Diagnosing And Treating Wallet Sciatica

Symptoms Of Piriformis Syndrome

Wallet sciatica, better known as piriformis syndrome typically starts with pain in one buttock and from there the pain can extend down the back of the leg, toward the foot. The pain associated with piriformis syndrome can be severe like the referred pain of sciatica from other origins. The pain with wallet sciatica is considered to be due to the piriformis muscle compressing the sciatic nerve, which can result from simple activities such as sitting on a car seat, running or lunging… In some circumstances the pain may be severe enough that the individual tries to avoid putting pressure on the area, choosing to adopt a lopsided sitting approach with the sore buttock side tilted up as not to sit on the painful area.

Causes Of Wallet Sciatica

The exact cause/s of wallet sciatica are unknown, currently the main reasons suspected to be the cause of piriformis syndrome include:

• The piriformis muscle tightening, or piriformis muscle spasm resulting from irritation of the muscle itself, or irritation of a nearby structures such as the sacroiliac joint (SIJ), or hip joint.
• Swelling, or tightening of the piriformis muscle, due to injury such as direct blunt trauma to the area, or prolonged pressure such as sitting down with your wallet in your back pocket (hence the name, wallet sciatica).
• General trunk stability insufficiency and weakness of the deep hip stabilizing muscles.
• Muscle anomalies of the piriformis muscle and partial, or total anatomical nerve abnormalities.

A combination of any of the above, or simply one of the above in isolation can trigger wallet sciatica. The result being irritation to the sciatic nerve as it traverses adjacent to the piriformis muscle, ultimately causing pain, tingling, and/or numbness down the back of the leg, to the foot.

Diagnosing Wallet Sciatica

The diagnosis of wallet sciatica is controversial because it is a clinical diagnosis, one for which there is no agreed definitive test and no confirmatory investigations exist to support clinical findings. When arriving at a diagnosis of piriformis syndrome first spinal nerve root compression from disc bulges must be eliminated as a cause of the sciatic symptoms. The presence of sciatica in the absence of lumbosacral spinal pathology means piriformis syndrome may be a suspected cause of the radicular symptoms.
Due to it being a clinical diagnosis, diagnosis of wallet sciatica is made from the subjective history of the condition, coupled with the exclusion of any spinal involvement. Positive signs on clinical tests designed to cause stretch, or load to the piriformis muscle such as the Freiberg’s test and Pace test among others are frequently chosen objective special tests when considering a diagnosis of piriformis syndrome. Generally the use of MRI , CT, ultrasound, and other similar medical investigations are considered mainly useful in the excluding of conditions that could replicate wallet sciatica, not for confirming the diagnosis.

Treating Piriformis Syndrome

Once a diagnosis of piriformis syndrome has been established treatment will look to address the suspected underling reasons behind the onset of the symptoms, treatment may include any number of approaches.

• If pain is caused, or aggravated by sitting, or specific activities then alternatives need be offered in an attempt attempt to avoid positions that trigger/aggravate the pain in an attempt to allow symptoms to settle.
• If pain was triggered by blunt trauma to the area then rest, ice and even anti-inflammatory medication may be recommended in the early stages, implemented with the idea of reducing any swelling and bruising that is the cause of compression to the sciatic nerve.
• If the muscle deemed to be tight, or in spasm is thought to be causing compression around the nerve, then addressing this through massage techniques, dry needling, stretching, or foam rolling may be relevant and beneficial.
• If hip stability, weakness or some biomechanical trigger is considered to be the cause then the relevant approach would likely look to address this via orthotics, postural control and trunk strengthening exercises, targeting the areas of weaknesses in the hip, or pelvis regions.

Surgery, or injection with botulinum toxin (botox) are occasionally used as a last resort if symptoms aren’t settling with conservative treatment such as physiotherapy. The paralytic properties of botox injections are thought to relieve muscle tightness and spasm, thus reducing any sciatic nerve compression and helping minimize pain.

Prognosis And Prevention Of Wallet Sciatica

In the majority of cases wallet sciatica is effectively treated with physiotherapy, with short-term symptoms often resolving within only a few days. More longstanding piriformis syndrome symptoms may however take weeks to address.  Extended duration of symptoms can be due to any muscle strength, length and general biomechanics predisposing the individual to the complaint need be addressed prior to the condition settling. Until mobility, strength… has improved symptoms may well persist and given that these changes typically occur over weeks not days, some individuals will experience symptoms for many weeks. The good news is that botox, or surgery are rarely contemplated at treatment options as the vast majority of people manage to settle symptoms with non-invasive approaches.
Prevention of any recurrence of piriformis syndrome is generally through maintaining good muscle mobility and function in the hips, pelvis and lower back, as well as keeping ‘good form’ with loading activities known to stress the area such as lunging or running… As well as “form” during exercise being relevant, so too is sitting posture (form). Ideally aiming to avoid sitting in ways that cause direct pressure on the piriformis muscle and sciatica nerve pathway, as well as avoiding prolonged sitting without any movement. Oh yeah, and obviously keep that wallet out of your back pocket when driving, or sitting!

Disclaimer: Sydney Physio Clinic provides this information as an educational service and is not intended to serve as medical advice. Anyone seeking specific advice or assistance on Diagnosing And Treating Wallet Sciatica should consult his or her general practitioner, physiotherapist, sports medicine specialist, orthopedic surgeon or otherwise appropriately skilled practitioner.