Misunderstood Sciatica...
This is the first in a series of articles on often-misdiagnosed conditions.
Sciatica is one of the most commonly misdiagnosed conditions I see on a regular basis. So let’s talk about what it is, what it feels like, and the most common problems that cause similar symptoms.
Sciatica, or ‘ciatica’ in Spanish, is the common term to describe any pain along the sciatic nerve. This is a thick (often as thick as your thumb) and long nerve that runs from the low back, along the buttocks, and back of the leg. Your pain can be at any point along the nerve pathway. Even though the sciatic nerve technically ends where it splits into other nerves, pain can run down any of those branches into the lower leg and foot.
Even though most people and many doctors use the term ‘sciatica’ this way, the true diagnosis of sciatica should be reserved for lower extremity radiculopathy. That’s when the small nerve roots are compressed and inflamed from a herniated disc in the low back. But since this is NOT usually the cause of pain along the buttocks and back of the leg, “sciatica” is one of the most commonly misused terms in health care.
True Sciatica.
In true sciatica, a herniated disc (HD), or other lesions in the lumbar spine causes compression and inflammation of the nerve roots that make up the sciatic nerve. Pain runs down the leg and is felt below the knee and sometimes into the foot. Pain that does not run past the knee is almost certainly not true sciatica. This is important to understand because sciatic pain caused by an HD needs very different treatment than other types of sciatic pain. The HD that causes true sciatica sometimes requires epidural injections or surgery. Still, I frequently meet new patients that have undergone invasive treatment for an HD when their pain clearly was not true sciatica. Many doctors are guilty of making this mistake and leading their patients down the wrong path of painkillers, injections, and even surgery based on sloppy diagnoses.
Other Causes.
Referred Low Back Pain.
Much more frequently, sciatic pain is caused by some other factor. Often referred pain from the low back can run down into the buttocks or leg, but is not related to an HD or nerve root compression. Even if a mild herniated disc can be seen on an MRI, it may not be the cause of the pain. Jumping right into treatment for the disc without careful consideration is a great injustice to trusting patients. Usually, gentle exercises, chiropractic, or manual therapy can reduce the cause of low back pain and the referred pain that goes with it.
Piriformis Syndrome.
An often misdiagnosed problem, piriformis syndrome can cause pain in the buttocks and down the back of the leg and is often mistaken for sciatica. The piriformis muscle is a muscle of the hip much like the rotator cuff of the shoulder. Since the sciatic nerve passes around (or sometimes through!) this muscle, any problem with it can often cause pressure or inflammation on the nerve. Commonly, I find the sciatic nerve entrapped by the piriformis muscle, causing severe pain in the buttock and leg. Luckily, this can usually be fixed quickly and easily with some manual therapy, and weeks, months, or even years of pain can be eliminated very quickly!
Peripheral Nerve Entrapment.
Like the sciatic nerve at the piriformis muscle, the branches of the nerve can be entrapped in other muscles further down the leg. The back of the knee or the top of the calf is a very common place for this to happen. Often runners will suffer this type of nerve entrapment after heavy training or if they have cramped up during a run or a race. Because there can be pain, numbness, tingling, or weakness associated with lower leg nerve entrapment, sciatica is often the (mis)diagnosis. However, with a careful exam, the entrapment can be identified and released very easily, with the right treatment.
The Right Diagnosis Leads to the Right Treatment.
At my practice in Tamarindo, Costa Rica, I often help patients that have been through failed treatment for sciatica, including painkillers, injections, and even surgery. But with careful diagnosis and the correct treatment, most causes of “sciatica” can be relieved quickly and completely.