As a massage therapist, I empathize with my clients who complain of sciatica. Before I switched careers, I spent many years in the restaurant industry as a server, a bartender, a busser, and a prep cook. What those jobs all had in common were long hours, prolonged time on my feet, and hard, unforgiving floors. By 2010, I had been in the industry for ten years, and even though I was only in my twenties, my body was really starting to feel it. My feet hurt from walking, my face hurt from smiling, and I started experiencing a strange pain when I finally stopped moving for the night.
When I got home at the end of a shift, I felt this shock of pain that ran from my backside, through the back of my leg, and into the sole of my foot. Sometimes it ached, sometimes it stabbed, but it was always only on my right side. Sometimes, it hurt so much I could not sit down or find a comfortable way to sleep.
I was young and I worked in an industry that did not prioritize “time-off” or “healthcare.” I chalked it up to nothing more than nonspecific fatigue, overuse, and the physical toll of the job. I came to find out that this sharp, electrical sensation and its particular path was indicative of something more specific: sciatica.
I was far from alone. Sciatica symptoms have a lifetime occurrence in ten to forty percent of the population, show no gender predominance, and a higher incidence in physically demanding jobs.
“Sciatica” is often used rather loosely and refers to a particular set of symptoms rather than the specific underlying medical condition. It is sometimes referred to as lumbar radiculopathy. The symptoms can range from discomfort to debilitating pain and can be difficult to diagnose due to similar profiles presented by other conditions. Getting treatment and identifying the cause of these pains can be a process of elimination. In this case, sciatica will be referred to as an irritation of the sciatic nerve not otherwise covered by another condition.
Anatomy of the sciatic nerve and hips
The anatomy of the sciatic nerve and the surrounding structures give some insight into why this area can be fraught with sensory complications.
The location and sheer size of the sciatic nerve has earned it an infamous reputation. The largest nerve in the body, the sciatic nerve originates in the lumbar and sacral spine at the nerve roots of L4 to S3. Part of the sacral plexus, which joins with the lumbar plexus to form the lumbosacral plexus, it runs through the gluteal region by way of an opening in the pelvis called the sciatic foramen.
It branches through the gluteal muscles and into the hip, and then descends through the leg muscle anatomy to enter the back of the thigh down through the back of the knee. Around this area (as each body is a bit different) it splits in two to become the tibial and common fibular nerves.
The branches that extend into the hip supply the hip joint. The hip is a ball-in-socket joint with a variety of muscles around it for support and movement. The ball-in-socket shape allows the hip to move on its axis in many directions. In this variety of motion, the area also offers a variety of scenarios where nerves can be pinched, irritated, or otherwise impinged.
The sciatic nerve has both motor and sensory functions. The motor qualities of the nerve include bending the knee, bringing the thighs in toward the midline, and pointing the foot and toes both downward and upward. The sensory aspects include innervation of the skin of the front, back, and outer aspect of the thigh and lower leg, as well as the skin of the top, outer side, and sole of the foot.
Movements such as twisting, bending, and coughing can cause sciatica pain to intensify. Pain can also be caused by flexion of the spine due to sitting, continual lifting and twisting. A Finnish study in 2002 linked jogging to a lower risk of incidental pain, but a higher risk for ongoing symptoms. Conversely, physical exercise and sports activities did not seem to affect sciatic pain.
Symptoms that point to sciatica are pain below the knee, leg pain that is worse than the back pain, a pain pattern that radiates towards the foot or toes, numbness that radiates down the leg into the foot, and leg pain induced by the straight leg raise test. Sciatica often is experienced in only one side at a time.
Sufferers may experience some collection of pain, burning, and numbness along the nerve route through the low back, the buttocks, the back of the leg, and into the foot. A shooting, sharp pain and pins and needles are common descriptors of the complaint. The individual nerve root affected determines where these sensations are experienced.
As sciatica presents as irritation of the sciatic nerve, it can often be conflated with a variety of other more specific conditions. In fact, sometimes symptoms attributed to sciatica may not involve the sciatic nerve at all. Injuries and pathologies of the neighboring structures like the gluteal muscles or the hip joint can mimic sciatica symptoms.
One common incidence of this is piriformis syndrome, wherein the behavior of the piriformis muscle causes irritation of the sciatic nerve and creates similar pain patterns. The sciatic nerve runs below the piriformis muscle, but there are several anatomical variations in which the arrangement is different. The sciatic nerve could divide at this point and pass both through and below the muscle, through and above the muscle, or the entire sciatic nerve could pass superiorly to the piriformis. As the piriformis muscle tightens or spasms it can put pressure on and irritate the sciatic nerve resulting in similar radiating patterns of pain as sciatica.
Another nerve cluster response that may be mistaken for a sciatic complaint involves the cluneal nerves. The entrapment of the superior cluneal nerve near the iliac crest can be responsible for feeling pain in the low back and the leg. This is an example of a similar pain referral pattern that while unrelated to the sciatic nerve, could certainly be confused for sciatica.
Femoroacetabular impingement (FAI) refers to irritation caused by friction between the bones of the hip joint or pinching of tissue in the hip joint by the bones. This friction or pinching can cause damage to the cartilage of the joint. This condition can cause pain while sitting, low back pain, pain surrounding the sacroiliac (SI) joint, gluteal area, or side of the hip, or a clicking sensation in the hip. This is caused by irritation between the bones of the hip joint due to friction or pinching of tissue. After an evaluation by a doctor, FAI can be confirmed by X-rays or by a type of magnetic resonance imaging (MRI) called magnetic resonance arthrography (MRA).
Hip osteoarthritis is a degenerative type of arthritis in which the cartilage in the joint gradually wears away. As one of the primary weight-bearing joints, the hip is a common place for osteoarthritis. This is a common cause of hip pain, and being that the sciatic nerve is so close to the hip joint, damage to the structures in the hip may be interpreted as sciatic pain. Disambiguating may involve identifying symptoms of stiffness, and groin pain or administering further medical imaging tests.
One case study even draws the connection between a herpes zoster (commonly known as shingles) outbreak and misdiagnosis of sciatica. Without the characteristic skin lesions, and with a burning nerve pain also endemic to shingles, an outbreak around the buttocks or thigh could mimic sciatica pain.
What causes sciatica
Causes of sciatica include muscular spasms, disc herniation, spinal stenosis, and an overgrowth of bone on a vertebra. Mechanically, a combination of both inflammation and compression must be present for the nerve to display symptoms.
A muscular spasm adjacent to the path of the sciatic nerve can put pressure on the nerve and cause irritation. This is most common from muscles in the low back, glutes, or hip. A herniated disc occurs when the soft filling between the bony spinal segments is damaged or displaced and, while not always correlated with pain, can cause sciatic pain if the disc compresses the nerve. In the case of lumbar spinal stenosis, the spinal cavity that houses the spinal cord begins to narrow with age, leading to compression on the sciatic nerve and resulting in pain. If there is an overgrowth of bone on a vertebra, or a “bone spur”, the bone can pinch or rub against the nerve and stimulate a pain response.
Lifestyle, demographic, and environmental factors can heighten risk for incidences of sciatica.
A scoping review of the literature of common spinal disorders in 2018 found that higher incidences of sciatica are found in people who are overweight, smokers, and manual laborers.
Poor mental health, depression, age, and physical stressors specific to the spine, such as the vibrations of heavy machinery or vehicles, can also be predictive factors for sciatica. Individuals with multiple risk factors such as obesity and lifting heavy objects increased risk of a more serious case.
Diagnosis of sciatica
Initial assessment of a sciatica-like complaint involves a physical examination and review of medical history. The goal is to identify the underlying cause of the pain, therefore narrowing down treatments that will be most effective. Details such as the onset of the pain, accompanying symptoms, specific qualities of the pain, a change in leg strength, or a history of trauma to the area can help this diagnosis.
Clinical tests can also be conducted such as the straight leg raise test and the slump test. The straight leg raise test is performed with the patient lying on their back while their extended leg is lifted. This is testing to see if the patient experiences radiating pain in a specific pattern. Also commonly employed is the slump test, which is conducted seated.
This test notes if pain occurs as the patient bends forward at the hip while extending a knee, with their chin brought to their chest, and their ankle flexed back. These tests are the most effective in identifying causes such as a herniated disc and may miss causes outside of mechanical compression.
A reliable diagnosis may involve time spent eliminating other options since sciatica symptoms may be mistaken for other sources of pain.
How long does sciatica last?
Sciatica can have different causes, can be mistaken for another condition, and can come on suddenly. But there are good news.
Sciatica does go away.
Many cases resolve in fewer than four to six weeks even without seeking medical treatment or manual therapy. Once a medical professional has eliminated more serious causes, there are a variety of self-care options and treatments that can be employed to minimize pain and recurrence of symptoms. Finding symptomatic relief through application of heat or cold, stretching, and comfortable positioning can help defray the discomfort for the time being or until it goes away on its own.
Identifying and changing actions that may be stressing one side of the body more than the other may help. If self-care solutions are not providing relief, seeking care from a trusted medical provider can help pinpoint the cause of the pain and introduce you to further treatment options.
While the onset of sciatica pain has more to do with exacerbating physical factors, maintaining healthy mental and physical habits make an impact on sciatica going away.
Common therapies for sciatica include non-steroidal anti-inflammatory drugs (NSAIDs), steroid injections, stretching or yoga, and in some cases, spinal surgery.
Several systematic reviews of sciatica treatment seem to reveal one thing: effectiveness of treatments varies and the research supporting specific interventions does not make strong cases for any one treatment. Certain approaches like nonopioid drug intervention, epidural injections, and surgery show some positive result, while opioids, bed rest, traction seem to have no positive effect.
One trial showed no significant difference during follow ups for patients who received six months of conservative care versus patients who underwent surgery. As surgical intervention does not show a higher success result than more conservative treatments, a conservative approach should be tried first, and the higher risk of surgery should be considered only when the more conservative approaches have not worked.
Following surgery, acute cases that have been active for less than six months have a better outcome than chronic cases of more than six months. While NSAIDs showed effective management of non-specific back pain, the evidence is not strong that they will positively affect sciatica pain.
As sciatica proves to be easily conflated with other conditions, and evidence for specific treatments is not strong, it is important to treat each case on an individual basis. Finding medical professionals that will work along with patient experience and focus on patient education is key.
Quitting smoking, losing weight, and committing to a mindful movement routine can all help ensure a better recovery. Treating the symptoms can provide some relief by using hot or cold packs to ease the pain, staying mobile and taking breaks from prolonged sitting and standing, gentle stretching, and being mindful of twisting and lifting.
A popular stretch to relieve sciatic pain is a yoga pose called pigeon pose. Starting on all fours, bring one knee forward towards the same wrist. The opposite leg slides back with a pointed foot.
With one leg bent and brought forward and the other leg stretching back, it stretches the muscles in the buttocks, the anterior thigh, and surrounding the pelvis. This can create a sensation of more space around an irritated sciatic nerve and bring relief. Lean forward onto elbows or forehead to intensify the stretch. Using the arms for support in this position can allow more control over the stretch and weight, allowing only an amount that feels comfortable.
Another stretch that might be helpful to try is the Figure Four stretch, which stretches across the glutes and into the hip. This is conducted lying on the floor or seated with one ankle crossed over the opposite knee and pulling them both back into the body. An added comfort of this position is to move the hips side to side on the floor to add a pleasant pressure on the back.
This article is for informational purposes only. The information provided is not to diagnose, treat, or prevent any type of disease or medical condition. For diagnosis and to determine your best course of treatment, please consult with a physician or other qualified medical professional.
Sciatica and massage therapy
Dealing with these sharp pains or tingling sensations in the back and legs can feel very dramatic and cause a lot of fear. Massage therapy offers a noninvasive approach to managing pain. Ongoing pain can cause the nervous system to be on high alert, making everything feel more sensitive. When a client is already coming to you with pain, it is important not to add more pain.
A slow and gentle hands-on approach will give both the therapist and the client a chance to explore the sensations present and to find some sensory input that brings comfort and relief. In addition to a pain relief goal, the relaxation effect of a general massage can be helpful when managing a lasting or chronic pain condition. Relaxing can help decrease stress levels, and empower the client with more resilience to manage their situation.
It is important to be aware of red flags that can be associated with low back pain and leg pain. There are several spinal pathologies to think of when a client comes in with pain that seems like sciatica: cauda equina syndrome, a spinal fracture, spinal malignancy, or a spinal infection. Cauda equina syndrome could include numbness in the lower limbs and sudden onset bladder or bowel dysfunction.
An older client with a history of trauma to the area, osteoporosis, or corticosteroid use could be a red flag for a spinal fracture. The combination of a history of cancer, low back pain, and unexplained weight loss might point to spinal malignancy.
Lastly, indicators of a spinal infection could be fever, chills, sweating and recent infection. If any of these conditions are suspected, it is a good idea to have the client contact their doctor to eliminate these symptoms as a possibility for the pain.
After a thorough assessment and a referral out if anything comes up as a red flag, it is important to make them comfortable. Positioning can be very key in hands on work with clients suffering from sciatica. If the client is experiencing pain in a neutral position, any approaches attempted from that point will be an uphill battle. It is difficult to see anything improve further if just lying on the table puts them under greater strain.
Lying flat may cause discomfort, so using bolsters and pillows to support the hips, knees, and legs can alleviate passive pain as you work with them. Other adjustments that may bring relief include lying supine with knees bent and feet flat, adding a pillow under the hips while prone to move them into slight flexion, or having them move into a side lying position with knees bent.
From the prone position, try supporting the leg of the affected side while bringing it over the sane side of the table. With a slight bend in the knee, gently pull the heel of their foot towards you while internally rotating the leg.
Alternatively, try pushing the heel of their foot away while externally rotating the leg. Check in periodically with the client to see how everything feels and if any adjustments need to be made. You may also monitor any hot spots of pain in the gluteal area for changes.
From side lying, start with knees bent and stacked, and then gently move the top knee up and over, letting it drape over the bottom knee. Apply gentle pressure to the low back, hip, and glutes while they are in this position. Creating a feeling of space in the low back area can also be helpful. This can utilize skin stretching, myofascial release, or any other slow stroke in any direction around the sacrum.
Whatever approach you try, let your clients’ experience guide your choices, and give their body time to adjust to any changes. Encourage them to be patient with their body, and consider taking your own advice.
With something like sciatica that can easily masquerade as another condition, diagnosis is complicated and is best left to a medical professional with a diagnostic scope. Encouraging a client to reach out to their doctor may give them more peace of mind and rule out any potentially dangerous causes.
In my case, I never sought out a medical diagnosis. I suppose I am a lucky example of someone for whom the pain resolved on its own. There could be a variety of contributing factors to pain, and “sciatica-like” symptoms do not always add up to sciatica. In fact, now that I know more about how my body responds to physical stressors and I am armed with a little more anatomical knowledge, I suspect this may have been the work of a touchy piriformis.
Halley Moore, LMT, can be reached at firstname.lastname@example.org at Calliope Insights in St. Louis, Missouri.
Feature photo: Halley Moore