As a patient said to me this week, ‘My mother-in-law called my back pain some old name … err … sciatica … that’s it.’ Patients regularly tell me they have sciatica. Sometimes they are correct and sometimes it is no such thing. So what is it?
Where is it?
Whenever a patient tells me they have ‘sciatica’ I always request that they point to the pain. As a therapist it is sometimes a little comical where people point to. I hear that Aunt Rosemary told them, ‘Oh yes, that’s sciatica. I had that when I was 31. I remember the day because I had just pruned the roses. They were red you know … …’
Anyway.
The simplest definition of sciatic pain is pain radiating down one or both legs, usually down the back of the bum, the thigh and into the calf, and in some cases other parts of the leg. In many cases of sciatica, although the pain is caused by pressure on the sciatic nerve in the back, there is little or no pain in the back itself.
What is the sciatic nerve?
Your sciatic nerve is actually not a nerve but a bundle of nerves. Every vertebral joint of your spine has nerves that exit it. So you may have heard someone refer to their ‘L5 nerve’. L5 describes the nerve that exits just below the fifth lumbar vertebra. Your C6 nerve in your neck exits your sixth cervical vertebra and your T10 nerve is the nerve that exits your tenth thoracic vertebra. Get it?
So … Your sciatic nerve is not one nerve but a bundle of nerves. A bunch of lumbar and sacral nerves are bundled together to pass through your hip and bum and into your leg. Then as the bundle traverses down your leg, individual nerves branch off and supply goodies to all sorts of structures throughout your leg. If you are an electrician you will know exactly what I am talking about. You bundle 10 wires together that all have to go in the same direction, wrap them in conduit and then at the other end you separate them to supply power to different jobs. Sciatic nerve bundle is one of these.
Why does it give pain?
Nerves are designed to carry information. They are super sensitive and carefully protected in the body. It is no coincidence that bundles of very sensitive nerves travel through the deepest and most protected recesses in the body to try to protect them. Wherever nerve bundles are close to the surface you have a protective response for them, it’s called being ticklish! Bundles of nerves are closer to the surface around your neck, under your arms, in your groin and to a lesser extent behind your knees. So you can see what I mean. You naturally guard these areas.
When pressure is applied to your sciatic nerve bundle you will get pain and other symptoms, not necessarily at the point of pressure but anywhere along the path of the nerves. The pressure on the nerve bundle may be in the back or bum, but because these nerves run all the way to your foot, your symptoms might be in your foot or leg!
Pain is the most compelling symptom but remember nerves provide information regarding touch, temperature, pressure and much more so pressure on a nerve will normally give not only pain but numbness, burning or cold or tingling and so on.
There are many types of sciatica.
Like many medical terms, especially popular ones, one word can describe many conditions. Sciatica is no different. Pain arising from any nerve compression in or around the lower back that results in leg pain is generally called sciatica. But there are two main variations.
a. Pressure from a muscle.
The first type is where the whole bundle of nerve is compressed. As you can imagine, when you bundle eight or more individual nerves together you end up with quite a thick cord. This thick cord made up of lumbar and sacral nerves exits your spine and has to literally weave under muscle and over bone through your hip/backside area before it reaches your leg. Now there is a number of ways this thick bundle can be compressed but without getting technical with the variations, the most common occurrence is due to the piriformis muscle (see the diagram). The bundle of nerves has to pass between piriformis and bone. If the piriformis muscle is very tight it will literally squash the nerve bundle against the bone which of course has no give in it at all.
This type of sciatic pain presents as pain in the bum, back of the thigh skipping the knee and extending to the back of the calf. Treatment consisting of Myofascial manipulation to the piriformis, stretching exercises and heat to relax and ease the piriformis muscle are typically very effective. Often this complaint can be fixed permanently in a handful of treatments.
b. Pressure from disc or inflammation.
The second major category of sciatica is when the pressure on the nerve is caused by a disc or inflammation. In this scenario the concept is the same but the symptom is different.
Remember that I said that the sciatic nerve is not one nerve but a bundle of nerves. Well the first example above describes when the whole bundle is compressed. The other scenario is when just one individual nerve out of that bundle is compressed. So lets take L5 as an example. The L5 nerve exits the spine at the fifth lumbar vertebrae (see diagram). It then joins the other nerves and travels with them along the sciatic path before finally supplying sensation and feedback to the outside of your calf in particular. So if there is pressure on just this one nerve, rather than the bundle it will still cause pain in the leg but not the whole bum, thigh and calf as described above. It will only cause pain where that one nerve goes. In this case the outside of the calf.
Often I will see a patient with terrible pain in the outside of their lower leg, with no back pain whatsoever. Very often this has been misdiagnosed as some kind of lower leg injury, but in many cases the culprit is L5.
L5 and any other vertebral nerve for that matter can be compressed very close to the spine. Where nerves exit the spine they are at their most vulnerable. Even changes in hydraulic (fluid) pressure near the spine will cause symptoms. In most cases like this, the patient has inflammation present around the disc and this is placing pressure on the nerve as it exits the spine. The solution? Relieve the inflammation and you will relieve the pressure and the pain.
What treatment should I get?
It is very important to get sciatic pain properly assessed by a professional. If your pain is due to piriformis, anti-inflammatory techniques won’t work but deep manipulation will work famously. However if your pain is due to inflammation around the discs, deep manipulation will make it worse!
See a therapist you trust. In my experience most therapists worth their salt should be able to resolve sciatic pain in 2-4 treatments assuming your cooperation with corrective exercises. If the pain is due to inflammation around a disc the process will take longer but you will definitely see improvement inside the three treatments. If you are not seeing change in three treatments then get a second opinion.
My friend had to get surgery to fix their sciatica?
Yes. In some cases the disc is so damaged that it is pressing directly on the nerve and there is no solution but to surgically remove that part of the disc. When this is the case back surgery is very successful. BUT … do not decide you need surgery just because you have had the pain for a long time. The ONLY scenario where surgery is indicated is when the pain is 24/7 for six weeks or more. This means that for at least six weeks at no point at any time of the day or night will the pain lessen or move, and secondly the disc injury can be clearly seen on scans.
I have seen cases where a patient has had 50 sessions with a therapist only to find that three sessions with me has fixed the sciatica permanently. The previous therapist had simply assessed the cause of the sciatica incorrectly. I have also seen cases where disc injury was clearly seen on scans and yet conservative treatment resolved the pain.
So in short, if your sciatic pain has not resolved inside a few weeks, get it assessed. Always seek conservative treatment from a Myotherapist or similar before jumping to conclusions and bear in mind that Aunty Rosemary’s diagnosis may be totally wrong!
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Have a great day,
Tim
