Sciatica is an intense, nagging pain that steals your sleep and makes everyday tasks like climbing stairs or driving an agonizing effort. The term is often used for any nerve pain in your lower back or leg, and it is one of the most common forms of nerve pain that we see and treat. Unfortunately, it is also well known for becoming a chronic, long-standing problem. The sooner you get the right diagnosis and treatment the better.
The Anatomy of your Sciatic nerve
The sciatic nerve “starts” in your lower back, with branches from 5 levels of your spine. These branches are from the nerves that exit between the last 2 vertebrae of your lumbar spine, or lower back, and first 3 of your sacrum. In anatomical terms, we call these levels L4 to S3. After the sciatic nerve is formed by these smaller branches, it runs through your buttock and exits the pelvis right next to the ischial tuberosity. A more common name for this tuberosity is your sitting bone. From here we can follow the nerve down the back of your thigh, underneath your hamstring muscles. The nerve splits into two branches, the common peroneal nerve and tibial nerve, when it reaches about two-thirds of the way to your knee.
The sciatic nerve is the longest and largest nerve in the human body, starting in your lower back through the buttocks and down each leg. It plays a crucial role in connecting your spinal cord with the muscles and skin of your legs, facilitating movement and sensation.
What does it do?
Nerves are like the wiring system in your body, carrying messages from your brain, down through your spinal cord and then along a whole network of nerves branching out all the way to your fingertips. This is how your brain controls everything from your heart rate to the muscles you use when you take a step. Other nerves carry messages back to your brain, with information like temperature, pressure and the position of your body parts. The bad news is, if anything happens to a nerve before it gets to its destination, like a pinched nerve, the message is interrupted which causes pain and dysfunction.
The Sciatic nerve is a mixed nerve, which means it has branches to muscles, skin and a joint. It innervates your hip joint, hamstring muscles and a part of adductor magnus which runs along your inner thigh. Lower branches of the Sciatic nerve also supply the skin over your foot, heel and the outer part of your lower leg.
I have a sciatic nerve pain… How did it happen?
Nerve pain occurs when there is compression (pressure) or irritation (friction) of one or more nerve branch. Nerves are most vulnerable at places where they travel through narrow spaces or where there isn’t a lot of soft tissue to protect them. Structures that can pinch a nerve are anywhere along the nerve’s path where it weaves through and between tissue like muscle, tendon, bone and ligaments.
Nerve irritation happens due to repetitive movement, in other words doing the same movement over and over again. As the nerve glides over muscles, tendons and bone, it will become irritated and inflamed. The nerve’s outer protective barrier gets damaged and causes swelling, which causes extra pressure. Scarring may form around the nerve, which in turn disrupts its normal glide over the surrounding structures.
Sciatic nerve compression or entrapment happens when the surrounding structures prevent the normal gliding movement of the nerve. An entrapment happens after you were in a cast, after surgery or even from scar tissue after a hamstring muscle tear. Another common cause of Sciatic nerve entrapment is piriformis syndrome, where the piriformis muscle in your hip pinches the Sciatic nerve. If any of these problems is left untreated for too long, it leads to nerve compression and long term damage.
In up to 90% of patients with Sciatica, the problem is caused by a herniated disc in their lower back, even if they don’t have back pain at the same time. The inflammation caused by a slipped disc can irritate the Sciatic nerve, or the disc physically compresses the nerve which leads to Sciatica symptoms.
Causes of Sciatica
- Lower back disc injury or slipped disc
- Pinched nerve in your lower back
- Piriformis syndrome
- Hip dislocation
- Scar tissue
- Spondylolisthesis
- Pregnancy
- Degenerative disc disease
How severe is my Sciatica?
Sciatica isn’t a problem that develops overnight. Instead, you will experience repeated attacks of discomfort that comes and goes. Over time, the discomfort gets more intense and turns into pain. Without treatment, you will find that these episodes of pain happen more often, last for longer periods until it eventually becomes your constant companion.
At first the pain feels more like discomfort, or stiffness in your buttock and thigh. It doesn’t really interfere with your life too much, but you will notice that you can’t sit for too long and walking long distances make the pain worse. If you ignore the stiffness, you notice that it becomes a deep, dull pain that is there most of the time. Rest gives you some relief, but never takes the pain away completely. With time, the deep, dull pain becomes more intense, and you may start noticing pins and needles or numbness. These symptoms usually start in your buttock and back of your thigh, and sometimes radiates to your calf or even foot.
Now the pain starts interfering with you life, as it starts to wake you up at night if you stay in the same position for too long. You can still find a comfortable position to fall asleep in, but the stiffness and pain will be worse in the morning. After you wake up it takes a while for the pain to ease, almost as if the nerve needs to “warm up”. Throughout the day your pain increases as you go about your daily activities until it becomes so severe that you have to stop and rest. You will start avoiding chores where you have to spend time standing or walking for more than a few minutes.
Don’t wait until the pain stops you – rather get a diagnosis and treatment for your sciatica before it starts stealing your sleep.
Diagnosis
Physiotherapy diagnosis
Our physiotherapists are experts at diagnosing and treating Sciatica. We follow a structured plan to diagnose and classify the severity of your nerve pain. We stress, screen and scan all the possibilities to get to the root cause of your problem. The road to recovery may seem long and difficult, but we will guide you through it.
We understand the physiological healing stages you need to go through, and custom-fit your treatment program. By knowing the extent of the problem we can guide you through a structured rehabilitation program to recover faster and safely return to the things you love doing.
X-rays
X-rays give us an indication of the integrity and alignment of joints in your spine, but nerves and muscles cannot be seen on these images. Therefore, X-rays are not very useful when diagnosing sciatica.
If your physiotherapist suspects a spinal problem that may be related to your symptoms, we can refer you for X-rays.
Diagnostic ultrasound
Diagnostic ultrasound can give us an indication of scar tissue or swelling around the nerve, but only in areas where the nerve is superficial i.e. close to the skin. This is not a very useful test when diagnosing sciatica, but your physiotherapist can refer your for ultrasound imaging if necessary.
MRI
Although an MRI cannot diagnose sciatica, it can be used to confirm or exclude the underlying cause of your sciatica. The majority of sciatica cases are due to lower back disc injuries, but simply confirming a disc injury won’t change the treatment plan.
Why is the pain not going away?
Whether your pain eventually goes away on its own or becomes chronic often depends on the underlying cause of your sciatica. One thing that all the causes have in common, though, is that you need to find the balance between rest and activity. You will notice that your pain gets worse if you do “too much” and then gets better with rest. Our goal with physiotherapy is to change what “too much” is.
For instance, you have unbearable pain after a day of shopping or browsing in a store. Our aim with physiotherapy treatment will not just be to get rid of the stiffness and muscle spasm that contribute your pain. We will also give you exercises to strengthen the muscles around your lower back and hip, so that your body doesn’t think that these normal activities are “too much”. If you are stronger you will be able to do more without flare-ups and, if you do have a flare-up, you will need less rest for the pain to get better.
Waiting too long to seek help
A big problem that we see with sciatica is that people wait until the pain is unbearable before they make an appointment. Some patients have pain when sitting or walking for months or even years before they come for physiotherapy treatment. Over time they realize that the pain becomes more intense and takes longer to go away. Eventually it never goes away, but stays there as a deep, dull, constant reminder that something is wrong.
Prolonged irritation of your sciatic nerve causes increased nerve sensitivity, muscle spasm in the surrounding areas, limited hip range of movement, numbness at the back of your thigh that spreads to your knee or calf and difficulty taking large steps.
Looking for a quick fix
Another big problem we see with sciatica is that patients shop around for quick fixes without finding the root cause of the problem. Medication is usually high on the list of things that promise relief from sciatica. Although there are medications available to help with pain management, these are like putting a plaster on a thorn. The pain feels better, but it only hides the actual problem. Other options out there that make promises to heal your sciatica include back braces, oils, herbal supplements, and even mattresses. The bad news is that there isn’t a one size fits all, “magic” fix for sciatica.
Incorrect diagnoses and treatment
If you do a search on sciatica, you will find thousands of suggestions and opinions on treatment. A lot of those options might sound good, but if you only treat the pain you will always be disappointed. Unfortunately, the root cause will still be there, and you will quickly realize that pain is only the sign of a deeper problem. The biggest problem we see with incorrect diagnosis and treatment is that patients are advised to stretch. A stretch will give you a tiny bit of relief for a short while because it relieves some of the muscle tension, but then the pain comes back with a vengeance. Nerves, especially when sensitized due to pain, do not respond well to stretches.
Problems we see when patients come to us with …
Muscle weakness
Nerves carry messages from your brain to muscles, so any pain will interfere with these messages. Your muscles can handle this interference for a short while, but if left untreated the muscle will start to waste away leading to noticeable muscle weakness. As mentioned before, your Sciatic nerve supplies many of the muscles in your leg. Therefore, the muscle weakness from persistent Sciatica can range from slight weakness in your hip to a drop foot.
Movement pattern compensation
If you have Sciatica, something simple like taking a step becomes excruciating. To avoid the pain, you will develop a limp or lean away from the sore leg to take your weight off of that side. In the short term, these compensations might give you some relief. However, as your Sciatica sticks around, these compensations become habits that don’t go away when the pain settles.
Unrelenting pain
In the early stages of Sciatica, the pain might only be an annoyance which you can easily avoid by sitting down or taking a nap. Unfortunately, if left untreated, the pain builds from annoying discomfort, to nagging ache and eventually constant, excruciating pain that doesn’t even ease with the strongest medication you can get your hands on.
Permanent nerve damage
Nerves “hold a grudge” and take much longer to heal than muscles or ligaments. If left untreated for too long, the Sciatic nerve can suffer permanent damage, increasing your risk for long-term nerve pain. You also run the risk of other nerve symptoms, like persistent pins and needles or numbness in your leg. That’s why it’s crucial to have your pain treated sooner rather than later.
Phases of rehabilitation
Phase 1 – Focus on pain relief
The early phase of Sciatica is characterized by pain. Even though you may also have some muscle tension or tightness, the overwhelming sensation that brings you to our door is pain.
Fortunately, physiotherapists have a variety of options to treat pain. In this stage of treatment, we use electrotherapy like ultrasound, TENS and interferential current to decrease pain by desensitizing the nerve. We also use techniques like dry needling and laser to promote healing and activate your body’s own defenses to relieve pain. Strapping or taping techniques are also used to support the area and, if necessary, avoid movements that irritate your Sciatic nerve.
This stage of treatment usually takes about two weeks to complete. At the end of this phase you should be sleeping better and have less pain getting up in the morning.
Phase 2 – Stiffness and pain
There will always be some overlap between phases of healing, but after your first 2 to 3 sessions, you will find that your pain is less prominent. Now the underlying stiffness will come to the surface.
While we still use many of the modalities from phase 1, we will start adding stronger techniques like myofascial release, joint mobilization and gentle nerve mobilization. Even though you feel tightness in your hip muscles and lower back, now is not the time for stretches and deep tissue massage. The nerve is still settling and healing, so we will start muscle activation and initial strengthening during this stage of treatment.
This treatment stage is usually from weeks 2 to 6. At the end of this phase, you should be able to walk and sit with little or no pain. Your pain should not wake you at night, and you should have minimal stiffness in the morning.
Phase 3 – Muscle tightness and strength
This phase usually starts at around week 6 after starting treatment. By now, you should be walking, sitting and driving without pain. If you have a very busy day or spend long hours at your computer, your Sciatica will still remind you that it’s there, but overall you should be back to all your normal activities.
Now, the focus shifts to long-term maintenance and conditioning. The muscle tension will still be ready and waiting to jump in if the nerve is irritated, so we need to make sure your muscles are strong enough to handle extra load. If the surrounding areas are strong, or conditioned, the muscles don’t have to go into spasm to protect you. Your prescribed exercises during this phase will increase the load on muscles to improve strength while maintaining mobility we worked on during the first 6 weeks of treatment.
During this stage, we will still be using many of the previous treatment techniques and modalities, but the intensity of treatment will increase while the frequency of sessions will decrease. Where we used gentle, superficial, “calming” techniques in the earlier stages of treatment, this phase will include deeper joint mobilization and myofascial release to desensitize the nerve. Nerve mobilization will also progress to techniques and exercises that add tension to the nerve.
How long will my Sciatica take to heal?
Healing and recovery belong together and usually overlap, but the goals and timelines are often very different. If a structure is injured, the timeline for healing is generally about 4-6 weeks. Recovery, on the other hand, is an ongoing process that starts at the same time as healing, but just because a structure has healed doesn’t mean there’s full recovery. Also, the presence of pain doesn’t always mean a structure needs to heal, so sometimes recovery is the main goal of treatment.
With physiotherapy treatment, your pain will be the first thing that goes away. But does that mean the recovery process is complete? Recovery is the process that gets you back to everything you were doing before your pain started. Depending on your injury, and specifically how long you’ve had the problem, recovery can last anywhere from 6 weeks to a year or more. Initially, we will see you twice a week until your pain settles. Thereafter, we will book sessions once a week for 3-4 weeks. In the last phase of treatment, we will need to see you once a month to monitor progress, adapt your exercises and identify any setbacks or complications as soon as possible.
Other treatment options
- GP– Over the counter medications usually don’t give much relief from nerve pain. A doctor will prescribe something that will help with symptom relief while your physiotherapist treats the root cause of the problem.
- Biokineticist – Training with a biokineticist is useful in the late phase of treatment, when your pain is under control and doesn’t interfere with your day to day activities.
- Chiropractic – About 90% of Sciatica cases are caused by a lower back disc injury. Strong techniques or adjustments to an already injured disc often causes more damage.
- Vitamin supplements – There is evidence that vitamin B12 can promote nerve healing.
- TENS – There are TENS units available that help with pain management. Although it won’t help your Sciatic nerve to heal, it can help to ease your pain while a medical professional treats the underlying cause.
- Sports massage – While massage is a useful tool for temporary pain relief, it won’t solve your problem.
- Ice and heat – These are useful modalities to use at home for pain management, under the guidance of your physiotherapist.
- Stretching – Even though your muscles feel tight, stretching will only make your sciatica worse in the early stages of healing.
- Acupuncture – This is another technique for temporary relief, but if you don’t treat the actual cause of your sciatica, the results of acupuncture on its own will leave you disappointed.
Is surgery an option?
Non-surgical management is always the first choice for Sciatica. Even though there’s no quick fix for your problem, physiotherapists are experts in treating your pain and guiding you through the rehabilitation process.
In very rare cases, surgery may be indicated for Sciatica. These cases can include nerve pain that doesn’t improve with non-surgical treatment after 3 months, worsening signs of nerve damage, or if there is an underlying structural problem like lumbar stenosis. Unfortunately, surgery is always damage control, so there are no guarantees that the operation will solve your problem. Sticking to your rehabilitation program is the best way to ensure a positive outcome after surgery.
What else could it be?
- Lower back disc injury
- Radiating pain from your lower back
- Pinched nerve in your lower back
- Piriformis syndrome
- Hip muscle pain
Also known as
- Sciatic nerve pain
- Pinched nerve
- Sciatic nerve compression
- Lumbar radiculopathy
