Sciatic Pain - No Cure? Please!

© 2003 By Dr. Tim Maggs

I recently spoke with a runner who’s suffering with a severe case of sciatica. The pain got so bad she couldn’t sleep at night. I asked my usual question, “So what’s causing it and what are you doing for it?”, but her response was one I hadn’t heard yet. “I looked up a bunch of info on the internet, and evidently there is no cure for it”.

What is Sciatica

This misunderstood condition is proven by her finding that there is no cure. To understand sciatica, it’s important to understand some simple anatomy. The sciatic nerve exits the low back and travels down through the butt and down the back of the thigh. It continues down to the lower leg, but for the most part, all symptoms remain in the butt and back of the thigh. It is the largest nerve of the body, approximately the size of one’s little finger.

When that nerve gets pinched or becomes inflamed, it hurts. And, although I’ve never had the condition myself, I can only tell you it’s one of the more painful conditions that patients come in with. The first goal for anyone suffering with this condition is to locate the sight of irritation on the nerve. So, to ever say there is no cure for the condition borders on lunacy, since there are so many different causes.

The most common cause of inflammation of the sciatic nerve is due to injuries, restricted motion in the lumbar spine or abnormal weight-bearing, or weight distribution, in the low back (detected on standing, low back x-ray). This will produce an added stress on the sciatic nerve causing the pain. The second most obvious cause of the condition is tightening of the piriformis muscle, which is a muscle that runs straight across the butt. All of us have 2 piriformis muscles, and usually only one will go into a spastic state at a time. If you think of your muscles in the low back and butt as wires holding up a flag pole, when the pole leans one way, the wire on the opposite side tightens, and that’s what happens to us.

Now, there are other causes for this condition, but none are as common as the two causes above. Despite that fact, I had a patient come in about 15 years ago with sciatic pain, and on x-raying the low back, we found an abdominal aortic aneurysm that put him into surgery within 2 days. Whether the aneurysm was in any way directly or indirectly causing the sciatic pain is unknown, but doing a thorough work-up saved this patient’s life.

Determining the Cause

Most sciatic conditions are due to long term conditions. Structural imbalances place too much stress for too long a time on one or more areas of the low back, and the sciatic nerve gets pinched. The easiest way to find out what’s causing it is to have a structural, or biomechanical exam done. This consists of a foot exam, leg lengths, low back range of motion and a variety of other structural tests. The most conclusive test is the standing low back x-ray (front and side-view), because that shows the unique structural positioning and condition of the vertebrae and disc spaces. The most important findings are the sacral base angle, the weight bearing gravity line and the quality of the disc spaces. (For more information on any of these, feel free to e mail me).

Correction

In most cases, once the exact cause is learned, proper treatment, home recommendations and exercises can be determined. Since most of us stand or walk or run a lot of the time, symptoms may take longer than normal unless we eliminate the majority of these from our schedule.

In the case of a degenerative joint, the condition may take a little longer, since the inflammation is due to a lack of motion within the joint as well as a compromise of the amount of space for the nerve to exit the joint. But, with proper treatment and home recommendations, symptoms and the condition can be improved greatly.

Treatments

A good approach to treating all conditions would start with ice treatments to the low back, since the majority of sciatic problems originate there. Secondly, the tennis ball technique on the hip muscles will greatly help to relax the piriformis muscle, thus reducing the stress on the sciatic nerve. Stretching this area could also help to take pressure off the nerve.

If custom orthotics are needed, they almost become a must, since the imbalance in the feet will continue the stress on the low back until corrected. And, as written about in prior articles, the orthotic should be flexible for the foot and fitted in a standing position.

Finally, with regard to training, running should only resume once all symptoms are gone. This may sound harsh, but sciatic problems can last a lifetime, and the only way to get rid of them and keep them gone is to “get rid of them” before you run. So, ice, treatment if needed, orthotics if needed and patience will get most runners back the soonest and keep them back the longest.

Hamstring vs. Sciatica

by Dr. Timothy J. Maggs, ©1999

One of the more difficult diagnoses to determine is that of an athlete with pain in the back of the thigh and into the buttocks. A pulled hamstring can often mimic a sciatic neuralgia, often known as sciatica. Both conditions can be debilitating and the appropriate treatment, both immediate and long term, is critical for improvement. The problem is the treatments are significantly different, so an incorrect diagnosis can delay recovery and encourage further injury.

Hamstring

The hamstring muscle is attached to the base of the buttocks as it attaches to the ischial tuberosity, which is that area of the butt that hurts after you've ridden your bike too much too soon. It runs down to the back of the knee. The function of the hamstring is to flex the knee, as happens during every stride when running. Every time the heel approximates the butt, the hamstring is doing it's job.

Usually, a pull will occur in one of two places--either in the belly of the muscle or at the attachment point at the top of the leg. Localized pain in either of these areas might be caused by a pulled hamstring. If activity such as walking or bending your knee increases the pain, and inactivity reduces the pain, a pulled hamstring is the likely diagnosis.

Sciatic Nerve

A pinched sciatic nerve is a completely different condition and should be addressed very specifically. The sciatic nerve is the largest nerve in the body. It originates as branches at the lower joints in the low back and it unites to form a nerve the size of your little finger. It then runs through the middle of the buttocks and down the back of the thighs to the knee. At the knee, it branches into two separate nerves--one continuing down the back of the calf and the other down the outside of the leg to the ankle.

Signals that suggest sciatica are varied. Radiating pain can originate in the lower back and run through the buttocks. The pain can continue down the back of the leg and possibly into the calf or the ankle, and it can be sharp. The straight leg raise (lay on your back and have someone else lift the involved leg, which remains straight, off the ground) will generally produce pain. A history of low back problems can also influence the onset of sciatica. There can also be tingling or weakness in the leg. If any of these symptoms are present, sciatic neuralgia is a likely diagnosis.

When you have a preliminary diagnosis, you can then take steps to alleviate the symptoms and the condition. Home treatment can be attempted initially. If improvements are too slow, however, or there are continued flareups, the need for professional help may be indicated.

Treatment

With a pulled hamstring, the muscle has gone through overuse and needs to heal. Localized massage will provide significant benefit as it helps to flush the muscle and increase the blood flow, which will produce a more rapid healing. Stretching should be avoided initially. Ice should be used if there is pain and inflammation. Once the pain is reduced, moist heat might be beneficial, again to increase blood flow to the injured area. Some period of rest is needed to allow for healing. Also, if necessary, an elasticized brace or support may be indicated as well as physical therapy. Obviously, you always want to do as much as you can at home to reduce unnecessary costs. When treated at home, however, discipline is the key.

Sciatic nerve involvement is generally a little trickier to solve. Conservative, at home treatment might work if the condition is a first time condition. If the condition is chronic, professional help may be indicated. At home treatment consists of some period of rest, ice to the low back (15-20 minutes at a time, 4-5 times per day) and anti-inflammatories (all natural, if available), if necessary. The tennis ball technique under the buttocks muscles several times per day for deep specific massage is beneficial as it forces relaxation of the gluteal and hip muscles which often reduces pressure on the sciatic nerve.

The cause of sciatica can be from many different conditions, such as a low back strain, a degenerative disc, a protruding disc, piriformis syndrome, hip problems or some pathology. This is when an accurate diagnosis and professional help becomes critical.

Always find out the specific cause, and the likelihood for a more rapid recovery goes way up. Too often, we hope for the American dream ("Hopefully, the problem will be gone in the morning"). Very seldom does this treatment method work. Running is a repetitive motion and the low back, gluteal muscles and hamstring absorb much of the burden making the area prone to injury. Apply a little logic and patience and your career as a runner will last a lot longer. Good luck.