If you have primarily low back pain, please change articles: you need to be reading Save Yourself from Low Back Pain!
Sciatica is a description of a symptom — pain in the buttock and down the back of the leg. It implies impingement of the large sciatic nerve, but this is rarely the primary problem. There are several closely related scenarios that can cause buttock and leg pain, and true sciatic nerve impingement is much less common than muscle pain. Even when the sciatic nerve is being pinched, this is often a relatively trivial effect of muscular dysfunction — help the muscle, and the pinch goes away.
Here are several ways that you can have sciatica:
Each of these scenarios involves muscle knots. To a great degree, muscle knots are both a cause and a complication of sciatica. Treating them is also usually the easiest way to intervene — to break the grip that piriformis has on the sciatic nerve, or to improve the soft tissue environment of unhappy lumbar nerve roots.
Rarely (almost never) is the problem “mechanical” in nature, despite the popularity of this view among virtually all health care professionals. Chiropractors are particularly prone to diagnose a sciatica problem as a symptom of some kind of joint dysfunction, alignment or postural problem. The sacroiliac joint is routinely diagnosed as being “out,” and the lumbar joints are portrayed as being fragile and vulnerable when quite the opposite is true in general. Although chiropractors are most likely to diagnose in this way, physicians, physiotherapists and massage therapists are all equally prone to this kind of “structural” diagnosis, ignoring the most obvious and straightforward explanation and treatment opportunity.
It can be difficult to tell the difference between the pain of trigger points and true sciatica nerve or nerve root impingement. And bear in mind that, even when it is possible to identify actual nerve impingement, the main problem is probably still muscular. The two problems are generally treated in much the same way.
The clearest sign of nerve impingement is significantly altered sensation below the knee, either:
Another relatively clear sign of nerve impingement is:
Nerve impingement pain is technically called “lancinating” pain. It is typically hot or sharp, instead of diffuse and aching. Most people strongly agree that it feels “electrical.” However, do not be too convinced by the quality of the pain alone: trigger points are quite capable of causing pain that feels exactly like nerve pain.
Trigger points rarely causes a “pins and needles” sensation, so if you have pins and needles, that is a pretty strong indication of nerve impingement. But even then, you can’t be sure, because trigger points do occasionally cause a very nervy tingling.
The only symptom that is virtually guaranteed to be caused by nerve impingement alone is true tactile numbness. If you have a “dead” patch of skin, then you almost certainly really do have a pinched nerve.
However, even then, some uncertainty remains. Although trigger points cannot cause a truly numb patch of skin, they can (and routinely do) cause a feeling of “dead heaviness.” People routinely start an appointment for sciatica by telling me that their leg is numb — but after a little discussion, it becomes clear that they mean that the leg feels sick, heavy, weak and useless … but not actually numb to the touch. Without numbness to touch, nerve impingement cannot be diagnosed, and by far the more likely cause of the symptoms are a batch of nasty trigger points in the low back and hips.
This difference between nerve impingement and trigger points can be extremely difficult for patients to wrap their heads around, so I’ll go into more detail in the next section. But first, a delightful patient quote of the day from Dr. Grumpy:
“The pain went down through my legs. Not all my legs, I mean, but just the ones on the bottom of my body.”
And if you think that’s weird, you should see my inbox.1
I recently came across this full-page advertisement in National Geographic magazine:
“Do you feel burning pain in your feet?” the ad asks. “Or uncomfortable tingling, numbness, stabbing, or shooting sensations? If so, you may have nerve pain.”
Yes, you might. But it’s not bloody likely! For the reasons discussed above, the clinical reality is that neuropathy is a lot less common than patients and doctors believe — most of it is caused by myofascial pain syndrome.
Yet nerves have a mystique. They make people nervous! So to speak. The whole idea of nerves gets people anxious. Could it be a nerve? people ask. Is this a nerve problem? What if it’s a nerve? Is something pinching my nerve? Something must be pinching a nerve.
The idea of a pinched nerve root is deeply embedded in the public consciousness, thanks to decades of excessive medical and emphasis of the idea. Chiropractors especially have promoted this kind of thinking to the point where many people think they can hardly get out of bed in the morning without pinching a nerve root.Nerve pain is a lot less common than patients and doctors believe.
I had a nice old Italian client who would ask me, over and over again, in a thick Italian accent, “So, it’s-a nerve, eh?” No, I would say, it’s just a muscle knot, not a nerve. And then, as if we’d never discussed it, five minutes later he would ask again, “So, that’s a nerve, eh?” He was obsessed with nerves!
Like everyone else. Sometimes it seems to me as if modern civilization is still getting used to the whole idea of nerves. When people talk about their nerves, it’s like they’re talking about something just revealed by science early last year. They speak with some awe about something barely understood … and feared. Nerves! It could be my nerves!
Just like the chiropractic perspective, the kind of advertisement you see above aggravates our society’s general anxiety about nerves. It drives me nutters, in fact, that I spend my career trying to demystify nerve pain and guide patients towards the much more common causes of their pain — and then Pfizer comes along and spends about a gazillion dollars on a marketing plan that will create more anxiety about nerve pain than I can counteract in an entire lifetime of low-budget public education! Bummer.
Recently I was working with a young woman who had “sciatica.” Allegedly, either her sciatic nerve or a lumbar nerve root was being pinched, and sending hot zaps of pain down her leg. She came to me with this diagnosis already in place. She also had some tingling in her feet … much like in the magazine advertisement. The description of her symptoms did, indeed, sound a lot like a nerve impingement problem. On the face of it, it did seem likely that something was being pinched.
However, a couple things didn’t add up. For instance, she had no numbness at all — no dead patches of skin, which are highly characteristic of true nerve impingement. Instead, she had a lot of “dead heaviness” in the leg. As discussed above, this is a different kind of numb feeling that is much more closely associated with trigger points than with nerve pinches — and a lot more common.On the face of it, it did seem likely that her sciatic nerve or a lumbar nerve root was being pinched.
So I quizzed her very carefully about the quality of her pain. She assured me it was “zappy” and “electrical,” definitely “sharp” … just as you would expect of nerve pain. Yet something didn’t seem quite right. I couldn’t shake the impression that she was interpreting an intense non-neurological pain as a “zappy” pain simply due to her strong belief that she had a nerve problem. When you think a pain is nervy, you’re much more likely to interpret, feel and describe it in nervy terms.2
So I did some experimenting, and clinched the case:
This young woman’s “nerve” pain could be perfectly reproduced by poking muscle knots that were nowhere close to any nerve tissue. Pressing on the side of her hip, on a gluteus medius trigger point several inches away from the sciatic nerve, she reported the same “electrical” pain flowing down her leg, even producing the weird, tingling sensations in her foot. This virtually eliminates a diagnosis of sciatic nerve impingement.3
In spite of spending most of my career trying to explain to people that this kind of thing is extremely common, I was actually surprised myself. The symptoms really did seem awfully neurological to me at first. Yet the evidence was hard to argue with, and — in retrospect — I realized that I had been fooled by “nerve anxiety” myself. In fact, her symptoms were strongly consistent with a diagnosis of myofascial pain syndrome (muscle knots). The only thing about her case that is the least bit unusual is that her muscle knots produced referred pain even more similar to nerve pain than usual, and even that may have been a by-product of my earlier leading questions (i.e. she was led into using terms like “electrical” to describe something she might just as well have described in a less “nervy” way if she’d been given the proper chance).I had been fooled by “nerve anxiety” myself.
Muscle knots are always doing this — fooling patients and professionals alike. Vastly more common than nerve problems, and often more painful, they nevertheless get upstaged and misdiagnosed. Do you feel burning pain in your feet? Or uncomfortable tingling, numbness, stabbing, or shooting sensations? If so, you may have muscle knots!
The take home message of this section is: do not underestimate the power of trigger points to cause pain that seems like a nerve pinch.
Most cases of sciatica will resolve with no special treatment within 3–6 weeks, just like low back pain or a crick in the neck. Most of these people will never have the problem again, or only once or twice more in their lives.
The most painful cases are completely debilitating for brief periods, but most of the time cause only extremely annoying pain that makes daily activities frustrating, but not actually impossible.
A minority, perhaps 20% of patients, will become chronic and/or recurrent sufferers.4 An even smaller, unluckier minority of sciatica sufferers face a lifetime of pain that never or rarely leaves, or episodic pain that inevitably returns. Stubborn cases may be at least partially explained by genetics,5 and this one of the important reasons why patients need to be wary of therapeutic wild goose chases looking for the cause of their pain. Once any kind of pain has been around for a while, it has the potential to actually damage the way the nervous system interprets pain — this is known as “central senitization,” meaning the central nervous system has become oversensitive to pain.
The next several sections go over some of the treatment options for sciatica. In summary, most people should avoid surgery, as it simply does not provide that much benefit. However, it may be a worthwhile option for very painful cases of sciatica. For everyone else, the best therapy is to try to “act normal” as much as possible — reduce fear and anxiety, move as much as reasonably possible, stretch and wiggle, keep the surrounding muscles happy with heat, and so on.
Surgery is only an option when it is related to a herniated disc, as opposed to when the sciatic nerve is being impinged by the piriformis muscle, or (obviously) if sciatica-like symptoms are being generated by muscle knots alone.
Even when there is a herniated disk, surgery should only be seriously considered in the worst, most painful cases.
For the rest of us, sciatica surgery is barely worthwhile. In 2008, a group of Dutch researchers published the results of an excellent study of surgery for sciatica.6 Although not perfect, it is certainly the best such experiment yet performed, and will be more or less the “last word” on the subject for a while, the new-and-improved conventional wisdom.
(It is also quite readable for a scientific paper, and keen patients or professionals readers might want to browse the full paper, which is freely available on the British Medical Journal website.)
Peul et al found that operating relatively quickly on a herniated disc causing sciatica “roughly doubled the speed of recovery from sciatica compared with prolonged conservative care.” However, that sounds a lot better than it is, because a year later there is basically no difference between people who had surgery, and people who didn’t. In fact, “These relative benefits of surgery, however, were no longer significant by six months’ follow-up, and, even at eight weeks, the statistically significant difference between treatment groups in primary outcome scores was not sufficient to be clinically meaningful.”
In other words, the effect of surgery is pretty underwhelming. A graph shows this very clearly:
That pretty much says it all, doesn’t it? For your trouble of getting cut open, you get a pretty modest dip in pain in the early days, but it’s not very long at all before you’re pretty much back in the same boat as the fellow who didn’t bother. “Neither treatment is clearly preferable,” the researchers concluded. They argued that it might be time to stop recommending surgery based on physician preferences, and start asking patients what they think of the options.
It is worth noting that this study is considerably less optimistic about operating than some previous studies. Previously, the conventional wisdom was that operating relatively soon could result in more significant pain relief in the short term. However, this new study was better-designed, much more “scientific” — more of a carefully controlled test of the theory, so it gives us many reasons to put more stock in its results.
In fact, the results of the research are so conclusive that authors wonder “whether surgery has any effect at all on the natural course of sciatica.”
I have been arguing for years that back surgeries need to be compared to sham surgeries if we are ever to really know if they work, so I was particularly pleased that these scientists suggest exactly that — a somewhat radical proposal, virtually unheard of in this field. There are problems and challenges with comparing real surgeries to sham surgeries, but it can and has been done, with fascinating results.Does surgery have any effect at all on the natural course of sciatica?
Slightly faster recovery and relief of leg pain might be worthwhile for some patients. However, much of this eagerness (and probably some of the pain) is driven by fear — back pain and sciatic have a unique ability to scare the pants off patients. The fear around these conditions is in large part due to the ignorant fear-mongering of doctors who are too quick to scary expensive tests (MRI) and recommend surgery, when they should know full well that the vast majority of people recover quickly with no treatment at all!
The risks of surgery for sciatica are relatively low — but even when the risks are low, there is still a considerable financial, personal and social “overhead” any time people get cut open. We should generally avoid any kind of invasive medical procedure unless the benefits are extremely clear.
Like a charge of murder, it should probably be proven “beyond a reasonable doubt” that surgery is worthwhile. Such proof is simply not present in this case of surgery for sciatica!
So, if you’re not going to get operated on … what else can you do?
Whether the pain is caused by the crushed sciatic nerve itself, or just by tight muscles, the muscles need to relax in either case. Hot tubs, with jets, are ideal for all kinds of sciatica.
Due to the thickness of the tissue in the buttocks, the heat will not have any circulatory effect on the nerve or the piriformis muscle, but it will be neurologically sedative. The vibration of jets will amplify that effect. Muscles relax when they are vibrated — a neurological effect known as “proprioceptive confusion.”
(If you live in Vancouver, see the footnote for a great local tip.7)
To get the most out of using any hot tub, see A Better Hot Bath.
When stretching for sciatica, please stretch very gently and calmly: the piriformis muscle, which is producing the pain directly or indirectly, tends to be reactive in character. It needs to be gentled. The focus of the stretching should be neurological, not mechanical — that is, slowly get the muscle “used to” a greater length and lower tone. There are at least two stretches that are particularly useful in this scenario.
Piriformis stretch (seated version) — starting from a seated position, place your ankle (on the side you’re stretching) over the opposite knee. Let your lifted knee relax downwards for a moment, and then begin to lean forward from your pelvis. Avoid simply slumping forward, which is useless. The image that is the key to this stretch is to “push your belly button between your legs.”
Piriformis stretch (prone version) — lie down on your belly. Lift your lower legs straight into the air, and then let them fall out to the sides. Relax them there, but don’t let them fall out of position. This is a very low-intensity stretch — you probably won’t even feel it. This stretch works best if you sustain it for several minutes at a time, or even long periods. You can intensify it by wearing heavy boots or ankle weights, or by getting someone to help you by gently pressing your legs out to the sides.
Mobilize your hips. If you creatively explore your pain-free range of motion, it will gradually increase. If you don’t, the muscles in your hip will tend to remain as they are.
The muscles of the hip and buttock are one of the few places in the body where it is possible to effectively treat your own muscle knots with a tennis ball. Simply lie on a tennis ball such that it presses on deep, aching sore points — and wait for the sensation to fade. See Tennis Ball Massage for Myofascial Pain Syndrome for more information. I do have one caution about treating yourself in this particular case: the piriformis muscle is so unusually reactive, in my experience, that you must be particularly gentle and conservative in your approach.
Bed rest has been a popular treatment for sciatica for the better part of the last century. It’s more or less dying — most doctors know that it doesn’t work these days, and don’t prescribe it. But you still run across this myth from time to time.
In a 1999 sciatica study in New England Journal of Medicine,8 researchers “randomly assigned 183 subjects to either bed rest or watchful waiting” for two weeks and found that “bed rest is not a more effective therapy than watchful waiting.” Nor is less effective. The results were exactly the same. If that sounds like no big deal, consider the difference in the lives of those patients! Two weeks of bed rest? Compared to two weeks of going about your business!
Sciatica of these types are most commonly related to excessive sitting, and sometimes to poor ergonomic design of the chair, work station, and postural dysfunction as well. It is worth experimenting with these factors. The most obvious and relevant option is to buy a timer and use it to remind yourself to get our of your chair every fifteen minutes. For more ideas, see Does Posture Matter? and Unconventional Ergonomics.
This article was first published on January 12, 2003, and it then languished for four years while I put a lot of energy and attention into related projects, like Save Yourself from Low Back Pain! However, as of the summer of 2007, this article is being developed again.
Sunday, April 17, 2011 — Corrected some minor technical errors.
Tuesday, January 18, 2011 — Added reference concerned genetic causes of chronic nerve pain.
Wednesday, December 29, 2010 — Added information debunking bed rest as a treatment option.
Wednesday, June 11, 2008 — Okay, revisions are moving slowly! However, added a major new section today, “What about surgery?” which is based on some excellent new research evidence from Dutch scientists. Made a few other minor improvements at the same time.
August 6, 2007 — Began revisions by doing a wide variety of minor improvements to the introductory sections.
Mark your calendars: 2010 was the year researchers confirmed a gene as “one of the first prognostic indicators of chronic pain risk,” doubling or tripling the odds that a low back pain patient will recover in a timely fashion from nerve root injury. Screening for this gene is not yet something that is clinically available, but it probably will be someday, and then you will know: the universe really does hate you.BACK TO TEXT
BACK TO TEXT
OBJECTIVES: To evaluate the effects of early lumbar disc surgery compared with prolonged conservative care for patients with sciatica over two years of follow-up.
DESIGN: Randomised controlled trial.
SETTING: Nine Dutch hospitals.
PARTICIPANTS: 283 patients with 6-12 weeks of sciatica.
INTERVENTIONS: Early surgery or an intended six months of continued conservative treatment, with delayed surgery if needed.
MAIN OUTCOME MEASURES: Scores from Roland disability questionnaire for sciatica, visual analogue scale for leg pain, and Likert self rating scale of global perceived recovery.
RESULTS: Of the 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiscectomy. Of the 142 patients assigned to conservative treatment, 62 (44%) eventually required surgery, seven doing so in the second year of follow-up. There was no significant overall difference between treatment arms in disability scores during the first two years (P=0.25). Improvement in leg pain was faster for patients randomised to early surgery, with a significant difference between "areas under the curves" over two years (P=0.05). This short term benefit of early surgery was no longer significant by six months and continued to narrow between six months and 24 months. Patient satisfaction decreased slightly between one and two years for both groups. At two years 20% of all patients reported an unsatisfactory outcome.
CONCLUSIONS: Early surgery achieved more rapid relief of sciatica than conservative care, but outcomes were similar by one year and these did not change during the second year. Trial Registry ISRCT No 26872154.