If you have experienced lower back pain, you may have been told or thought you had sciatica. I find that term “sciatica” is similar to the term “migraine.” Not all bad headaches are migraines, and not all back or even leg pain is true sciatica. Let me elaborate
The sciatic nerve is the biggest and thickest nerve in your body. It gives nerve supply to almost all of the muscles and skin in the back side of the thigh and all of the lower leg. It forms from nerve roots exiting the spine at L4, L5, S1 through S3. Those nerves merge into one right around our piriformis muscle and travels as one huge nerve, through the sciatic notch as it exits the pelvis and down the posterior leg, before splitting right behind the knee.
If you have ever sat awkwardly, and had your leg fall asleep, you have compressed that sciatic notch or the piriformis, causing some temporary numbness. Congrats, you have sort of had sciatica before!
But sciatica is PAIN in the nerve tract; more specifically pain caused by irritation of the nerve. This irritation can come from only three things, heat (highly unlikely), pressure (mechanical), or chemistry (inflammation). Pressure would be a disc bulge or herniation, spinal stenosis, or spondylolysis pressure, something that causes the intervertebral foramen (IVF), the opening that the nerve passes through, to become narrowed or occluded. Spasm and tension in the piriformis muscle (which overlaps the sciatic nerve) can also cause sciatica.
Not all leg pain is true sciatica, and this is important when considering treatment. Trigger points in several hip and back muscles, or pain from the facet joints in the spine can create ‘psuedo-sciatica,’ leg pain that is like sciatica, but is not true irritation of the sciatic nerve. Nerve pain is fairly consistent in the adjectives one might use to describe it, qualitative terms that describe the nature of the pain, not the intensity. Both pseudo and true sciatica can cause immense amounts of pain. Descriptors such as numbness, tingling, burning, shocking, electric, lightning bolt are more nerve related, while terms such as heavy, dull, ache, throbbing, or cramping are likely not nerve related.
Trigger point referral pain is just as common if not more so, and can be extremely painful. It will require a different treatment than we go through here. This article should give you a better understanding as to the origin and nature of your pain.
Sciatic pain that is not easily reproduced or changed with mechanical testing, in my experience, is the best kind of pain that will respond to high strength anti-inflammatory medications. NSAIDs may be a common first line treatment (better than opiates) but in these cases where the nerve is clearly the culprit but pain is not affected much by mechanical testing or treatment, a stronger anti-inflammatory can be helpful. This is usually an oral steroid like prednisone that your medical doctor or nurse practitioner would have to order.
In these cases, sometime just unloading the back in this position is the best thing to do. It’s severely inflamed, chemically irritated, and letting it calm down is the first goal
Treatment must be guided towards the reason why someone has sciatica, but if we broadly describe it as compression (mechanical), or irritation (chemical), we can start to provide some relief right here and now. I’d advise all cases to start with my video on spine sparing strategies. The vast majority of sciatic cases are of spine origin.
Test what aggravates your LEG PAIN more; forwards or backward bending. With sciatica, the most distal symptoms matter most. As I like to say, “your leg may hurt, but you do not have leg pain, you have back pain that radiates to your leg.” If we can get the pain to return to the back, and go away in the leg, that is a fantastic first step.
In general, if you’re under 65 it’s forward bending, if you’re older it might be bending backwards. Just test it, and remember your results (how far you can bend before leg pain and how far down your leg symptoms travel. Then spend some time, 7-12 minutes, in a low level non weight bearing opposite position. Gradually, increase the amount of flexion/extension that you’re in over that time frame. After that walk around for a moment and re-test it. If it’s even slightly better, do it again. When this is effective, do the position 3-5 times a day.
In this we are going to slide the nerve back and forth in the most pain free way possible. Nerves, unlike muscles, do not stretch, they have to slide. When you extend you neck (look upwards) you put a little bit of slack in the entire nervous system, often allowing you to slide the nerve a bit more. Repeated reps and exposure to this can help immensely with sciatic pain. Play with this to see how it helps. We can do this seated, lying on our backs or lying on our sides. I actually think the side lying version goes home the best, and it transitions into our traction part well too. Again, you should test and re-test it to see if it’s going to be effective for you. Nerve flossing can seriously trigger pain, so go easy, don’t try to push it hard on a single rep, but try to gently ask for a tad more on each rep, doing up to 15-25 reps at a time
Lying on your side (affected leg up), try to stack your hips and shoulders close to 90degs, where your tall side lying. You’re going to bring the leg, knee straight, forwards. As you get nerve tension (you should feel it), stop and bring your head and shoulders backwards, creating cervical and thoracic extension. You should be able to bring your leg further. Then move your leg and head in rhythm with each other, sliding the nerve back and forth. You can generate more nerve tension in the leg by flexing the ankle upwards, towards the knee cap, and if you can rotate the leg downwards, pointing the knee cap towards the ground.