Understanding Sciatica & How To Manage It

By Dr Richard Thompson, DC

5 Minute Read

Sciatica is one of the most commonly used terms that we hear in clinical practice when patients are presenting with low-back, buttock, thigh, and/or leg pain. In actuality, the term sciatica is essentially not a true diagnosis. The term sciatic means related to the sciatic nerve, which is the large nerve that stems off of the spinal cord nerve roots at the lower lumbar and sacral segments of the spine. The term ‘atica’ means pain. So sciatica simply means pain related to the sciatic nerve, and true sciatica is what is referred to as radicular pain. However, the vast majority of cases of pain in the lower limbs that are related to conditions in the low-back or pelvis are actually not due to problems related to the sciatic nerve but rather referred pain. We will dive into the differences between those two types of pain shortly, but what’s important to know when it comes to sciatica is understanding how it develops, sources of the sciatic pain, and what you can do to manage the condition to help achieve a quick and effective resolution of your pain.

The sciatic nerve is the thickest and longest nerve in the human body, so it’s no surprise that we hear about problems with it more often than with other major nerves in the body. The nerve begins as it exits off of the spinal cord from the L4 through the S3 spinal segments and travels down through a very complex pathway next to the tailbone (sacrum), posterior hip/buttock and down the back of the thigh. In that region alone, there are a number of physical structures that when experienced compromised function, can impose pressure on the sciatic nerve.

The most important (and sometimes most difficult) aspect from a clinical diagnostic perspective is determining the source of the sciatic nerve irritation or compression. When true sciatica is being experienced, many healthcare providers often lean towards an intervertebral disc herniation (the jelly-like cushion between the vertebrae) in the lower spine as the cause of the sciatic pain. However, it could be one or more of several other tissues or non-musculoskeletal causes of the sciatica instead of a disc injury. These could be problems in the ligament or muscles of the pelvis/buttock/posterior hip, infection in the vertebral column, and more seriously, lesions such as tumours in or around the spine. Fortunately most cases are not caused by the more serious, worrisome diseases such as cancer.

Sciatica can even be caused by chemical irritation of the nerve tissue from inflammation of the area, so even if the nerve isn’t being compressed or entrapped, inflammation from other injured tissues can cause the pain to travel down the sciatic pathway. When seeing a healthcare provider for assessment and diagnosis of your sciatica, asking questions like “where is the source of the sciatica” is helpful, as it helps you understand where the problem resides and what you need to focus on to help recover from the problem at home and at work.

If sciatica is caused by compression of the nerve from a herniated disc, patients can be experiencing pain down the leg, typically like a lightning bolt through the buttock, the back of the thigh, and into the calf and foot. This may or may not be accompanied with lower back pain. Some patients will experience numbness and tingling down the lower limb, and in severe cases, motor weakness to the foot, where it’s difficult to walk normally because the foot can’t be actively raised off the ground. Severe cases could also involve changes in pubic/genital area – difficulty with bowel or bladder control and/or numbness and tingling in the perineal region are signs of a condition called cauda equina syndrome, which is compression of the terminal nerves of the spinal cord and is considered a medical emergency. Patients experience any unusual changes in sensation in the genitalia and/or genitourinary/gastrointestinal control, they should seek care at the ER immediately.

Other common causes of true sciatica are what are referred to as entrapments (the nerve getting stuck to tissues it passes by or through). These entrapments can occur in a number of different tissues around the posterior hip, gluteal or hip rotator muscles, and/or hamstrings. The most often diagnosed condition where the sciatic nerve is entrapped in the buttock is called piriformis syndrome, where the piriformis, the largest muscle in the group of hip rotator muscles deep in the buttock, causes tension or compression on the sciatic nerve due to dysfunction or injury to the muscle. Anatomically, the sciatic nerve passes the piriformis either immediately above it, just below it, or in approximately 20% of the population, the nerve pierces directly through it. The goal of therapy in these cases is to relax the muscle tissue, eliminate inflammation caused by the entrapment, and ensure normal nerve mobility through the piriformis. Stretching and icing/heating at home can also be very helpful during your recovery from this condition.

Going back to the topic of radicular pain (true sciatica due to nerve compression, irritation or entrapment) versus referred pain, it’s important to understand the differences between the two. As you now know, radicular pain is when there is a direct physical or chemical (inflammation) impediment on the nerve, causing relatively significant pain down the pathway of the nerve. Referred pain relates to areas of injury in the body where you experience pain, but the pain is being caused from network of sensory nerves that also supply an injured structure higher up in the neural pathway. Now that sounds complicated, but let’s give you a well known example that will help simplify it. Almost all of us have experienced “brain freeze”, where we’ve eaten something cold like ice cream or a milk shake, and we get that overwhelming pain throughout our heads. That’s an example of referred pain, where in this case, our vagus nerve is reacting to the extreme cold temperatures in our mouths and sending pain signals elsewhere. In the lower back, hips and buttocks, we see the same type of referred pain. Muscle, fascia, ligaments, and joint capsules, when irritated or injured, can cause the nervous system to send pain signals down into the lower limbs. This pain tends to be more generalized and not lightning bolt-like, as in radicular pain, and typically centralized around a specific area of the limbs where that nerve tissue also innervates. It’s a bit more complicated than that, but for the purpose of this article, I think it helps us illustrate that not all pain that travels down the lower limbs is sciatica.

Although it’s critical for patients to obtain a specific, accurate diagnosis for your sciatica, there are some general rules of thumb that you can follow to help manage your symptoms and promote healing, even if you have yet to seek help from a healthcare provider.

First and foremost, assess what seems to aggravate the symptoms down the leg. Is it prolonged sitting? Bending forward? Laying flat on your back? Driving? Whatever it may be, whenever you are dealing with pain down the limbs, either radicular or referred, the primary goal is to promote ‘centralization’ of the symptoms, where limbs down the limbs disappear first and centralize towards the source in the buttock, pelvis or low-back. You can promote faster healing by reducing or avoiding positions of pain aggravation down the limb and maximize working and resting in positions of relief. Unfortunately this is challenging to do, which often leads to prolonged recovery times, but every little bit counts.

Early on when pain and immobility are significantly impacting your day to day, we need to think about pain, inflammation, and spasm control. This is best managed early with the application of ice in intervals on and off. Typically my recommendation for icing a low-back or buttock would be approximately 10-15 minutes of icing on and off as regularly as possible. There is no limit to how often you apply the ice – every time you apply it, you will get benefit. As pain becomes centralized and minimized, heat can be introduced to help now with tissue mobility and function. It’s also helpful to experiment with where you place the ice on your body, especially if you haven’t seen a healthcare professional yet to diagnose your condition. Referred or radicular pain traveling down the leg is almost always sourced to an injury in the low-back or buttock. If applying ice over the low-back doesn’t help reduce the pain in the limb, move it down over the respective buttock, or vice versa. As previously mentioned, the radicular or referred pain in the limb doesn’t always present with pain at the source.

If the above recommendations do not seem to be helping your lower limb pain after about 2-3 days, it’s best to seek help from a healthcare professional such as a chiropractor or physiotherapy who are trained at assessing and treating musculoskeletal conditions with conservative therapy options. In most cases, the clinical assessment can determine the source of the pain/injury and rarely are advanced diagnostic imaging (MRI, CT Scans) warranted. It’s important to not push through ongoing radicular/referred pain in the lower limbs as the longer the symptoms persist and/or progress to more prominent symptomatology, the longer the recovery time and greater the possibility of more invasive procedures, such as injections and/or surgeries. We’re here to help – if you are someone you know are struggling with sciatica-type pain, give us a call or send us an email. We can offer a number of treatment options and help you Get Back to Your Active Life today!