What is Sciatica and What Can I Do About It?
- chiarahildenbrand
- Aug 9, 2024
- 17 min read
When you google “Sciatica” you often get descriptions that include a “pinched nerve” or a “compressed nerve”. This isn’t quite the case as we will explore in this article. First lesson here is probably, don’t google your symptoms. The second is, sciatica is not so much a condition as it is a cluster of symptoms that, if present, can be defined as sciatica.* Caveat here - read on to find out
*In any case it seems like a bad idea to rely on a google search to replace a health provider and so, while I will do my best to provide you with the tools to understand more about “sciatica”, you should always get assessed by a health professional.
Common “Sciatica” symptoms
pain along the course of the sciatic nerve (buttock, back of thighs, behind the knee, in calves or side of shin, in the foot) with or without back pain
Altered sensation along the path of the nerve (pins and needles, tingling, numbness)
Decreased tendon reflex
Weakness in the leg e.g. foot drop (decreased ability to lift foot towards shin) which can cause difficulty walking
(Jensen et al., 2019)
This article aims to help you understand the symptoms of “sciatica” and provide you with strategies to manage these symptoms for you to be able to do the things you want to do. This is to be a guide rather than a fool proof method or a quick fix recipe. Anyone claiming that there is one is either fooling themselves or fooling you. Rather, I will give you the tools to understand where you’re at and what you can do to recover.
I also want to set your expectations: there will be ups and downs and that there will be some trial and error to get it right, but you can most definitely get there and the vast majority of these symptoms do subside within a couple months.
What is “Sciatica”
Before looking into what “sciatica” is, I want to clarify that it is again a collection of symptoms. When considering “common sciatica symptoms” listed above, they really just describe features of nerve root* involvement that can be split into radicular pain and radiculopathy.
*The nerve root is the part of a nerve as it exits the spine and combines with other roots to branch off and supply your body.)
Radicular pain describes nerve root irritation causing altered sensation e.g. pain, tingling, pins and needles, etc.
Radiculopathy describes a nerve root problem causing the loss of or decreased function of a nerve e.g. weakness, numbness, decreased reflex, etc.
This means that “sciatica” (the cluster of symptoms above) describes a type of radicular pain with or without radiculopathy. Within these definitions, people can experience “sciatica” on a scale, with some having mild symptoms down to the knee, while others have pain, numbness and decreased reflex all the way down to their foot.
While there is a distinct overlap of symptoms listed, they can vary and definitions both across different health professions and research articles vary. This creates a lot of ambiguity around the diagnosis and is also contributing to the murky research surrounding this presentation, since it’s hard to pin down consistent results when the different research groups and health providers can’t even decide what falls under “sciatica” and what doesn’t. Much like we’ve adopted the generic trademark of Kleenex, when referring to any tissue or paper towel, sciatica has come to encompass a whole range of back related leg pain presentations. The international association for the study of pain urges people to move away from “sciatica” and one of their research groups is working to define the various spine related leg pain presentations more clearly. (Schmid et al., 2023)
And so I will from now on refer to what we understand as “sciatica” as “radicular pain” where the added loss of function (such as foot drop or decreased reflex) would be “radicular pain with radiculopathy” or “painful radiculopathy”.
Sciatica in terms of leg pain and altered sensation = radicular pain
Sciatica in terms of leg pain and altered sensation, with loss of function = radicular pain with radiculopathy
“Sciatica” is often assumed to involve the “sciatic nerve”, the large thick nerve in our body that spans from the lower back (spinal segments L4-S3) down your buttock and back of your thighs to the back of the knee where it branches to supply the lower leg and foot. However, as we just clarified the irritation of any nerve root can cause radicular pain or radiculopathy and so it is not confined to the sciatic nerve.
For clarification, nerves provide sensory (pressure, temperature, etc.) and motor (contracting muscles) innervation, and as such, affecting the nerve means to affect sensory and motor changes (e.g. weakness, altered sensation, numbness, etc.), which are as described the symptoms that can be present.
When to see a doctor
First things first we want to get the so called “red flags” out of the way. There can be an overlap in the symptoms with other conditions and so if you experience any of the following, please seek a health professional as soon as you can. (Wiseman, 2024)
Issues with or loss of control of bowel and bladder movements
Numbness around the genital, anus or buttock region
Weakness / loss of power in your lower limb/s (foot drop included)
Wide-spread numbness
History of cancer, osteoporosis, and/or recent trauma
If none of the above apply, the vast majority of people experiencing radicular pain / “sciatica” make a full recovery within two-three months. (Koes, 2020)
Recovery times and experience of symptoms can differ due to both external and internal factors. Here external factors may include your work environment, your ability to modify activities, your access to guidance, and sleep while internal factors may include genetics, previous experiences with pain, what you know and believe about injury and pain, your self-efficacy and more!
(What is self efficacy you ask? Check out my reels on instagram to get an idea)
What causes Radicular Pain
While it seems to be impossible to google “sciatica” and not stumble upon “disc herniation” or “squashed nerve”, I want you to put aside this bias and understand the ethology of radicular pain is not as clear cut as that.
The reason “sciatica” is named after a cluster of symptoms rather than being a descriptor of the cause, is because there can be many causes for the presenting symptoms and it’s not super clear or consistent. Many articles will explain it as a pinched nerve or a disc herniation leading to the compression of the nerve root. However, with the presence of studies showing various stages of disc herniations without any symptoms, as well as radicular pain without any imaging findings it is hard to ignore the fact that the ethology is more complex than that and likely has a multitude of factors feeding into it. (Suri et al., 2014)
To generalise and simplify the issue, while nerves are very strong structures they can be very sensitive. Consider the experience of hitting your funny bone (ulnar nerve along your elbow) the force with which you hit your elbow rarely corresponds to the amount of pain and sometimes altered sensation, such as tingling or numbness, that you may feel around the elbow and down the forearm all the way to your pinky. In the case of sciatica the current understanding seems to be that an whether it really was a herniation causing local inflammation or other factors playing into the initial cause (these can be many factors coming together), the result is an increased sensitivity of the nerve. (Jesson, 2020)
The heightened sensitivity around and/or along the sciatic nerve can cause a number of symptoms and has the potential to land anywhere on a large scale from mild referred symptoms in the buttock, to pain and altered sensation all the way down to the big toe. To calm this sensitivity down, we want to build tolerance and desensitise the nerve in order to manage the symptoms.
The bucket analogy
Think of a bucket that’s filling with water. In your day to day and week to week, you may do things that cause certain stress on various structures in your body - in this case we will focus on this nerve. Usually, as the water flows into the bucket, there is a steady trickle out of it, preventing the bucket from overflowing. Here the steady trickle out may signify getting enough sleep, having a balanced diet, relaxing with friends and family. The balance of stress (this is both physical and mental) and recovery. Now, when looking at an irritated or sensitive nerve, this bucket is smaller. The same amount of stress may very well cause the overflow of water, or and in this analogy, the onset of your symptoms.
How to Recover from Sciatica
Now this all might sound daunting but there is good news on the horizon. While everyone is different, your path to recovery usually follows a set of guidelines that can be followed quite easily.
The main principles for recovery consist of
Calm down your symptoms and avoid aggravating activities
Do what you can do
Continue with as many things from your usual routine as possible
Progress what you can do towards what you cannot currently do
We will go over each of these steps below and I will give you some general examples that you can follow. One thing to keep in mind is that when in pain, many of us expect pain in certain positions or with certain movements. Sometimes this can really limit your movement as you build a fear of certain movements, where there needn’t be any. So do try various movements and test whether you actually do feel an increase in symptoms or not. After testing various movements keep in mind that this may temporarily increase your symptoms. If you feel it flare up a little while figuring out which movements you can tolerate it’s perfectly normal.
During that time you want to manage the symptoms during the recovery period and maximise your function, so that you can still do most of the things you want to do.
If you have been experiencing the symptoms for a few months, chances are that there has been inadequate modification of activities that resulted in prolonged aggravation of the symptoms so that they persisted longer. Once the symptoms persist for several months, a certain amount of sensitisation may have taken place, which means that the tissue sensitivity has become more chronic and may take a while longer to improve under the right guidance.
The current best guidelines are conservative care (which I am outlining in this article) with little evidence supporting pain medication / drug therapies and exceedingly few cases needing surgery of any kind. (Liu et al., 2023)
Let’s go over the stages of rehab:
1. Calm down your symptoms and avoid aggravating activities
Identify your aggravators. There will always be movements or positions that are less pleasant than others. Perhaps you notice your symptoms increase after sitting for 10 min. Maybe you notice them more when standing on the spot or with specific exercises or when driving. Try to find a line of demarkation - when symptoms get worse. If it’s 10 min of sitting, try to get up before that 10 min mark, if it’s standing on the spot for more than 5 minutes, try swaying from one foot to the other or marching on the spot instead; if you can’t tolerate running you can try the elliptical, and if you exacerbate your pain with your usual deadlift or squat you could try to offload (drop the weight by x percent) or do bodyweight exercises and work up the resistance from there. You could also reduce the range of motion you work through. The point is, the sky is the limit. There is no movement that that isn “avoid at all times”, no movement that is inherently bad. There is just the movement that you cannot currently tolerate well and need to adjust, and those that you can continue on with without needing any adjustments.
On a side note, if your day does includes movements that you cannot avoid, perhaps driving to work or sitting in a meeting for a few hours on end, do not worry. While it is recommended to avoid aggravating activities, pain is not an indicator of damage and so, while it is favourable to avoid eliciting pain, it isn’t going to make or break your rehab if you do. Much like poking a bruise or a sore muscle it isn’t pleasant but won’t have massive effects on the recovery.
2. Do what you can do
You want to find movements and activities that alleviate or at the very least don’t aggravate your symptoms. This may be any of the activities below:
Walking. Walking is a great way to introduce low impact movement. If you find symptoms worsening with walking, you can break it up into bouts of x minutes and adjust your stride length (taking smaller steps) or shoe wear (sneakers instead of thongs etc.) as needed. The bottom line is, do whichever adjustments you need to in order to walk daily.
Change positions. Getting up more frequently in the day (especially if you’re sitting at a desk for most of it) can be very helpful in alleviating symptoms. You will likely gravitate towards various positions, maybe leaning on the arm rest, slouching with a pillow behind your low back or adjusting the chair to be higher. Switch between comfortable positions and get up more frequently.
Exercising / training. If you usually go to the gym, you should be able to do the majority of movements. For lower body lifts, you may want to drop the weight for your squats and deadlifts (or other lower body exercises) and test a few sets of increasing weight to gauge what load you tolerate. If bodyweight movements are still sore, you could work through a smaller range, e.g. replacing an air squat with a box squat. Upper body lifts may need to be adjusted, e.g. a seated cable row could be more comfortable in standing.
3. Continue with as many things from your usual routine as possible
If you’re participating in classes or team sports, are there any parts of it that you can do e.g. the warm up or the circuit without weights/ with lighter weights? Perhaps you can slow down the movement and leave out those that aggravate your symptoms. Alternatively, you could find a temporary replacement, e.g. instead of running you could use the elliptical, or go swimming.
If you usually meet up with friends and sit for longer times, maybe you could instead go on a walk together.
The take home message here is to continue with as many things from your usual routine as possible.
4. Progress what you can do towards what you cannot currently do
If you can only sit for 10 min, sit in 8 min bouts and increase this towards 10, 15, 20 minute bouts over the coming weeks.
At the gym, work with a load and rep range you can tolerate. Generally you might want to increase the repetitions to about 8-15 reps and work with a much lighter weight or bodyweight depending on your exercise routine.
The factors you can play around with are:
Volume so kg, reps and sets or time
Exercises (substituting barbell squat for smith machine or box squat, performing a plank instead of sit ups, prone hamstring curls instead of seated, etc)
Range you move through (elevating the surface for your deadlift, box squats, upright or prone hamstring curls instead of seated, taking smaller steps, etc.)
Exercises for pain relief
If it’s very acute and any movement is irritating, here are 4 exercises that might help in the super acute stages to calm things down. This is not an exhaustive lists and there are plenty of different ways to do this. These examples are for you to try if you have no idea where to start. However, if you are seeing progress with your modifications we discussed above, there is no compelling need to do these.
Exercises can be done in sets of 2-3, with 10-20 repetitions each. The sets give you breaks to assess how you’re feeling and the high rep ranges give you the opportunity to see if symptoms calm down with repetition, since sometimes symptoms can spike before they get better.
Bridges
Lying on your back, knees bent and feet planted
Flatten low back to the ground as comfortable
Squeeze glutes (butt) to lift hips up a far as comfortable
Lower down and repeat
Cat cows
On all fours, hands below shoulders and knees below hips
Perform two movements alternating between them
1. Round your back like an angry cat, pushing away from the ground
2. Arch your back (like Kim K) sinking belly to the ground
Standing rotations
Stand along a wall, outer leg forward in a split stance
Bring arms out in front of your and place them flush to the wall
Turn outwards, keep closer arm to the wall while the other leads the turn
Push into the wall with your closer arm to increase the twist
Roll downs
Standing, tuck shoulders and chin down
Then lower down, tracing hands along your legs
Round your back as you bend down
Once you reach a point of pain or the end of your range, come back up still keeping back rounded
Then straighten gradually and repeat
Reduce your risk of sciatica
While prevention is a very loaded term in the health space, there are things you can do to reduce your risk of sciatica. To do so, you should first understand the risk factors for sciatica:
40-50 years old
History of sciatica symptoms
Inactive lifestyle/ sedentary
Smoking
Obesity
Work environment / habits
Now here we specifically are interested in the Modifiable risk factors!
Load management
Load management - what this means is to consider the 'Rule of Toos’: tissues are adaptable unless the stress put on them is too quick, too strong, too long or too often. (Jesson, 2021)
The best way to minimise risk of injury is to know when to adjust load. Consider a day at work, sitting for 10 hours at a time and barely getting up. Potentially fine when other factors are cared for - you’ve gotten enough sleep, you’re training regularly, stress is moderate to low. The same scenario but you’re stressed with a work project and haven’t gotten a good night’s sleep in two weeks, this may be enough to affect your sitting tolerance. Alternatively, consider you’re at the gym lifting, and you decided to listen to your gym bro and hit 9/10 effort on every single lift that week - and then you wonder why you tweaked your back. While the check and balances aren’t always as clear as this, it is a good idea to be aware of other factors that may influence your performance or habits at work and in training.
Other factors
Sciatic pain will take a while to calm down and there is a component of natural course of the injury that needs to take place. In the meantime the goal is to maximise your function to at the very least be able to to most things while you deal with it and at the very best reduce your symptom duration.
Some people may tell you that posture, stride length or spinal alignment matters. It does not.
However there is some nuance to this.
DOES POSTURE MATTER?
IF you have experienced sciatica in the past, then you are more likely to experience it again vs someone who has not. This is not guarantee, but it means that you may know certain positions that if you do it for too long, it may aggravate symptoms. That may be the one time I will say that posture can matter. By and large posture association to pain or injury has been debunked. You can sit like a T-REX typing away on your laptop and never experience pain. The issue is usually being stuck in a position for too long FULL STOP. Meaning, that no matter how amazing your posture is for 99 Allied Health Standards, hold it for long enough and you will likely experience pain (99 problems but perfect posture ain't one). Now everyones threshold for that pain onset may differ, some people can sit in positions for 8 hours before they feel they need to move, others are aching if they exceed 1. Ideally you should move around and switch positions every 90 min or less if you can. (90 min is made up by me - I am yet to encounter a paper going over this but I’ll insert my clinical experience here and say that up to 90 min is usually not problematic for most people that have no pain or recovered from it).
STRIDE LENGTH?
Again, when experiencing symptoms or having just recovered, you may for some time after be a little more sensitive to certain positions or movements. Taking smaller steps for the time being can offload as you’re putting less tension through your sciatic nerve and hamstrings. However, this is not something I would implement unless it made a difference to your symptoms (i.e. is the difference between you walking and not walking). However, once recovered or if you have never had this issue in the past it is not something you would need to modify to reduce your risk. In fact, I would argue that exposing yourself to a larger range regularly and being used to it can only help.
WHAT ABOUT SPINAL ALIGNMENT?
I don’t even want to dignify this term by paying it any attention, but I also understand that it is because of health practitioners of the past (and unfortunately some present) that this term is being thrown around in the health and fitness industry. It’s a monster of our own making.
Spinal alignment seems to be the notion that your spine can go in and out of alignment. Unless you have been through a significant car accident or otherwise this is not going to be the case.
I will cover this in more depth in the future but the good news is that however your spine is aligned is good and fine and not only does it not need to be changed, it cannot be changed neither by me pressing nor by you cracking or making a wrong move. The spine is one of the strongest structures in our body, layered with muscle and ligaments that would make it very hard to move anything ‘out of place’.
The best thing you can do for your spine and your body in general is being healthy and fit and strong. Exercise does not only improve your cardiovascular health, your bone density and your soft tissues (muscles, tendons, ligaments + more!). It also improves your tolerance and your resilience. This means you’re less likely to fall victim to an ‘overload’ and if you do you are more likely to recover quickly. It is much easier to keep up a healthy routine than to implement one from scratch. Now add an injury to the process and starting a new routine seems incredibly hard.
So my advice would be to have a really strong baseline.
The Australian government department of health recommendations are:
Adults should be active most days, preferably every day. Each week, adults should do either:
2.5 to 5 hours of moderate intensity physical activity – such as a brisk walk, golf, mowing the lawn or swimming
1.25 to 2.5 hours of vigorous intensity physical activity – such as jogging, aerobics, fast cycling, soccer or netball
an equivalent combination of moderate and vigorous activities.
The American Heart Association recommendations are:
Get at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous aerobic activity, or a combination of both, preferably spread throughout the week.
Add moderate- to high-intensity muscle-strengthening activity (such as resistance or weights) on at least 2 days per week.
Spend less time sitting. Even light-intensity activity can offset some of the risks of being sedentary.
Gain even more benefits by being active at least 300 minutes (5 hours) per week.
Increase amount and intensity gradually over time.
The take away message
The take away message is that your symptoms should resolve in time so keep moving and be patient with the process.
Do what you can to maximise your recovery so look to
get enough sleep
general health (nutrition, hydration, mental well being)
If we think back to our bucket analogy where stressors increase the water level, think of recovery as increasing the drain. This means that if your general health and wellbeing is better you can handle more stress.
Yes, there will be ups and downs. Days where moving is easier and days where symptoms flare up. This is normal, however we want to see a gradual decline of the symptoms and more importantly an increase in your function as time goes on.
You have lots of options for movements and modifications you can introduce into your life to give you relief, help you manage your symptoms and enable you to pursue your usual activities.
If you want to know more about it or need guidance I am always happy to help - check out my website and book an appointment.
And you are not alone. Countless people have experienced and recovered and returned to all the things they want to do.
I hope this was helpful to you.
Take aways points
Sciatica describes radicular pain (increased sensitivity) (with or without radiculopathy (decreased function)). It comes from an irritation of a nerve root and can present on a scale of symptoms and intensities of those symptoms.
There a multiple factors to consider and it’s rarely a single cause
The vast majority of ‘sciatica’ resolves by itself and you want to maximise function while the natural progression of the issue takes place
Movement and exercise is encouraged as tolerated - do what you can!
Here are some references if you want to know more:
American Heart Association recommendations for physical activity in adults and kids (2024) www.heart.org. Available at: https://www.heart.org/en/healthy-living/fitness/fitness-basics/aha-recs-for-physical-activity-in-adults#:~:text=Recommendations for Adults,preferably spread throughout the week. (Accessed: 09 August 2024).
Australian Government Department of Health and Aged Care (2022) Physical activity and exercise guidelines for all Australians, Australian Government Department of Health and Aged Care. Available at: https://www.health.gov.au/topics/physical-activity-and-exercise/physical-activity-and-exercise-guidelines-for-all-australians (Accessed: 09 August 2024).
Jensen, R.K. et al. (2019) Diagnosis and treatment of sciatica, The BMJ. Available at: https://www.bmj.com/content/367/bmj.l6273.full (Accessed: 09 August 2024).
Jesson, T. (2021) Why would sciatica take a fortnight to kick in? pt 2., Why would sciatica take a fortnight to kick in? Pt 2. Available at: https://tomjesson.substack.com/p/why-would-sciatica-take-a-fortnight-c05 (Accessed: 09 August 2024).
Jesson, T. (no date) What is sciatica? - The back pain & injury podcast, The Back Pain & Injury Podcast. Available at: https://omny.fm/shows/the-back-pain-podcast/what-is-sciatica (Accessed: 09 August 2024).
Koes, B.W. (no date) Improving the management of sciatica , The Lancet Rheumatology. Available at: https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(20)30130-2/fulltext (Accessed: 09 August 2024).
Liu, C. et al. (2023) ‘Surgical versus non-surgical treatment for sciatica: Systematic review and meta-analysis of Randomised Controlled Trials’, BMJ, 381(e070730). doi:10.1136/bmj-2022-070730.
Schmid, A.B. et al. (2023) Recommendations for terminology and the identification of neuropathic pain in people with spine-related leg pain. outcomes from the Neupsig Working Group, Pain. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10348639/ (Accessed: 09 August 2024).
Suri, P. et al. (2014) ‘Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: Retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (laidback)’, BMC Musculoskeletal Disorders, 15(1). doi:10.1186/1471-2474-15-152.
Wiseman, D. (2024) Cauda equina syndrome, AANS. Available at: https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Cauda-Equina-Syndrome (Accessed: 09 August 2024).
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