If you mainly have low back pain, please change articles: you need to be reading Save Yourself from Low Back Pain!
Sciatica is a symptom — shooting pain in the buttock and down the back of the leg, which is caused by irritation of the sciatic nerve by one of several mechanisms. It is often associated with back pain, but it can happen independently. There are several related scenarios that can cause buttock and leg pain, and a sciatic nerve pinch is much less common than simpler muscle pain. Even when the sciatic nerve is being pinched, this is often a relatively trivial side effect of muscle pain — help the muscle, and the pinch goes away.
Here are several ways that you can have sciatica:
Each of these scenarios involves muscle knots. To a great degree, muscle knots are either a cause and/or a complication of sciatica. Trying to treat them is often a good way to intervene — to break the grip that piriformis has on the sciatic nerve, or to improve the soft tissue environment of unhappy lumbar nerve roots. By no means is it guaranteed to work, but it’s quite easy, inexpensive, and safe to make the attempt.
Rarely is the problem “mechanical” in nature, despite the popularity of this view among virtually all health care professionals. Chiropractors are particularly prone to diagnose a sciatica problem as a symptom of some kind of joint dysfunction, alignment, or postural problem. The sacroiliac joint is often diagnosed as being “out,” and the lumbar joints are portrayed as being fragile and vulnerable when quite the opposite is true. Although chiropractors are most likely to diagnose in this way, physicians, physiotherapists and massage therapists are all equally prone to this kind of “structural” diagnosis…missing the most straightforward explanation and treatment opportunity.
The intervertebral discs are little pucks of tough, fibrous material between vertebrae. Disc herniations — often misleadingly called “slipped” discs — are associated with sciatica. When a disc herniations enough, it may irritate nerve roots emerging from the spine, and be the main cause of sciatica.
But do not fear disc herniations! No matter how bad it looks on a CT scan or MRI, it is not necessarily the cause of the problem. Herniations correlate very poorly with pain. They are routinely a distracting sideshow that unnecessarily worries people.
“Slipped” discs usually un-slip. This is called “resorption” — a nifty back trick that most people are unaware of (including too many healthcare professionals still). Most herniations, roughly 60%, just go away, like a snail tucking back into its shell, according to about a dozen studies.4
And of course a disc probably does not have to fully de-herniate to resolve sciatica.
It can be difficult to tell the difference between the pain of trigger points and true sciatica nerve or nerve root impingement. And bear in mind that, even when it is possible to identify actual nerve impingement, the main problem is probably still muscular. The two problems are generally treated in much the same way.
The clearest sign of nerve impingement is significantly altered sensation below the knee, either:
Another relatively clear sign of nerve impingement is:
Nerve impingement pain is technically called “lancinating” pain. It is typically hot or sharp, instead of diffuse and aching. Most people strongly agree that it feels “electrical.”
However, do not be too convinced by the quality of the pain alone: trigger points are quite capable of causing pain that feels exactly like nerve pain.
Trigger points rarely causes a “pins and needles” sensation, so if you have pins and needles, that is a pretty strong indication of nerve impingement. But even then, you can’t be sure, because trigger points do occasionally cause a very nervy tingling.
The only symptom that is virtually guaranteed to be caused by nerve impingement alone is true tactile numbness. If you have a “dead” patch of skin, then you almost certainly really do have a pinched nerve.
However, even then, some uncertainty remains. Although trigger points cannot cause a truly numb patch of skin, they can (and routinely do) cause a feeling of “dead heaviness.” People routinely start an appointment for sciatica by telling me that their leg is numb — but after a little discussion, it becomes clear that they mean that the leg feels sick, heavy, weak and useless … but not actually numb to the touch. Without numbness to touch, nerve impingement cannot be diagnosed, and by far the more likely cause of the symptoms are a batch of nasty trigger points in the low back and hips.
This difference between nerve impingement and trigger points can be extremely difficult for patients to wrap their heads around, so I’ll go into more detail in the next section. But first, a delightful patient quote of the day from Dr. Grumpy:
“The pain went down through my legs. Not all my legs, I mean, but just the ones on the bottom of my body.”
And if you think that’s weird, you should see my inbox.5
I came across this full-page advertisement in National Geographic magazine:
“Do you feel burning pain in your feet?” the ad asks. “Or uncomfortable tingling, numbness, stabbing, or shooting sensations? If so, you may have nerve pain.”
Yes, you might. But it’s not bloody likely! The clinical reality is that neuropathy is a lot less common than nearly all patients and most doctors believe.
Nerves make people nervous! So to speak. The whole idea of nerves gets people anxious. Could it be a nerve? people ask. Is this a nerve problem? What if it’s a nerve? Is something pinching my nerve? Something must be pinching a nerve.
The kind of advertisement with the stinging ants you see above greatly aggravates our society’s general anxiety about nerves. Pfizer and other pharmaceutical companies spend about a gazillion dollars on marketing that can create more worry about nerve pain in a year than I can counteract in an entire lifetime of low-budget public education! Bummer.
It’s amazingly difficult to actually pinch most nerves, or nerve roots (as they exit the spine). In general, nerves have extremely generous “wiggle room.” For instance, in the lumbar spine, the holes between the vertebrae that the nerve roots pass through can be more than a couple centimetres at their widest, while the nerve roots themselves are only about 3-4mm thick.6 If you stretch or compress the spine, the holes do change size a little — as much as 70–130% in the looser neck joints,7 a little less in the low back.8 But even at their smallest, there’s still plenty of room.
There’s so much space for nerve roots that even dislocations routinely fail to cause impingement.9 Once again, I invoke the example of a patient with a severe lumbar dislocation … and no symptoms at all, not even symptoms of pinched nerve roots. Her nerves seemed to be fine, even in an anatomical situation most people would assume to be extremely dangerous.
Yesterday I was working with a young woman who had “sciatica.” Allegedly, her sciatic nerve was pinched by her piriformis muscle — a reasonably common scenario — and sending hot zaps of pain down her leg. She came to me with this diagnosis already in place. She also had some tingling in her feet. The description of her symptoms did, indeed, sound a lot like a nerve impingement problem. On the face of it, it did seem likely that her sciatic nerve was being pinched.
However, a couple things didn’t add up. For instance, she had no numbness at all — no dead patches of skin, which are highly characteristic of true nerve impingement. Instead, she had a lot of “dead heaviness” in the leg, a different kind of numb feeling that is much more closely associated with muscle knots than nerve pinches — and a lot more common.
I quizzed her carefully about the quality of her pain. She assured me it was “zappy” and “electrical” … just as you would expect of nerve pain. Yet something didn’t seem quite right. I couldn’t shake the impression that she was interpreting an intense non-neurological pain as a “zappy” pain simply due to her strong belief that she had a nerve problem. When you think a pain is nervy, you’re going to interpret, feel and describe it in nervy terms.
So I did some experimenting, and clinched the case:
This young woman’s “nerve” pain could be perfectly reproduced by prodding muscle tissue that was nowhere close to the sciatic nerve. Pressing on the side of her hip, on the gluteus medius muscle, several centimetres away from the sciatic nerve, she reported the same “electrical” pain flowing down her leg. It even stimulated the weird, tingling sensations in her foot.
This largely eliminates a diagnosis of sciatic nerve impingement.
In spite of spending most of my career trying to explain to people that this sort of thing is common, I was surprised myself — fooled, really. Muscle knots are always fooling patients and professionals alike. Vastly more common than nerve problems, and often more painful, they nevertheless get upstaged and misdiagnosed by another phenomenon.
Do you feel burning pain in your feet? Or uncomfortable tingling, numbness, stabbing, or shooting sensations? If so, you are more likely to have “muscle knots” than nerve pain.
The take home message of this section is: do not underestimate the power of trigger points to cause pain that seems like a nerve pinch.
Most cases of sciatica will resolve on their own, with no special treatment, within 3–6 weeks, just like low back pain or a crick in the neck. Most people will never have the problem again, or only once or twice more in their lives.
The worst cases are completely debilitating for brief periods, but most of the time cause only extremely annoying pain that makes daily activities frustrating, but not actually impossible.
Unfortunately, a minority — perhaps 20% of patients — will become chronic and/or recurrent sufferers.10 An even smaller, unluckier minority of sciatica sufferers face a lifetime of pain that never or rarely leaves, or episodic pain that inevitably returns. Stubborn cases may be at least partially explained by genetics,11 and this one of the important reasons why patients need to be wary of therapeutic wild goose chases looking for the cause of their pain.
Once any kind of pain has been around for a while, it has the potential to actually damage the way the nervous system interprets pain — this is known as “central sensitization,” meaning the central nervous system has become oversensitive to pain.12
The next several sections go over some of the treatment options for sciatica. In summary, most people should avoid surgery, as it simply does not provide that much benefit. However, it may be a worthwhile option for very painful cases of sciatica. For everyone else, the best therapy is to try to “act normal” as much as possible — reduce fear and anxiety, move as much as reasonably possible, stretch and wiggle, keep the surrounding muscles happy with heat, and so on.
Surgery for sciatica is only an option when it is caused by a herniated disc, as opposed to when the sciatic nerve is being impinged by the piriformis muscle, or (obviously) if sciatica-like symptoms are being generated by muscle knots alone (or something else altogether).
Even when there is a herniated disc, surgery should be seriously considered only in the most painful and persistent cases. As with most orthopedic surgeries, as of 2017, most of the evidence is poor quality and discouraging and what shreds of good news there are cannot really be trusted.13 There’s barely any difference between people who get surgery versus people who just focus on basic activity-based rehab. I’ll go over some specific research examples below.
Bear in mind that herniated discs are not necessarily painful. Even if they have made an appearance on an MRI, that does not necessarily mean that they are related to your problem. Or it might be. The idea of microdeskectomy is to cut away the disc that might be irritating the spinal nerve roots that the sciatic nerve comes from.
In 2008, a group of Dutch researchers published the results of a good study of surgery for sciatica.14 Although not perfect, it is one of the best such experiments available, and will be more or less the “last word” on the subject for a while, the new-and-improved conventional wisdom. This remains the case as of 2017. (It is also quite readable for a scientific paper, and keen patients or professional readers might want to browse the full paper, which is freely available.)
Peul et al found that operating relatively quickly — not long after diagnosis — “roughly doubled the speed of recovery from sciatica compared with prolonged conservative care.” However, that sounds a lot better than it actually was: the speedy recovery didn’t last for long. In fact, “These relative benefits of surgery, however, were no longer significant by six months’ follow-up, and, even at eight weeks, the statistically significant difference between treatment groups in primary outcome scores was not sufficient to be clinically meaningful.” In other words, the effect of early surgery was quite underwhelming. A graph shows this very clearly:
That pretty much says it all, doesn’t it? For your trouble of getting cut open, you get a modest dip in pain in the early days, but soon after, you’re back in the same boat as the fellow who didn’t bother. “Neither treatment is clearly preferable,” the researchers concluded. They argued that it might be time to stop recommending surgery based on physician preferences, and start asking patients what they think of the options.
This study is less positive than some previous ones have been. However, it was a more carefully controlled test, and gives us many reasons to put more stock in its results. In fact, the results are so conclusive that authors wonder “whether surgery has any effect at all on the natural course of sciatica.”
I have been arguing for years that back surgeries need to be compared to sham surgeries if we are ever to truly know if they work, so I was particularly pleased that these scientists suggest exactly that. There are major challenges with comparing real surgeries to sham surgeries, but it can and has been done, with fascinating and routinely disappointing results.15Does surgery have any effect at all on the natural course of sciatica?
Slightly faster recovery and relief of leg pain might be worthwhile for some patients. However, much of this eagerness (and probably some of the pain) is driven by fear — back pain and sciatica have a unique ability to scare the pants off patients.
The risks of microdiscectomy are low as surgeries go, but there is still a considerable financial, personal, and social “overhead” any time people get cut open. We should avoid any kind of invasive medical procedure unless the benefits are extremely clear. Like a charge of murder, it should probably be proven “beyond a reasonable doubt” that surgery is worthwhile. Such proof is simply not present in this case of surgery for sciatica!
So, if you’re not going to get operated on … what else can you do?
Whether the pain is caused by the crushed sciatic nerve itself, or just by tight muscles, the muscles need to relax in either case. Hot tubs, with jets, are ideal for all kinds of sciatica.
Due to the thickness of the tissue in the buttocks, the heat will not have any circulatory effect on the nerve or the piriformis muscle, but it will be neurologically sedative. The vibration of jets will amplify that effect. Muscles relax when they are vibrated — a neurological effect known as “proprioceptive confusion.”
(If you live in Vancouver, see the footnote for a great local tip.16)
To get the most out of using any hot tub, see A Better Hot Bath.
The muscles of the hip and buttock are one of the few places in the body where it is possible to effectively treat your own muscle knots with a tennis ball. Simply lie on a tennis ball such that it presses on deep, aching sore points — and wait for the sensation to fade. See Tennis Ball Massage for Myofascial Trigger Points for more information. I do have one caution about treating yourself in this particular case: the piriformis muscle is so unusually reactive, in my experience, that you must be particularly gentle and conservative in your approach.
Bed rest has been a popular treatment for sciatica for the better part of the last century. It’s more or less dying — most doctors know that it doesn’t work these days, and don’t prescribe it. But you still run across this myth from time to time.
In a 1999 sciatica study in New England Journal of Medicine,17 researchers “randomly assigned 183 subjects to either bed rest or watchful waiting” for two weeks and found that “bed rest is not a more effective therapy than watchful waiting.” Nor is less effective. The results were exactly the same. If that sounds like no big deal, consider the difference in the lives of those patients! Two weeks of bed rest? Compared to two weeks of going about your business!
Exercise is the closest thing there is to a miracle cure in musculoskeletal medicine (or any kind of medicine).18 Rather than bed rest, you should try to stay as active as possible, mostly working within the limits imposed by the pain. As shown by Fernandez et al (covered above), this is probably just as good as surgery for most people, certainly in the long run. Also, you don’t need to bother with any special “technical” therapeutic exercises (like core strengthening, training specific muscles, or working on coordination) — also shown by Fernandez et al (in a different paper in 2015).19 Supervised, “structured” therapeutic exercise — allegedly tailored for the treatment of back pain and sciatica — are only slightly more effective than simply advising patients to stay active in the short term … and no difference at all in the long term).
So you might get a little bit of an edge by getting a physical therapist to give you a rehab regimen, but not a big one. But if you find it hard to be active at the best of time, perhaps the investment in some expert assistance is valuable for motivation and focus if nothing else!
But you can also just “keep it simple stupid,” and a great example is to do mobilization exercise…
Mobilizations are basically active or “dynamic” stretches and rhythmical movements that “massage” your muscles and joints with movement — wiggle therapy. It involves a lot of moving a joint through its full range, without resistance — an easy exercise. What makes it a therapeutic is a little bit of method: systematically and repetitively exploring range of motion.
For sciatica, just move your hips and low back in as many ways as you can think of: toe touches, swinging your hips in circles, lunges, etc. Figure how far you can comfortable move your low back, pelvis, and hip joints and then go up to the edge again and again. A mobilizations regimen for chronic sciatica might involve a 10 minute ritual a couple times per day of batches of hip circles, toe touches, and lunges.
Read more about mobilizations.
When stretching for sciatica, please stretch very gently and calmly: the piriformis muscle, which is producing the pain directly or indirectly, tends to be reactive in character. It needs to be gentled. The focus of the stretching should be neurological, not mechanical — that is, slowly get the muscle “used to” a greater length and lower tone. There are at least two stretches that are particularly useful in this scenario.
Piriformis stretch (seated version) — starting from a seated position, place your ankle (on the side you’re stretching) over the opposite knee. Let your lifted knee relax downwards for a moment, and then begin to lean forward from your pelvis. Avoid simply slumping forward, which is useless. The image that is the key to this stretch is to “push your belly button between your legs.”
Piriformis stretch (prone version) — lie down on your belly. Lift your lower legs straight into the air, and then let them fall out to the sides. Relax them there, but don’t let them fall out of position. This is a very low-intensity stretch — you probably won’t even feel it. This stretch works best if you sustain it for several minutes at a time, or even long periods. You can intensify it by wearing heavy boots or ankle weights, or by getting someone to help you by gently pressing your legs out to the sides.
Ordinary sitting involves significant spinal flexion near the end of the lumbar spine range of motion, and could conceivably constitute “poor posture.” The tissue stagnancy of long hours in a chair, suspected of being unhealthy in other ways, seems like another obvious cause for concern. And yet … back pain and sciatica are actually not linked to sitting a lot.
People who sit a great deal in ordinary chairs at work have, at worst, only slightly more back pain than people who get more activity and stand more at work20 — but many studies have found no evidence of this at all.2122 And if seriously chronic stagnant spinal flexion isn’t a problem, or not much of one, probably no other minor poor posture is either.
Sciatica and “back pain” aren’t synonymous, and because sciatica may involve disc herniation that can be slightly aggravated by spinal flexion, sitting probably is more of a problem for some sciatica patients. If sitting makes your pain worse, avoid it! But sitting a lot should be regarded more as an aggravating factor to minimize during recovery than a cause of sciatica to be worried about avoiding long term — an important distinction.
Obviously awkward postures are a problem, and so is vibration, exemplified in helicopter pilots, who get about four times more back pain than most people.23 It makes complete sense to try to fix any challenging or awkward posture that you are forced to deal with regularly — but that’s so obvious it hardly needs to be said. If it’s not obvious, it’s probably not a problem.
There’s no evidence that sciatica is caused by any common ergonomic deficiency in office chairs, no evidence that any kind of chair — no matter how special or clever — can prevent or treat back pain. If you like fine and comfy office chairs, by all means treat yourself to a fancy ergonomic chair. But don’t buy it to help with your sciatica!
If you have a chair that specifically seems to aggravate your sciatica, by all means replace it — just replace it with an ordinary chair that doesn’t aggravate your sciatica.
Despite the lack of a link between sitting too much and back pain, I still recommend that people take frequent microbreaks from sitting and use them to exercise gently — small batches of rhythmic stretches are the most practical — because even if sitting still a lot isn’t the problem, activity is one of the best possible ways to deal with all kinds of pain. And sitting too much is generally a bad idea.
Over-the-counter (OTC) pain medications are fairly safe in moderation and work in different ways, so do experiment…cautiously. There are four kinds: acetominophen/paracetamol (Tylenol, Panadol), plus three non-steroidal anti-inflammatories (NSAIDs): aspirin (Bayer, Bufferin), ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn). Don’t take any of them chronically — risks go up over time, and they can even backfire and cause pain (rebound headaches). Acetominophen is good for fever and pain, and is one of the safest of all drugs at recommended dosages, but overdose can badly hurt livers and it doesn’t work well (at all?) for musculoskeletal pain. The NSAIDs are a better bet (Derry 2015): they reduce inflammation as well as pain and fever, but at any dose they can cause heart attacks and strokes and they are “gut burners” (they can badly irritate the GI tract, even taken with food, and especially with booze). Aspirin is usually best for joint and muscle pain, but it’s the most gut-burning of them all. Voltaren® Gel is an ointment NSAID, safer for treating superficial pain.
Voltaren is so useful and relatively safe that it’s probably worth a shot, but unfortunately sciatica is one of the least likely kinds of pain to be affected by a topical pain-killer: the tissue is just too thick.
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
Ten updates have been logged for this article since publication (2006). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more
When’s the last time you read a blog post and found a list of many changes made to that page since publication? Like good footnotes, this sets PainScience.com apart from other health websites and blogs. Although footnotes are more useful, the update logs are important. They are “fine print,” but more meaningful than most of the comments that most Internet pages waste pixels on.
I log any change to articles that might be of interest to a keen reader. Complete update logging of all noteworthy improvements to all articles started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.
See the What’s New? page for updates to all recent site updates.
— New section: “Disc herniations are much less of a problem than most people think.”
— Exercise and surgery updates related to two valuable new citations, both from Fernandez et al. Improved the mobilizations section especially.
— Threw out the stale, simple old section about posture and ergonomics and wrote a completely new one.
— Minor update. Edited sciatica surgery section.
— Added a section about over-the-counter pain-killers.
— Corrected some minor technical errors.
— Added reference concerned genetic causes of chronic nerve pain.
— Added information debunking bed rest as a treatment option.
— Revisions are moving slowly! However, added a major new section today, “What about surgery?” which is based on some excellent new research evidence from Dutch scientists. Made a few other minor improvements at the same time.
— Began revisions by doing a wide variety of minor improvements to the introductory sections.
This dissection study of 275 dead buttocks found that 6.4% of them had variations of sciatic nerve and piriformis muscle anatomy, with considerable variety in the variation. They found several different arrangements, and concluded: “Some rare, unclassified variations of the sciatic nerve should be expected during surgical intervention of the region.” Prepare to be surprised, surgeons!
All of these differences are potentially clinically significant, probably especially in the cases where the nerve (or part of it) passes right through the muscle. For a couple case studies, see Arooj 2014 and Kraus 2015.BACK TO TEXT
Researchers dislocated neck joints in corpses to measure the effect on the size of the intervertebral foramina. (Interesting chore!) Dislocation made the spaces quite a bit larger, indicating that any nerve root pain associated with these injuries “is probably due to distraction rather than due to direct nerve root compression.”BACK TO TEXT
Mark your calendars: 2010 was the year researchers confirmed a gene as “one of the first prognostic indicators of chronic pain risk,” doubling or tripling the odds that a low back pain patient will recover in a timely fashion from nerve root injury. Screening for this gene is not yet something that is clinically available, but it probably will be someday, and then you will know: the universe really does hate you.BACK TO TEXT
Pain itself often modifies the way the central nervous system works, so that a patient actually becomes more sensitive and gets more pain with less provocation. That sensitization is called “central sensitization” because it involves changes in the central nervous system (CNS) in particular — the brain and the spinal cord. Victims are not only more sensitive to things that should hurt, but also to ordinary touch and pressure as well. Their pain also “echoes,” fading more slowly than in other people.
For a much more detailed summary of this paper, see Central Sensitization in Chronic Pain.BACK TO TEXT
Based on a review of twelve mediocre trials, surgery for disc herniation causing sciatica is only a modestly superior treatment to physical activity and only in the short term; in the long term, there’s no important difference. Surgery for stenosis and spondylolisthesis was more decisively superior to exercise in the short and long term, but this good news still cannot be trusted. We need to take any seemingly good news about surgery with a grain of salt. Conclusions based on anything less than data from placebo-controlled trials is highly suspect, as shown ad nauseum about several other orthopedic surgeries (see Louw et al and related papers). This good-ish news is mostly based on comparative benefits, patient reported outcomes, and cost analyses… and that’s just not good enough anymore. Garbage in, garbage out!BACK TO TEXT
This review of a half dozen good quality tests of four popular orthopedic (“carpentry”) surgeries found that none of them were more effective than a placebo. It’s an eyebrow-raiser that Louw et al could find only six good (controlled) trials of orthopedic surgeries, and all of them were bad news.
Surgeries have always been surprisingly based on tradition, authority, and educated guessing rather than good scientific trials; as they are tested properly, compared to a placebo (a sham surgery), many are failing the test. This review introduction is excellent, and does a great job of explaining the problem. As of 2016, this is the best single academic citation to support the claim that “sham surgery has shown to be just as effective as actual surgery in reducing pain and disability.” The need for placebo-controlled trials of surgeries (and the damning results) is explored in much greater detail — and more readably — in the excellent book, Surgery: The ultimate placebo, by Ian Harris.
The surgeries that failed their tests were:
This is the primary authoritative source of the quote “exercise is the closest thing there is to a miracle cure.”BACK TO TEXT
This review of 35 scientific papers (8 of them high quality) about sitting-while-at-work as a risk factor for low back pain found that the “extensive recent epidemiological literature does not support the popular opinion that sitting-while-at-work is associated with LBP.”BACK TO TEXT
This review of 18 studies of risk factors for low back pain confirmed strong evidence of no link to sitting, standing, walking, or common amateur sports; “conflicting” evidence about leisure activitiues like gardening, whole body vibration, hard physical work, and even “working with ones trunk in a bent and/or twisted position”; and no evidence of any quality about sleeping.BACK TO TEXT