Straightening Out Sciatica

Breaking Down the Facts on Sciatica

Annette Aho

ATP 312

Dr. Kabay

April 15 2014

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Introduction

In Lose the Back Pain, Steve Hefferon says "nothing will change, until something

moves" 1. The importance of movement through therapy is discussed and different types of back

pathologies are analyzed. One of the most important pathologies that is overlooked in back

patients, but is important for physicians, physical therapists, and other health care professionals

to look at, is Sciatica. Sciatica is a common type of pain, affecting the sciatic nerve, a large nerve

extending form the lower back and down each leg. This pain affects the back, hip, and outer side

of the leg, and is caused by compression of a spinal nerve root in the lower back, often owing to

degeneration of an inter vertebral disc. There are many other names for sciatica, including

lumbosacral radial syndrome, radiating low back pain, nerve root pain, and nerve root

entrapment1.

Anatomy Introduction

The bones of the pelvis and lower back work together to support the body’s weight,

anchor the abdominal and hip muscles, and protect the delicate vital organs of the vertebral and

abdominopelvic cavities. The vertebral column of the lower back includes the five lumbar

vertebrae, the sacrum, and the coccyx2. These bones work together to provide flexibility to the

trunk, support the muscles of the trunk, and protect the spinal cord and spinal nerves of the back.

Lumbar vertebrae support much more body weight than the other vertebrae in the body and are

therefore the largest and most robust vertebrae in the body. The lack of a supporting rib cage in

the lower back also increases the amount of force acting upon the lumbar vertebrae. The sacrum

and coccyx form the inferior end of the vertebral column where it meets the hip bones to form

the pelvis. The triangular sacrum forms joints between the lumbar vertebrae and the hip bones. It

also contains many passages for the spinal nerves that exit the spinal cord and spread through the

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pelvis and legs. The coccyx, or tailbone, is inferior to the sacrum and made of several tiny, fused

vertebrae. Several pelvic muscles attach to the coccyx. A pair of large, flat bones known as the

coxae, or hip bones, extends anteriorly and laterally from the sacrum at the sacroiliac joints to

form the bulk of the pelvis. The left and right hip bones meet anteriorly at the body’s midline in a

band of fibrocartilage known as the pubic symphysis (or symphysis pubis). The hip bones also

form the ball-and-socket hip joint with the femur. Many muscles that move the trunk and legs,

such as the abdominal muscles, hip flexors, quad and hamstring group, attach to the hip bones. In

addition, the broad hip bones provide protection to the delicate internal organs of the pelvis, such

as the intestines, urinary bladder, and uterus2. There are many structural differences between the

male and the female pelvis, most of which reflect the role of childbirth in the female. The male

pelvis is smaller and narrower with a thinner pubic symphysis. The female, on the other hand,

has a much wider and more prominent pelvis that provides extra interior space with a wider,

more flexible pubic symphysis2.

The sciatic nerve is the largest and longest single nerve in the human body, about as big

around as a man's thumb at its largest point. The nerve originates in the lower spine as nerve

roots exit the spinal cord, and extends all the way down the back of the leg to the toes. The

sciatic nerve is comprised of five nerves. It is formed on the right and left hand side of the lower

spine by the combination of the fourth and fifth lumbar nerves and the first three nerves in the

sacral spine. Each nerve exits the spine between two vertebral segments and is named for the

segment above it.

Mechanism of Injury and Pre-Existing Condition

Sciatica most commonly occurs as a result of a lumbar disc herniation, or bone spurs on

the spine that directly press on the sciatic nerve. This causes inflammation and any inflammation

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of the sciatic nerve can reproduce symptoms of Sciatica. This irritation of nerves as a result of an

abnormal inter vertebral disc is referred to as radiculopathy. Aside from a pinched nerve from a

disc, other causes of sciatica include irritation of the nerve from adjacent bone, tumors, muscle,

internal infections, injury, and other causes. Sometimes sciatica can occur because of irritation of

the sciatic nerve during pregnancy3.

Nearly one-third of obese Americans experience musculoskeletal pain, particularly back

pain, according to the American Obesity Association. The more weight an individual carries

around them, the more stress is placed on their bones, ligaments, and muscles. Because of this

extra weight, an individual is at a high risk for injuring and stressing their spine and causing

sciatica to occur. Weight may be gained due to bad eating habits and environmental factors, or

due to pregnancy. In either case, it is important to understand the risk of sciatic pain occurring,

and therefore leading up to the diagnosis of sciatica4.

Signs and Symptoms of Sciatica

Lower back pain that radiates to the hip, buttock, and down a lower extremity is the most

common symptom of sciatica. Sometimes sciatica pain worsens with bending at the waist,

coughing, sitting, or sneezing. Sciatica can also cause tingling, numbness, or weakness of the leg.

Sciatica symptoms can occur rapidly and persist for weeks4.

Pain caused by sciatica may feel like a mild tingling dull ache, or burning sensation. In

some cases, pain is severe enough to make a person unable to move. The pain most often occurs

on one side of the body. Some individuals get a sharp pain in one hip or leg, and numbness in

another part. The pain or numbness may also be felt in the back of the calf or even down into the

sole of the foot. The affected leg will feel weak and hard to function. Sciatica pain often starts

slowly and increases over time, and during activities such as: standing after sitting for an

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extended period of time3. At night, when one is trying to fall asleep, pain can arise. Also,

bending forwards and backwards or even when sneezing, coughing, or laughing, can irritate the

lower back. Some risk factors that may increase when an individual has sciatica are:

degenerative arthritis that can occur in the lumbar spine, lumbar disc disease, and an increased

chance of traumatic injury to the hip area5. 

Diagnosis of Sciatica

The symptoms and certain examination maneuvers can assist a health care professional in

diagnosing sciatica. Tests are often not needed unless pain is severe or long lasting. If complex

tests are ordered they may include X rays and other tests such as CT scans, MRI scans, and

electromyograms, which are used to further define the exact cause of sciatica. A health care

provider will perform a physical exam that may show weakness when bending the knee,

difficulty bending the foot inward or down, difficulty bending backwards or forwards, abnormal

weak reflexes, loss of sensation or numbness, and pain when performing a straight leg raise6.

Special tests, done in an evaluation of a patient with sciatica, may include the straight leg

raise test, supine to long sit test, and Braggards test. In the straight leg raise test, if the patient has

pain down the back of their leg below the knee when the affected leg is raised, the test is

positive1. This means that one or more of the nerve roots leading to the sciatic nerve may be

compressed or irritated. In Braggards test, the result is positive if the pain radiates down the back

of the buttock, thigh and in extreme cases, calf and bottom of the foot. This test indicates a disc

lesion or subluxation ranging from fourth lumbar vertebra down to the third sacral segment6.

A diagnosis of sciatica may be delayed or missed because symptoms, such as leg

weakness, pain and tingling may be mild, develop slowly, and can differ greatly from person to

person. In addition, symptoms of sciatica can be similar to or accompany symptoms of other

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conditions and diseases. Other issues that may seem like sciatica, but are not, include the

bursting of a hip bursa, entrapment of the femoral nerve, and even knots in trigger point areas of

the hip and leg. For a diagnosis of Sciatica, alternative diagnoses to consider during the

diagnostic process for Sciatica are lumbar disc herniation, lumbar spinal stenosis, lumbar facet

joint degenerative arthritis, piriformis syndrome, sacroiliitis, epidural abscess, peroneal nerve

palsy, ischial bursitis.

Sciatica pain is often misdiagnosed with other conditions that share the same pain and

symptoms. Hip bursitis, femoral nerve entrapment, a trigger points are all examples of conditions

that may lead a health care professional to the wrong diagnosis. While it is common for patients

to misdiagnose themselves, there is a responsibility the clinician or doctor needs to take, in

assessing every aspect of the patients issue and advocating proper and detailed patient care6.

In order to be confident that the proper diagnosis is being made, it is important for a

physician to analyze the possible dysfunctions, such as disc herniation, piriformis syndrome, or

spinal stenosis. The gold standard for diagnosing any one of these issues is to get an MRI.

Managing the patient’s pain is the main goal of a health care professional, while still in the

process of confirming sciatica as the diagnosis 3. Until further research is done in the field of

back pain and sciatica, it is important for physicians and patients alike to realize that sciatica is

not truly the diagnosis. It is simply a sign that will lead to the confirmation of another diagnosis6.

Treatment of Sciatica

Because sciatica is a symptom of another medical condition, the underlying cause needs

to be identified and treated. In some cases, no treatment is needed and recovery occurs on its

own. Conservative treatment is best in many cases. A doctor perform and suggest the patent to

follow these initial steps in treatment: Applying heat or ice to the painful area. In most cases,

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applying ice for the first 48 to 72 hours, and then using heat, is most effective and taking over the

counter pain relievers, such as ibuprofen, (Advil or Motrin IB) or Acetaminophen (Tylenol) and

relieve pain discomforts8. 

There are measures that a patient can apply at home, to relieve the pain of sciatica and

assist in the treatment process. Bed rest is not recommended for sciatica patients because sitting

or lying for long periods of time does not help the pain. An individual needs to be moving and

using their joints and muscles in order to maintain blood flow and mobility in their lower back,

hips, and legs8. Reducing activity for the first couple days, then slowly getting back into ones

daily activities and lifestyle is recommended. However, this should not be interpreted as bed rest

time. Avoiding lifting heavy items or twisting ones back for the first 6 weeks after the pain

begins is recommended, so muscles do not become overly stretched. Exercises that include

strengthening the abdomen and improve flexibility of the spine are recommended. Other

treatment options that are more invasive and may be recommended by the physician

when therapy is not progressing include: injections, physical therapy, or surgery9.

Sciatica Exercises

Doing the right exercises, but performing them incorrectly, will not benefit the patient in

the healing of sciatica10. Performing exercises without proper form can make the exercises

relatively ineffective, and possibly may lead to continued or increased pain. It is generally

advisable to learn the exercises under the guidance of an appropriately trained health practitioner,

such as a physical therapist, chiropractor or physiatrist. Regularly, a hamstring stretch is done to

relieve sciatica pain. The hamstrings are muscles located in the back of the thigh. Overly tight

hamstrings increase the stress on the low back and often aggravate or even cause some of the

conditions that result in sciatica. In addition to specific sciatica exercises, aerobic conditioning

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may also be encouraged for general body fitness11. Walking is an excellent form of exercise for

the low back because it is relatively low impact but can provide all the benefits of an aerobic

workout. If possible, it is best to gradually progress to doing up to three miles of exercise

walking at a brisk pace each day.

Here are several stretching exercises that are preformed to relieve sciatica pain. Below

the description, you will find a visual display of the stretch. The low back is gently placed into

extension by lying on the stomach (prone position) and propping the upper body up on the

elbows, keeping hips on the floor. This should be started slowly and carefully, since some

patients cannot tolerate this position at first. This should be done for ten seconds, and repeated

ten times11.

Fig 1: Rise up on elbows, keeping hips on floor.

From the prone position (lying flat on the stomach), press up on the hands while the

pelvis remains in contact with the floor. Keep the lower back and buttocks relaxed for a gentle

stretch. This position is typically held for one second, repeated ten times10.

Fig 2: Press up on hands slowly, keeping hips in contact with floor. Relax low back and

buttocks.

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If the patient is unable to lie flat, a similar exercise can be done standing by arching

backward slowly with hands on hips. However, the prone position described above is usually

preferred. These extension exercises are done regularly, about every two hours. More

importantly, the spine specialist may recommend that the patient with this condition should avoid

getting into a forward flexed (bent over) position. This tends to counteract the effects of the

extension exercises. The specialist may ask the patient to correct any forward flexed positions

immediately by doing an extension exercise10.

Fig 3: Standing backward bend.

With hands on hips and knees slightly bent, arch back slowly and slightly.

Some advanced abdominal exercises for sciatica pain. In the prone position with hands

clasped behind the lower back, raise the head and chest slightly against gravity. While looking at

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the floor (stay low). Begin by holding position for five seconds, and gradually work up to twenty

seconds. Aim to complete eight to ten repetitions. This will work to elongate and extend the

upper back10.

Fig 4: Clasp hands behind back and lift hands and chest slightly off floor, keeping chin

tucked.

In the prone position with the head and chest lowered to the floor, lightly raise an arm

and opposite leg slowly, with the knee locked, two to three inches from the floor. Begin by

holding position for five seconds, and complete eight to ten repetitions. As strength builds, aim

to hold position for twenty seconds10.

Fig 5: With knee straight, raise one leg and opposite arm 2-3 inches off floor.

Curl-ups are done for the upper abdominals; the patient should lie on the back with knees

bent, arms folded across the chest, and the pelvis tilted to flatten the back. Then curl-up lifting

the head and shoulders from the floor. Hold for two to four seconds, and then slowly lower to

starting position. As strength builds, aim to complete two sets of ten curls10.

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Fig 6: Fold arms across chest, flatten back by tightening lower abs, and raise head and

shoulders from floor.

For the lower abdominals, tighten the lower stomach muscles and slowly raise the

straight leg eight to twelve inches from the floor, keeping the low back held flat against the floor.

Hold leg raise for eight to ten seconds, and then slowly lower to starting position. As strength

builds, aim to complete two sets of ten lifts10.

Fig 7: Tighten lower abs to flatten back, slowly raise straight leg 8-12 inches off floor.

Another form of therapeutic exercises is water therapy. Water exercises are excellent to

strengthen the lower abdominal muscles, and even just walking in waist-deep water can be

helpful. Buoyancy, viscosity, and hydrostatic pressure are all factors of how water therapy is an

advantage. These properties allow development of an exercise regimen that minimizes the

weight placed on the spine (axial load) and risk of injury due to unintended movements during

exercises10.

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Conclusion

While sciatica is a common problem, for all ages, it is important to be aware that it is

misdiagnosed, many times due to similar signs and symptoms that are shared with other back and

spine issues. Being aware of what to look for and what to do, once you are properly diagnosed

with sciatica, will help your treatment and rehabilitation process11. Staying inactive was, and

never will be a solution to any problem, especially one related to the spine. Exercise is a form of

medicine, and movement is crucial to one’s health1.

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Reference Page

1. Heferon, S. Lose the back pain. New York City, NY: The Healthy Back Institute;

2010: 3

2. C. Benjamin Ma, MD. Medline Plus: Sciatica (2014, February 26).

http://www.nlm.nih.gov/medlineplus/ency/article/000686.htm. Published: October 4,

2011. Accessed April 2, 2014.

3. Anne Julsrud Haugen1. Prognostic Factors for Non-success in Patients with Sciatica

and Disc Herniation. BMC Musculoskeletal Disorders. 2012; 3(4):2-5

4. Cleveland Clinic. Cleveland Clinic What is Sciatica.

http://my.clevelandclinic.org/disorders/sciatica/hic_what_is_sciatica.aspx.Published:

September 24, 2010. Accessed April 1, 2014

5. Abdelilah El Barzouhi. Magnetic Resonance Imaging Interpretation in Patients with

Sciatica who are Potential Candidates for Lumbar Disc Surgery. PLOS One. 2013; 5

(137):10

6. Michael Perry M.D. Diagnosing sciatica.

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Published January, 16 2014. Accessed April 3, 2014.

7. Valat JP. (2005). Sciatica. US National Library of Medicine National Institutes of

Health. 2005; 11(5) 8-10.

8. Ron S. Miller, PT. Sciatica Exercises for Sciatica Pain Relief. Published December

14, 2000.

9. Armo Södervall. Heart Rate Variability in Sciatica Patients Referred to Spin Surgery:

A Case Control Study. BMC Musculoskeletal Disorders. 2013;4(149):4

10. S. Huber. The Effect of Early Isometric Exercises on Clinical and Neurophysiological

Parameters in Patients with Sciatica: An Interventional Randomized Single-Blinded

Study. IOS Press. 2011;(3):19.

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11. Hanne B. Albert. Centralization in Patients with Sciatica: Are Pain Responses to

Repeated Movement and Positioning Associated with Outcome of Types of Disc

Lesions. US National Library of Medicine. 2011;(7):10.

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