult, lift one leg, the one at the top. And to make it easier, if the first position is very difficult, put both knees on the ground.
Internal Rotation With Rubber
Internal rotation is usually one of the most limited hip movements in runners. You need the help of a rubber band to be able to perform this exercise.
- Lie prone (face down), and stand near an area where you can hook the rubber.
- Tie it to the ankle of the leg that is farthest from the hitch and try, with the knee bent, to bring the foot out.
- When you move it in this direction you are performing the internal rotation of the hip.
- Don’t forget to keep your back neutral, respecting its natural curvatures.
We come to one of the most used exercises for the lower body, the squat. This should not be missing in the planning of any corridor.
- Start by doing it unilaterally, that is, on one leg. We recommend a progression, start with a support and short range of motion.
- Then leave the support to make it more complicated, since this will be more unstable.
- In order to continue evolving, we recommend that you add a rubber, trying to keep your knees from going inward at any time.
- To be able to reach the last levels, add a load, you can achieve it with a barbell or with a simple dumbbell or disc.
Go Down Step
This exercise is a progression of the previous one.
- Get on a step to be able to find more range of movement in each repetition. In this case it is very important that you keep both hips aligned.
- Do not move your body to either side.
- You must check that your knee does not go inward (knee valgus).