by Nate Christopher, MPT at The Orthopedic Institute at Southwest Health
“I have sciatica” or a “pinched nerve” are words that are often heard in medical and physical therapy clinics. Sciatica is a general term that refers to pain that radiates into the buttocks, possibly down the thigh, and sometimes even into the lower leg and foot. This may or may not be accompanied by low back pain. The pain can range from mild to severe to disabling and can have a significant impact on daily function, work, and sleep.
I am often asked, “What are the best exercises for sciatica?” The answer to this is that “it depends” as not all sciatica is created equal! While the term sciatica describes the location of the pain, it does not indicate the cause of the pain. Sciatica can be caused by a variety of different conditions, and as a result, treatment must match the condition for maximum effectiveness. Let’s review a few of the conditions that can cause sciatica.
1) A disc bulge or herniation: This is most prevalent in younger individuals, ages 20 to 55. Often it hurts to sit, bend to pick things up, and/or bend over to tie your shoes. When very severe, it may feel like almost all activities hurt! People with a sciatic pain of this nature often demonstrate what is called a directional preference. This means that the pain improves when the back is moved in one direction and worsens when the back is moved in the opposite direction. Typically the leg pain feels better with bending the spine backward and worse with forward bending. It is usually necessary for a physical therapist to perform a comprehensive examination in order to determine the best direction and intensity of pain relieving exercises and how frequently to perform them. A physical therapist can also perform manual therapy or “hands-on” techniques to speed the recovery process and give advice on how to correct posture as well as what positions or activities to avoid while healing takes place.
2) Spinal stenosis: This usually occurs in older populations, often accompanied by age-related changes in the spine. Because the nerves in the low back have less room, they can feel “pinched”. Usually with spinal stenosis walking and standing feels worse, and sitting feels much better, which is again a directional preference meaning the spine “likes” one position or posture more than the other. People with spinal stenosis often exhibit a “shopping cart sign” in which they tend to lean forward against the cart when shopping and walking, as this alleviates their leg pain. This condition is often responsive to stretching of tight muscles of the hip and back region, as well as manual techniques performed by a physical therapist to increase mobility and modulate pain. As physical therapists, we can tailor an exercise program to fit your specific condition and characteristics.
3) Piriformis syndrome: This is a less common cause of sciatica. The piriformis (pronounced “peer-ee-form-us”) is a muscle that runs perpendicular to the sciatic nerve across the buttocks. This muscle can become tight or irritated with faulty posture or trauma, though sometimes the pain can seemingly come out of nowhere. People with piriformis syndrome are often very tender to the touch in the mid buttock and tend to be most uncomfortable when sitting. Treatment for piriformis syndrome consists of heating the muscle, stretching the piriformis, strengthening to correct muscle imbalance, and correcting postural habits that may be contributing to the irritation. Manual techniques geared towards relaxing the muscle, improving mobility, and modulating the pain can also be very effective.
These are just a few common causes of sciatica. In most cases, sciatica can be treated conservatively with physical therapy and without the need for surgery or invasive treatments. In scenarios in which “red flags” or signs and symptoms that may indicate more serious diagnoses are present, imaging such as x-rays, CT scan, or MRI may be necessary. These tests can assist in ruling out a fracture, cancer, infection, or severe nerve impingement. Red flags that raise the suspicion of fracture include a history of trauma corresponding to the onset of the pain, especially in people with osteoporosis or at risk of osteoporosis. Other “red flags” include prior history of cancer, unexplained weight loss, constant pain that does not change with activity or position, or sciatica that is accompanied by severe loss of strength in the leg, saddle anesthesia (numbness or tingling in the region that would touch a saddle if riding a horse), or changes in bladder or bowel control.
Screening for these conditions is performed at a physical therapy evaluation, and if present, you will be referred to a medical provider for further evaluation. However, in most cases, sciatica is very responsive to physical therapy. The first step is talking to your primary care practitioner about getting a referral for physical therapy, so you can get back to enjoying life without sciatica!
Nate Christoper, MPT holds his Master of Physical Therapy from UW-Madison and is a Board certified Orthopedic Clinical Specialist. He is also trained in McKenzie (spine care diagnosis and treatment), Mulligan (manual therapy), and Graston Techniques. Nate’s special interests include orthopedics, sports medicine, post-operative rehabilitation, joint replacements, injury prevention, and exercise for falls prevention. He is a co-investigator on research projects regarding yoga practice and falls prevention as well as a guest lecturer for Southwest Tech’s Physical Therapy Assistant program. For more questions visit orthopedic-institute.org or call 608-342-4748.