I am going to come right out and say it without a sugar-coated intro- more often than not, "sciatica" is what your medical professional tells you you have when they are too distracted, busy, or unskilled to provide you with an accurate diagnosis. Patients plop down on my table and announce "I have sciatica" as if they have acquired it like the common cold. Whenever this happens, I can feel the red wisp of annoyance start to travel through me. Not because my patients are being difficult, but because they have been grossly misinformed. We assume as medical practitioners that an accurate description of a patient's symptoms is somehow beyond them. We tell them they have sciatica because it is easier than taking the time to describe how strength, joint integrity, and soft tissue restriction may be causing a complex cascade of events that gives them pain. We prescribe them pills. We give them vague suggestions to lose weight, to improve their posture, and to avoid aggravating activities without any real direction. Anything to get them out of our office quickly and somewhat satisfied.
You have sciatica sir. Next please.
Sciatica has become the medical equivalent of saying "pain somewhere below the belly button". Imaging a scenario in which you are experiencing knee pain and schedule an appointment with your orthopedist. You cough up a hefty copay, spend the majority of your afternoon in the waiting room, and then your doctor waltzes in to poke at you a few times and announce "your knee has been hurting because you have knee pain".
How pissed would you be?
Yet when the diagnosis is a bit fancier and more medical sounding we accept it without hesitation. Sciatica. It's so sexy and mysterious, how could we possible question it?
Ask questions my friends. Not only because Knowledge is Power, but because knowledge leads you closer to staying off of pain meds, resuming your favorite hobbies, and finding a successful treatment plan. Although they say that "any question is a good question" we all know that some are undoubtedly better than others. So which questions should you ask?
What IS sciatica?
What does sciatica actually mean? First, it is important to understand that sciatica is not a diagnosis- it is a broad, umbrella description of symptoms that one may experience when their sciatic nerve becomes irritated. These symptoms nearly always occur on one side of the body, or are worse on one side than the other. They can include: radiating pain down the back or outside of the leg, a feeling of numbness and/or tingling in the leg or foot, weakness in the effected leg, pain with standing or walking, and pain with prolonged sitting. Symptoms of sciatica may or may not be accompanied by low back pain. In severe cases, loss of bowel and bladder control may occur.
What causes sciatica?
If this question popped into your head, GOOD FOR YOU. Why did your sciatic nerve become irritated in the first place? This can occur for a number of reasons, such as:
- Compression or chemical irritation of the nerve. The sciatic nerve can become compressed as it exits your spine, specifically between L4 and S3. A herniated disc, an unstable spinal segment, a bone spur, or poor postural habits can all compress or irritate the nerve roots which comprise the sciatic nerve.
- Myofascial guarding. The sciatic nerve can become compressed by the muscles that it travels near, under, and sometimes through. Muscle injury or stiffness in the quadratus lumborum, deep hip rotators, the infamous piriformis, or the lateral hamstring are common culprits.
- Prolonged sitting. Sitting for long periods of time can compress the sciatic nerve at the ischial tuberosity (AKA "sit bone") causing an acute injury to the nerve
- Poor movement patterns. This can include running form, walking form, or even the way that you may prefer to stand. Have you ever noticed that it just feels better to lean on a specific foot when you are having a conversation? Do you like to turn one foot out when standing in line, but not the other? Do you prefer to sleep on one side? All of these patterns can contribute to bodily asymmetries which change the stretch or compression on one side of your body.
- Weak core or hip muscles. The muscles which stabilize your pelvis and lumbar spine also protect the sciatic nerve by maintaining a neutral length without un-necessary stretch, compression, or twisting. Weakness in these stabilizing muscles can predispose you to injury with repetitive or sustained activity like standing, biking, running, or walking.
- Neural tension. Nerves need to slide and glide throughout your body in order to be healthy, happy, and well functioning. If nerves become bound down, adhered, or tethered at any point along their path we call this neural tension. Neural tension can eventually feel like general stiffness, fatigue, or ache in one limb. It can also give strength and sensation loss of the muscles and skin that the nerve innervates.
Why Do I have sciatica?
The next question you should be asking is this; specifically, what unique factors are happening in your body that are leading to irritation of your sciatic nerve? And why your left side verses your right, or visa versa? Bodily impairment and pain is never random. It is never a coin toss. There is always a reason one body part hurts verses another and especially why one side hurts. Having a general idea or theory is essential to a full recovery.
A physical therapist is educated to evaluate your strength, range of motion, and movement patterns in order to help you determine the best treatment AND root cause of your injury. Repeat: root cause or your injury. The analogy is as follows- if you suffer a deep cut to a major artery you will want to apply pressure to slow the loss of blood (treatment) but will need to close the wound to solve the issue (root cause). You wouldn't just go about your life tying and re-tying tourniquets about your nearly severed limb.
A physician will likely send you to a physical therapist anyway, so why not save yourself some extra time and an extra copay? In Tennessee, you can come directly to a physical therapist without a doctor's referral thanks to Direct Access law.
This is not to poo-poo the value of immediate symptom reduction. There are circumstances where medication may be completely appropriate. You have leg pain and are steadily getting better with physical therapy, but still need to go to work, raise your kids, and mow the lawn at some point this weekend? Yeah, I get that. There is no need to be a martyr all day every day. Sometimes pain medication helps you do what you need to do while you find a more long term solution.
What can I do to treat sciatica without surgery or pain meds?
Symptoms of sciatic nerve pain can be very effectively treated with manual therapy and specific strengthening and stretching exercises. The specific exercises will depend on your unique posture, strength, mobility, and situation. However most programs tend to include:
- core strengthening
- hip strengthening
- joint mobility work
- neural gliding exercises
- soft tissue mobilization
- specific stretching exercises
- activity modification
Surgery is very, very rarely indicated for symptoms of sciatic nerve irritation. I, for one, will avoid any surgery at any reasonable cost. That being said, if you are having loss of bowel and bladder control that is related to your leg pain, this indicates that compression to the nerve root is severe. In this case, your doctor will be able to guide you towards an appropriate course of action.
So faithful readers, understand that you do not have to live with pain. Understand that the diagnosis of "sciatica" is not an irreversible epidemic that you have no control over. Ask questions, get answers and Live Well. Move Well. Be Well.
Thanks to my editors, you know who you are :)
Until next time,