Sciatica is a nerve compression syndrome that can be extremely painful and difficult to manage for both the patient and practitioner. Sciatic pain often affects the lower back, gluteal region, and various areas of the leg and foot. Often, the symptoms effect only on one side of the body.
Sciatica can be caused by a disc herniation, compression of the lumbar nerve roots, spinal stenosis, and/or entrapment of the sciatic nerve along its path from the lumbar spine down the leg.
Most cases of sciatica are mechanical in nature (98%) and are not secondary to some other pathological process (Infections, tumors, blood clots).
The sciatic nerve is a very long nerve that extends from the hips down the back of the leg, to the heels. Sciatica symptoms vary depending on just where the sciatic nerve is impinged or restricted. Symptoms include:
- Pain when you sneeze or cough
- Pins and needles in your legs
- Burning or tingling down the leg
- Pain in the rear of the leg that gets worse when sitting
- A continuous, constant pain on one side of the buttocks and leg
- Weakness, numbness or difficulty moving the leg or foot
- A shooting pain that makes it difficult to stand up
- Pain that feels like a bad leg cramp, but which can last for weeks
Sciatica that is caused by a disc herniation is often precipitated by a lifting or twisting injury. This type of injury will often cause pain to shoot down the leg when a person coughs or sneezes. This pain can be reproduced by what is called a Valsalva maneuver. In this test you cough or bear down, as during a bowel movement. If you have a herniated or bulging disc, you will get pain shooting down the affected leg.
On examination of the patient the physician will notice changes in sensation that are specific to the discs that have been ruptured. These specific areas of sensation are called dermatomes. A dermatome is an area of your body associated with a specific pair of dorsal nerve roots from the spine. The most common pattern is a L4 to S2 distribution.
Argoff CE, Wheeler AH. Backonja MM, ed. Spinal and radicular pain syndromes. Philadelphia, WB Saunders: Neurologic Clinics; 1998:833-45.
A disc herniation may also cause changes in deep tendon reflexes to occur. Deep tendon reflexes provide information on the integrity of the peripheral and central nervous system. Usually, decreased reflexes indicate a peripheral nervous system problem, increased reflexes indicate a central nervous system problem.
Fortunately the majority of cases of sciatica caused by a disc herniation do not require surgery. Only 5% of disc cases require surgery. Most of these cases can be treated with manual therapy (ART, Manipulation), lifestyle management, and exercise.
Sometimes the nerve roots in your lumbar spine can get hung up or restricted at an area called the vertebral foramina. These foramina are the passages in the bones of the vertebra through which nerve roots pass. Each foramina varies in size depending on location.
In conventional medicine, when this foraminal compression occurs a medical operation called foraminotomy is performed to remove the pressure on the nerve roots. This nerve root compression can be caused by bone compression (from arthritic changes), disc herniation, scar tissue, or excessive ligament development
In many cases where the restriction is caused by a soft-tissue obstruction, Active Release procedures can release the restriction. Some of these procedures are taught in the “Long Tract Nerve Courses”. These nerve gliding procedures use patient body motion to help free up the restriction at the foramina. If the sciatica and related symptoms are due to a soft-tissue restriction the patient will often see some immediate improvement.
Spinal stenosis is a condition in which the spinal canal narrows (MRI photo), compressing the spinal cord or the nerves that branch out from the spinal cord. Serious cases of stenosis do require surgery. Milder cases of spinal stenosis can be treated non-surgically. Spinal stenosis can be caused by numerous factors such as disc herniations, thickening of ligaments, trauma (motor vehicle accidents), and spinal tumors.
Symptoms of spinal stenosis are:
- Leg pain that gets worse with walking and improves with bending forward or sitting. Generally the pain will only be on one side of the body. The degree of pain will depend on the amount of impingement.
- Muscle cramping in the legs. This cramping is usually worse going down hill and much better when the patient leans forward.
- RED FLAG – Loss of bowel or bladder function is an indication of cauda equina syndrome. This is a medical emergency, seek medical attention immediately.
To determine if you have spinal stenosis an MRI (Magnetic Resonance Imaging) test may be needed. Normal X-rays will not rule out spinal stenosis.
Mild to moderate cases of spinal stenosis usually respond very well to a combination of manual therapy, exercise, and activity management.
Manual therapy cannot remove the cause of spinal stenosis, but it can remove a considerable amount of mechanical stress from the spine and improve spinal stability. This is often enough to help the patient reduce pain and improve overall function.
Of all the causes of sciatica, in my opinion peripheral nerve entrapment is the most common. One of best known examples of sciatic nerve compression is piriformis syndrome. The piriformis muscle is one of the external rotators of the hip and leg. This muscle helps to turn the foot and leg outward. If the pirformis muscle is overworked it can become tight and restricted, compressing the sciatic nerve.
This type of compressive syndrome can actually happen anywhere along the entire length of the sciatic nerve. Active Release procedures can be effective at releasing these restrictions. I have used these procedures in my clinic for many years with very good results in the majority of cases. Of course to achieve good results the ART practitioner will have to have taken the correct ART courses and have a degree of experience in treating this condition.
Exercise programs for sciatica should focus upon returning your body to a state of full function without further injuring yourself in the process. Rehabilitation requires patience and time! Your body needs time to heal from your injuries. Many people, in their enthusiasm to heal themselves, often make their injuries worse by not giving their body sufficient time to recover.
To address sciatic nerve entrapment you must do specific exercises, but the type and combination of exercises will vary depending on the cause of the sciatica.
- Extension exercises often work well for sciatica caused by disc injuries.
- Sciatica caused by stenosis often responds well to flexion exercises.
- Sciatica that is caused from peripheral nerve entrapment (the most common cause) often responds to nerve flossing exercises that are combined with core stability training.
A nerve flossing exercise is a procedure in which a nerve is minimally tensioned, while performing a specific motion. A common analogy compares flossing your teeth with nerve flossing. However, in this case, the floss is your nerve, and instead of moving between your teeth, you are moving the nerve through soft tissue structures that may be entrapping that nerve.
Click on the following link for an example of a Sciatic Nerve Flossing exercise video.