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The simple explanation of sciatica is something is irritating the sciatic nerve, causing extreme pain down the back of your thigh and/or leg.
When any part of a nerve is compressed, the entire length of the nerve, including its branches, can be affected. The sciatic nerve begins at a point in the lower spine and runs down your hip and the back of your thigh.
Around your knee, this nerve splits into two nerves that run the back of your leg, which then divides into more nerves that reach your foot and toes.
Causes of Sciatica
Sciatic pain can be triggered by the following factors:
- The most common reason for sciatic pain is a bulging or herniated disc, called radiculopathy. Radiculopathy occurs when a nerve is compressed near a spinal segment in the lumbar spine. You feel the effects of this compression in the entire length of the nerve. Sometimes, you may not feel pain in your lower back, but most often, it is the most problematic part.
- Another theory of the cause of sciatic pain called the piriformis syndrome does not involve the lumbar spine. (1) A short muscle in your butt called the piriformis runs over the sciatic nerve. If this muscle is tight, the sciatic nerve that runs underneath is thought to be compressed, causing pain.
- Another cause may involve the sciatic nerve itself. The sciatic nerve may be shortened in length and tightened, causing pain. You may also experience inflexibility in the hips, hamstrings, and calf muscles.
Symptoms of Sciatica
Sciatica symptoms can be felt throughout the length of the back of one or both of your legs, as two sciatic nerves originate from each side of the lumbar spine.
- The most common symptom of a sciatic nerve problem is pain.
- You may have decreased reflexes, decreased sensation, or even numbness.
- At times, the symptoms you may experience seem bizarre. One patient reported, “It feels like a drop of water is running down my leg.” No pain was felt, but that symptom was very annoying and it shouldn’t be there.
- Motor issues may also be present. Besides sensation, most nerves play a part in how well your muscles work, so you may experience a foot drop or difficulty walking in general.
- There is a symptom of sciatica that is considered a medical emergency. It is called “saddle anesthesia” and affects your bowel and bladder. The saddle area refers to the part of your body that would be seated on a saddle if you were riding a horse. During the assessment, medical professionals would ask if you have any loss of bowel or bladder control or if you experience numbness in your saddle area, which may indicate saddle anesthesia. It is a sign that a disc in your lumbar spine is protruding and compressing an area of your spinal cord, which could lead to permanent disability if not treated immediately.
Getting to the Source of the Pain
Testing reflexes and sensation in the legs allows a physical therapist to determine the location of nerve compression and the spinal segment to be focused on. One way of doing this is by performing a test for an adherent nerve root. However, this test only works when lower back pain is present.
Directions:
- Start in a standing position, and then bend over forward. Make sure you are bending at the waist, not the hips. If you bend at the hips and keep your back straight (which is how you should bend forward all the time in your everyday life), this test will not work because you are keeping the spinal cord somewhat on slack. Bend forward at the waist, curling your back into a “C” shape. Does that make the lower back pain worse? If the answer is yes, then do step 2.
- Bend the knee of the leg that has symptoms and put your foot up on a chair. Then, with your knee bent, bend over forward at the waist again. Does this make the lower back pain worse? If the answer is still yes, something is going on in your lower back. The pain is originating in your lower back if giving the nerves and muscles of the leg a lot of slack fails to ease the pain. If the answer is no, the origin of the pain is likely somewhere else along the length of the nerve.
A positive test means that as the nerve comes out of the spinal column, it adhered to something and is not moving properly. So, every time tension is placed on the nerve, pain occurs.
Since the nerve adhered to something, when you move in certain directions and assume certain positions, the nerve does not move as it normally would and causes pain. You may not experience pain at the location of adhesion, but it can manifest somewhere else.
Adherent nerve roots frequently happen after surgery because all the scar tissue may trap a nerve. This can happen anywhere along the spine, but it is also most common with the nerves of the lower back/legs. One of the solutions is to break up the scar tissue and mobilize the nerve.
Treatment for Sciatica
Sciatica is treated according to its cause:
- If determined that the pain is originating from a bulging disc in the lower back, you would want to perform exercises that help to reduce that disc and stop compressing the nerve.
- If determined that the cause is true piriformis syndrome, which is rare, then stretching out and lengthening the piriformis muscle is the way to go.
- If the sciatic nerve itself is determined to be tight and causing the problems, then you will need to perform sciatic nerve mobilizations. In this case, you will be taught very gentle ways of performing nerve glides or nerve flossing, targeting the sciatic nerve.
- If an adherent nerve root is causing your pain, again nerve flossing will come into play along with other modalities to break up any scar tissue in the area that may be contributing to the adherence of the nerve.
Exercises for Relieving Sciatic Pain
Performing the following exercises can help relieve sciatic pain.
1. Stretching piriformis
Directions:
- Lie on your back and bend one leg.
- Place the ankle of the opposite leg over the knee in a “figure 4” position.
- Using both hands, grab the ankle and the back of the knee.
- Pull the knee toward your chest gently until you feel a gentle stretch at the buttock of the elevated leg.
- Hold for 10 seconds and perform 3 repetitions, twice a day.
2. Stretching hamstring
Directions:
- Sit on a sturdy and even-surfaced table, bed, or any raised platform, and stretch out one of your legs straight on the top while placing the other on the ground.
- Keep a small-sized pillow or rolled towel under the extended knee.
- Slowly and gently lean forward while keeping your spine totally straight until you feel a slight stretch behind your thigh. No need to exert your thigh muscles beyond the point of comfort.
- Hold for 10 seconds and perform 3 repetitions, twice a day.
3. Foam rolling glutes
Directions:
- Place your foam roller on the floor and sit on it, with one foot over the opposite knee in a “figure 4” position.
- Roll along your buttock in a front to back motion from your lower back to the bottom of the buttock.
- Tighten your abs and maintain a proper lower back posture during the exercise.
- Perform 5 repetitions, twice a day.
4. Passive lumbar extension
Directions:
- Lie on your stomach with your hands placed palm down on the ground next to your face.
- Gradually push your torso up with the strength of your arms, starting with raising your head, then your upper back, and finally your lower back, all the while keeping your glutes relaxed and without lifting your pelvis from the ground.
- Push up until you feel a small discomfort in your lower back.
- After feeling the pull at the back end, you can return to the starting position by slowly bringing down your upper body.
- Repeat the same exercise 10 times and perform 3 sets of 10 repetitions per day.
If your back pain seems to worsen AFTER the exercise, it is best you do not perform it again.
5. Lumbar extension
Directions:
- Stand facing a wall with your feet shoulder-width apart and hands on a wall at shoulder height.
- Allow your back to arch as you lift yourself toward the ceiling, starting with your neck, then your middle back, and finally your lower back.
- Slowly return to the initial position by following the same sequence and repeat.
- Perform 10 repetitions, three times a day.
If pain increases AFTER performing this exercise, do not perform it again.
6. Repeated lumbar extension
Directions:
- Stand straight and move your chin toward your chest until you feel a comfortable pull from your neck all the way to the base of the skull.
- Put your hands on your buttocks and slowly bend backward, arching your lower back while keeping your chin tucked in.
- Gradually return to the starting position, and repeat the exercise 10 times in the same way.
- Perform 3 sets of 10 repetitions per day.
If your back pain increases AFTER the exercise, it is best you do not perform it again.
Note: These next three exercises must be performed with great care. The aim of them is to mobilize the sciatic nerve, and nerves are very delicate. These exercises are not the same as stretching a muscle. DO NOT push into pain. The moment you feel a stretch, withdraw from the exercise.
These exercises are different ways of performing an activity directed to the sciatic nerve, with the same purpose. Different people may find different ways of doing them more comfortably. The following are three different options to try. Find what is most comfortable for you.
7. Sciatic nerve mobility
Directions:
- Lie on your back and wrap a belt around the foot.
- Lift the leg up toward the ceiling until a light stretch is felt, and hold the end of the belt with your hand.
- Slowly turn your leg toward the inside, and pull on the belt to move the leg toward the inside.
- Perform 3 repetitions, twice a day.
8. Sciatic nerve glide
Directions:
- Lie down on a flat surface and lift the pain-ridden leg at right angles to your back while keeping the knee bent, which will be your starting position.
- Keeping the foot relaxed, extend the knee without moving the thigh.
- When the knee is extended at its most, actively pull the toe toward your shin.
- When you reach the point where you feel a pulling sensation along your leg, let go and return to the starting position.
- Repeat the same exercise 3 times and perform 2 sets of 3 repetitions each on a single day.
9. Sciatic nerve flossing
Directions:
- Start in a sitting position with legs straight.
- Use a strap to pull your feet toward you, and slump your head forward until you feel a gentle stretch in the sciatic nerve.
- Hold the position for a few seconds, come up, and repeat the exercise.
- Perform 3 repetitions, twice a day.
We thank Phoenix Rehab and Physiotec for the images.
Helpful Tips
Proper treatment always depends on determining the correct cause of the pain. Here are some things always to be mindful of and to avoid that may help with sciatica.
Dos
- Posture, posture, posture! The number one thing that you can do at home and in everyday life is maintaining good posture at all times, whether you are sitting, standing, or walking.
- Take a walk every day, even a short one. The purpose of this is so that you do not allow yourself to become afraid of movement. However, if your pain increases significantly during or after an activity, please stop. You are not ready for that activity.
Don’ts
- Again, posture, posture, posture!!! Don’t allow yourself to slouch. Please be aware of your posture at all times, and the moment that you realize that you are slouching, correct your posture.
- Discontinue any activity that causes lasting, increased pain. “No pain, no gain” does not apply here.
Expert Answers (Q&A)
Answered by Dr. Martin M. Mortazavi, MD (Neurosurgeon)
Usually, sciatica subsides within 6 months of onset. If the pain does not resolve or is not responding to non-surgical methods within the first 6 months, surgery is a good option. A majority of patients who will undergo surgery will have pain resolution.
Yes, unless walking worsens the symptoms. Physicians usually recommend patients to stay mobilized. Often, the pain also causes muscle spasms in the back.
Walking sometimes worsens these muscle spasms and, consequently, the back pain. Thus, the affected individual is discouraged from walking. To relieve the muscle spasms in the back, muscle relaxants are usually prescribed.
Yes. A large, centrally located herniated disc can push the nerves at both sides of the spine. Also, spinal stenosis, a chronic disease that makes the spinal canal small and usually occurs with age, can affect both sides.
Yes, a large, centrally herniated disc can cause leg pain, weakness, and bowel and bladder dysfunction. This condition is called cauda equina syndrome and is a surgical emergency.
The herniated disc needs to be removed immediately to restore function. Affected individuals with bowel or bladder dysfunction should not wait to be treated with medicines or epidural injections.
There is no scientific data behind this therapy.
Not directly. However, theoretically, constipated people might bear down too much, causing pressure on the spine. However, no scientific data is available on the association between constipation and sciatica.
Final Word
When the sciatic nerve is irritated, any action that can stretch it would need to be avoided. Many patients experience increased pain while sitting, as it stretches the nerve.
Thus, it is recommended to avoid sitting for long durations, especially driving. However, complete inactivity can weaken your muscles and further deteriorate your condition. The idea is to stay moving but avoid any heavy lifting.
See a physician, usually a neurosurgeon or an orthopedic spine surgeon, for assessment and treatment. In most cases, you will be prescribed strong analgesics and anti-inflammatory drugs and sometimes even a short course of steroids to manage the frequent and severe pain.
The dependence on pain meds can be somewhat reduced through complementary therapies and exercises such as the ones mentioned above, provided they are done correctly and after consulting with your doctor.
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