Sciatica is a term for pain radiating down the leg. It is a general term like “car.” It doesn’t tell us where the injury is located or how much the tissue is damaged. Sciatica can be caused by several different injuries and types of hurt tissue. How, when, and where the pain radiates down the leg gives us indications of the actual injury.
During the examination different tests will be utilized to differentiate between different injuries. Often an MRI does not need to be utilized if the orthopedic testing can give us the necessary answers about the injury.
Not all radiating low back pain is the same and should be treated differently. Each cause of sciatic back pain responds to different treatments. A proper examination and treatment can speed any recovery and quickly get you out of back pain.
Below are several examples of conditions that cause radiating low back pain.
PIRIFORMIS SYNDROME BACK PAIN VS. DISC HERNIATION
Piriformis syndrome is a commonly missed diagnosis and injury. The piriformis muscle is located under the gluteal muscles from the sacrum to the femur. When the large muscle is injured it spasms and can compress, or entrap, the sciatic nerve. Entrapment of the sciatic nerve can trigger severe pain radiating from the butt down to the foot, numbness, weakness, tingling, or a deep ache. Some people describe more burning or a constant ache in their gluteal and hamstring regions.
The pain and tingling symptoms can look very similar to a disc herniation. Both conditions have pain that is worse when getting up from a seated position, going up and down stairs or prolonged walking. Positions that relieve the sciatic pain are the same for both piriformis syndrome and disc herniations.
Proper examination and orthopedic testing differentiates disc herniations from piriformis syndrome. The exam is critical. We have commonly seen people who have been misdiagnosed with a disc herniation and have been treated with traditional disc treatments for weeks.
A disc herniation will increase the sciatic pain whenever tension is increased on the sciatic nerve, such as with straight leg raise test, Braggard’s test, or Slump test. The radiating pain should also increase with tests that increase in abdominal pressure, such as with sneezing (Valsalva’s test), Milgram’s, or Bechterew’s test. The above mention orthopedic tests increase the stretch or compression on the sciatic nerves and positive findings are indicative of herniated discs.
A differentiating test between Piriformis Syndrome and spinal disc herniations are that the radicular pain can be significantly increased or decreased by changing the hip angle. Moving the hip and leg changes the piriformis muscle spasm levels. By decreasing the piriformis pressure on the sciatic nerve the radicular pain subsides, and then increases with the opposite movement in Piriformis Syndrome. With lumbar disc herniations the sciatic pain will not change during the procedure.
The other big differentiating test is pushing on the piriformis muscle and gluteal area. If pressure on the muscle reproduces the radiating pain it indicates the problem is coming from that region. Likewise, releasing hand pressure will get rid of the pain. Palpation of the piriformis muscle will not affect the radiating pain from a lumbar disc herniation.
When a treatment protocol for piriformis syndrome is introduced the sciatic leg pain, numbness, and tingling is quickly improved. Chiropractic, physical therapy, massage therapy, and laser treatments focus on decreasing the piriformis muscle spasms and sciatic nerve entrapment.
Lumbosacral sprains can radiate pain from the low back down the leg. There are stabilizing ligaments that connect the lumbar spine to the pelvis. Injuries that stretch the ligaments can cause enough injury to produce the radiating sciatic pain.
Think of the ligaments as rope, it is meant to be keep something from being pulled apart. However, a large and sudden force can stretch and damage the rope fibers. Low force repetitive pulling over time can often stretch the rope fibers and cause damage. The “rope fibers” become frayed and need to repair. However, during the repair process they are constantly being pulled on with normal activity, further damaging the fibers and preventing healing. This is one reason why the pain can last for months, or become a chronic source of pain over years.
Common injury mechanisms include bending forward and twisting, especially when lifting. Repeated forward bending, twisting, sitting, or pulling can quickly injure the ligaments. People often describe a sharp stabbing low back pain than begins to radiate down the leg over a few days.
The pain is usually worse in the low back. It can be a constant dull ache with sharp stabbing pains with movement, getting up from seated positions, twisting, leaning forward, and extending backwards. The pain radiates down the low back into the gluteal, hamstrings, leg, and even the foot. Usually the sciatic pain stops at the knee, but the pain can travel past the knee in more severe injuries.
Treatment utilizes chiropractic, physical therapy, massage therapy stretching, exercises, traction, ice, electric, and laser to decrease the pain and inflammation. Therapy speeds the healing of the injured ligaments, reducing the sciatic pain, limitation, muscle spasms, and returning you to normal activities.
This is an injury that can easily become chronic. People describe this as a chronic source of pain. It used to be a mild ache with activity a few times a year. It then begins to occur more often and be more severe. Eventually people describe pain constantly occurring in the low back with any prolonged sitting, bending, or lifting activity. They then can experience several episodes of radiating sciatic pain per year. The sciatic pain usually only lasts for a few days or a week per episode, but is becoming more common and severe with time.
Sacroiliac Sprains are a very common injury that causes radiating leg pain. The sacrum is the bone at the base of the spine, with an ilium bone on each side. The sacroiliac joint is slightly off center at the belt line. It feels like a “nub in your low back.”
The sacroiliac joint slides back forth as we walk or run. Sitting causes the joints to be flexed forward stretching the joint ligaments. Injuries often occur with chronic sitting, such as on long car rides or plane flights. The sacroiliac is being slightly stretched and strained for hours, which leads to the injury and back pain. Sacroiliac injuries also occur with bending and twisting activities. It is a common injury after moving furniture, working in the yard, or any heavy lifting activity.
When the ligaments that surround the sacroiliac joint are stretched it can produce a localized dull and sharp pain at “the nub.” The pain can also radiate from the joint into the gluts and hamstrings. The sciatic pain usually does not go past the knee, but it can radiate to the foot in more severe injuries.
Several orthopedic tests identify the sacroiliac pain. Usually people point directly to the sacroiliac joint and say right here! It always starts here. The pain travels down the leg from here with getting up from a seated position, bending, and lifting.
DECOMPRESSION MAKES A SACROILIAC SPRAIN WORSE
Spinal disc decompression treatments make this area worse because it stretches the injury the wrong direction. Treatment is about getting the pain and inflammation down first. Second stretch and increase flexibility of all the muscles above and below the pelvis. Next is to increase core and stabilizing strength. In more chronic sacroiliac sprains, the scar tissue should be broken down to speed the proper remodeling and repair of the ligaments.
SCAR TISSUE IN SACROILIAC SPRAINS
In some cases the sacroiliac joint develops scar tissue in the joint and surrounding muscle and tendon junctions. The scar tissue is a “bad patch” that keeps getting aggravated and triggering the pain. Treatments to reduce the scar tissue quickly reduce the duration of treatment and risk of returning severe pain.
MUSCLE TRIGGER POINT CAUSE SCIATIC PAIN
Muscle trigger points can refer pain down the leg. Trigger points are frequently associated with other low back injuries, which is why they are often missed. An injured muscle tightens up to protect itself. With bigger injuries the muscle begins to refer pain away from itself. Usually the pain radiates a few inches, such as around the neck and shoulders. In the low back, there are some common trigger points in the lower lumbar muscles, gluteal, and hip muscles that radiate pain toward the leg.
The radiating pain is reproduced with pushing on the injured muscle or stretching it. Releasing the pressure decreases the radiating pain. Muscle trigger point pain often increases the longer a person is using the muscle, such as walking or standing. It is relieved with rest, heat, and ice. The pain returns once the muscle is under stress or prolonged use.
We commonly treat trigger points involved with neck, shoulder, and headache pain that is worse with sitting, slouching, driving, computer work, or any position that requires the head to be forward. They are less common in the low back, but are still as severe and limiting.
We like finding trigger points because the pain quickly decreases with the right treatment. Physical therapy, heat, electric, ice, stretching, cold laser, and ultrasound do help. However, trigger points respond quicker to deeper muscle therapy such as massage therapy or Graston Technique.
GETTING RID OF SCIATIC PAIN IS ABOUT IDENTIFYING THE CORRECT INJURY
Proper diagnosis of sciatic back pain is critical. Applying the wrong treatments will either have little effect or be inefficient. Most sprains and strains can be significantly improved within two weeks. Treatment beyond that point depends on the history, severity, age, physical condition, and amount of effort put towards home therapy treatments.