We often see patients who have been given the diagnosis of sciatica by their GP and indeed report pain or other symptoms down the back of one or both legs. This may well be sciatica but that is not a true diagnosis. It simply means the sciatic nerve is, for some reason inflamed and therefore symptomatic. A true diagnosis is finding out what is aggravating the nerve in the first place. Only then can any intervention be targeted and effective.
The Sciatic Nerve
The sciatic nerve is the largest in the body. It starts from the small nerve roots in the lower or lumbar spine which join together to form the thick, rope like sciatic nerve. It then travels through the buttock and down the back of the leg to the knee. Here it branches into smaller nerves which go to different areas of the lower leg and foot.
For a nerve to function properly the chemicals and messages within it must be able to travel freely along it in both directions. This means the nerve itself must be able to stretch and slide within the tissues it passes through as we move. If it is pinched, irritated or stuck then the flow of these chemicals is interrupted and the nerve will start producing symptoms.
This can be one or a combination of pain, tingling, numbness, coldness or heat. Other more bizarre sensations may be felt such as crawling ants or hot oil running down the leg.
Causes of Sciatica.
As we have said the restriction in the nerve may be anywhere along its length from the spine (more usual) to the knee.
Nerve roots
Between every vertebra in our spine there is a small hole or foramen and through these the small nerve roots, branching from the spinal cord emerge. They lie near the spinal discs and joints and if there is any pathology in the spine at this point such as arthritis in the joints or an enlarged or bulging disc then the nerve can be restricted and cause problems.
Later along its length the nerve passes through other structures where a lack of space or movement may affect it- in the buttock (through or near the piriformis muscle), between the hamstring muscles and into the knee joint.
Patients often report points of particular pain at more than one of these sites.
Unfortunately when a nerve is restricted it becomes more sensitive, irritable and also swells so is more likely to become symptomatic at other points. This may result in a double or triple crush injury i.e. pain at 2 or 3 sites.
Spinal Discs
Probably one of the most common causes of sciatica is a disc problem. Our discs are shock absorbing, flexible structures between our vertebrae. Persistent pressure on them especially in a bent or flexed position i.e. leaning forward or sitting, causes the inner contents of the disc to move and push against the outer layer which may become deformed or stretched.. This can be very painful in itself but when a nerve root is touched then the nerve (neural) symptoms can be triggered. I.e. the sciatica.
So treating the disc problem is as important in the long run as the sciatic pain if we are to affect any long term solutions.
Spinal joints (facets)
Each vertebra is joined to the next one above and below by small joints either side called facets. These act as the same way as the major joints such as knees and shoulders. They can become inflamed with wear and tear, arthritis and injuries and subsequently enlarge and even grow extra spurs and bumps. This can then press on the nerve roots and irritate them.
So a completely different cause of sciatica, often found in an older age group than disc problems, and requiring a completely different treatment approach.
Piriformis muscle
Many people have heard of this deep buttock muscle probably as it can be enormously painful to press and palpate.
Unless it is very tight this muscle is not usually the cause of the sciatica but is often a point of great pain as the sciatic nerve passes very close or through the muscle. Once the nerve is enlarged and irritated it may not move freely through the piriformis muscle becoming stuck and irritated and causing local pain and tension in the buttock.
Hamstrings.
Like the piriformis the hamstring muscle is very involved with the sciatic nerve and runs alongside it down the back of the thigh.
A hamstring injury or significant tightness may affect the sciatic nerve and its ability to move and stretch.
As with the piriformis muscle it may just exacerbate an already sensitive nerve and produce another area of pain.
Physiotherapy Treatment
As well as treating the cause of the sciatica we do have to treat the issues within the sciatic nerve itself. Physiotherapy treatment helps it stretch and move freely within all the structures it passes through. Acupuncture, soft tissue and joint mobilisations are often used.
As you can see by the explanation of sciatica it is not going to be managed with a uniform treatment approach. Physiotherapists are experts in assessing what structures are the true culprits and dealing with them.
However, nerve pain is one of the most unpleasant and debilitating kinds of pain especially in a nerve as large and long as the sciatic nerve. Patients may come to see us in severe, sickening and debilitating pain. They are unable to sit or rest or get ANY relief from the symptoms. Sometimes they are most comfortable whilst walking and end up walking day and night to avoid the most severe pain.
Our initial aim in these circumstances is not try to diagnose the cause of the sciatica -the patient is often in far too much pain to be examined anyway.
So pain relief is the initial goal-we often use acupuncture, supportive taping, gentle mobilisation (if tolerated) and lots of advice and tips on how to reduce the pressure on the nerve and spine.
Occasionally, if the symptoms are severe and unremitting and really disturbing a patient’s sleep we recommend a discussion with the GP regarding specialist neuropathic painkillers which can be much more effective for this type of pain than standard painkillers. Often just getting some sleep can get someone’s pain relief started.
Once the pain has reduced we look at more long term treatment and management of the problem-to resolve this episode of sciatica and also reduce the chances of it returning.
This will include specialist exercises to mobilise the nerve and to regain the strength in muscles affected by pain and non-use. Plus specific mobilising techniques to spinal joints and discs to address the stiffness or restrictions.
At the end of your treatment programme we expect your symptoms to have resolved and you to have the knowledge, exercises and lifestyle strategies in place to reduce the chances of it ever reoccurring.
If you are experiencing persistent or particularly aggravating sciatica or back pain, Physio Answers can help – one of our experts will be more than happy to discuss any problems you may be having and will help provide you with the respite you need. To book a consultation or to share your thoughts or concerns, contact us today on 0203 538 3808 or email us at your convenience – and we will be back in touch with you to arrange a friendly chat with you regarding your problem
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Here at Physio Answers, you can receive a 10 minute physiotherapy ‘pre-assessment’ and discussion with the physiotherapist to see if physiotherapy is the right treatment for you.