For a pain that starts in the butt
I don’t think of reasons to cut
If a spasm is found
To relax it I’m bound
And I can change your limp to a strut.
Most of the time if a person comes in with pain going into the buttock, radiating down the back of the leg, accompanied by numbness and tingling, or even weakness, I think about a bad disc pressing on the spinal cord, but I always ask the patient to take one finger and point to where the pain starts.
Every once in a while the patient will point to the buttock and deny any pain in the midline.
On those occasions, I sometimes find a hard triangular lump at the seat of the pain. I mash on that lump and ask if the patient’s pain going down the leg got worse, and, usually, the answer comes back “Yes.”
I diagnose piriformis syndrome this way.
The piriformis muscle runs across the buttock from the sacrum to the outside hip bone at the top of the thigh. The sciatic nerve runs under, or sometimes through the pirirformis, and spasm here can give a person sciatica, the pain and numbness running down the back of the leg. In such a case we say the sciatica comes from the piriformis syndrome, and by the thinnest of coincidences I learned a simple maneuver to relieve it.
During med school I went to the home of a physician to meet a friend giving piano lessons there. While I waited, the doctor, waxing loquacious from whiskey, told me how to apply my shoulder to the flexed knee in an osteopathic manipulative technique I would later learn to call “muscle energy.”
Over the years this tool has given me immense professional satisfaction. Starting with a limping patient in pain, performing a maneuver, and watching the patient sit up and walk without pain is an experience that leaves me grinning for the rest of the day.
It doesn’t happen very often.
Last week, I diagnosed piriformis syndrom three times, and I manipulated one patient. I taught one patient how to self manipulate, and for the third I prescribed a muscle relaxant.
As with anything else in medicine, success depends on proper patient selection. Penicillin works well for strep throat and syphilis but for little else; sciatica from a ruptured disc does not respond to muscle energy manipulation.
Sometimes a person might be too big or too fragile for me to manipulate. In those cases I turn to the more commonly used mode of treatment: muscle relaxants.
My favorite, generic metaxolone, costs more, hence the insurance companies rarely pay for it. All the others bring sedation to the point of sleep so often that, on the rare occasions when I prescribe them, I tell the patient not to operate anything more hazardous than a salad fork.
I know. Because of my back problems, I’ve tried them all.