Sciatica is a common problem I see with my patients, and presents itself in many different ways. There is the slight twinge in the butt when getting out of a car, bending over, or sitting too long. There is the numbness down the leg after standing 20-30 minutes. There is sharp pain when rolling over in bed. There is weakness or giving way of the leg when walking or running. There is a burning, radiating pain that goes down the leg randomly, not provoked by activity. There is the god awful excruciating, can’t walk without sharp pain that brings you to tears. And many others. Whatever the issue, it is still a major problem that hinders your performance and ability to live pain free.
Sciatica is not actually the diagnosis, but a symptom of the problem. It is a result of nerve impingement or crowding. The term sciatica refers to the sciatic nerve, which is made up of nerve roots that exit from your lumbar vertebrae of L4-S3. It runs through the pelvis under the piriformis muscle, but in a small percentage of the population, the nerve can pass through the piriformis. It is the longest and largest nerve in our body, and provides motor and sensory function to our lower legs.
Impingement can be caused in several areas, which is why it can be tricky to diagnose. Impingement usually occurs in one of two places: either at the exit of the vertebrae or at the piriformis. When the spine becomes too extended and/or the pelvis becomes rotated too far forward, increased tension and pressure is placed on the spinal nerves. This can cause an variety of symptoms, from numbness, tingling, weakness, sharp pain, shooting pain, deep aching pain, and heaviness. Symptoms can be constant, or triggered by certain positions or movement.
An MRI or an XRay can sometimes show this impingement, but imaging has been proven to be ineffective in diagnosing back pain. (read more about that here.) There are several reasons for this. First, radiographs are a snapshot, often taken in a laying down position when the spine is positioned differently than in standing or moving. Secondly, often pain symptoms don’t correlate with what is shown on the radiograph. Imaging doesn’t look at the clinical side of the patient; how do they move, how do they not move, what triggers the pain vs. relieves it? Is there muscle involvement, tightness, or imbalance? Is the spine unable to flex or rotate? Where is the restriction?
I have seen this on NUMEROUS accounts. I’ve had patients with a horrible MRI showing awful disc disease, bulging discs, and arthritis, but showing very little pain symptoms. I’ve also had clients with essentially clean MRIs, but can hardly walk due to pain. But yet, people take MRIs as an absolute, when really their issue is more biomechanical than it is degenerative.
What can a physical therapist do about it? First and foremost, you HAVE to restore range of motion. In a PT’s mind, impingement means restriction. There is something NOT moving; it could be the pelvis (or one side of the pelvis), could be the sacrum, could be one or two spinal segments, ribcage, or a combination of these things. Restrictions will not show up on a XRay or MRI. Restrictions will not be diagnosed by a physician or orthopedist. Medication, shots or surgery will not fix the underlying restriction. Even if your symptoms improve on their own, the restriction will not correct itself on it’s own.
What will fix the restriction? Proper strength training and stretching – under the supervision of someone who knows what they are doing; i.e. physical therapist, personal trainer, athletic trainer. While I like group fitness and self-exercise tapes and routines, when you have a restriction or painful area, you need to assure that you are doing appropriate exercises and stretches, and you are doing them correctly. Because if you want to get better, you need to make sure that what you doing is actually doing what you think it should be doing right?
Sometimes restrictions are too much for strength training alone to correct; you gotta bring in bigger guns. PTs like myself can perform manual therapy and repositioning techniques to aid in reducing restrictions. Noticed I didn’t say massage. If you want massage, you need a massage therapist, which can also be very helpful, but not the same thing. Manual therapy such as ribcage repositioning, pelvis repositioning and mobilizations are highly effective is improving restrictions to allow the body to restore range of motion and activate tight muscles. You can’t expect a muscle to activate if it’s stuck in a tight position, and sometimes your body needs that manual/neurological push to unlock itself.
I like to take an interdisciplinary approach to treating sciatica. I start with physical therapy and depending on the individual and their symptoms, like to involve massage therapy, sometimes acupuncture, and personal training. I think functional training is super important, and clients have seen very quick results with the combination of PT and training.
If you take the effort to fix yourself, you will have long term results and an overall much healthier life. Sure, you can take medication, or get shots, or even surgery to help improve this problem, but overtime will you have more problems if you don’t look at the underlying reason why you have the restriction in the first place. We have to take a deep look into your life and see what you are doing (or not doing) as far as your movement is concerned. Are you inactive? Do you sit a lot for work? Do you have poor sleep habits? Are you very active, but not very strong? Do you have other issues going on like shoulder pain, neck pain, knee pain? All of these things (and others!) are very important into giving you the best outcome for your life, and to assure that you remain on top of your game.
Are you experiencing back pain or sciatica symptoms? Learn how you can start healing here.