Article reviewed and approved by Dr. Ibtissama Boukas, physician specializing in family medicine
Have you developed leg pain that bothers you and prevents you from maintaining a seated position for prolonged periods? If so, you may be suffering from an attack of sciatica.
But are you sure that it really is a pain in the sciatic nerve as such (also called sciatica)? What exactly do you know about this very common, but not always well understood, condition?
By reading this popular article, you will have a global and complete understanding of sciatic pain, from the diagnosis to the therapeutic options for treating yourself.
Definition and anatomy: What is sciatica?
Everyone knows the “popular” definition of sciatica. As the name suggests, it is a pain in the path of the sciatic nerve. Specifically, this term is used to refer to pain behind the leg.
Some call it a throbbing pain, others say they feel an electric shock, and others even compare it to a stab! It mainly affects the buttock or the thigh, but possibly extends into the foot. Most often, it only affects one side of the body, although there are cases where both legs are affected.
A little anatomy to better understand the problems of sciatica
La spine is composed of vertebrae superimposed, and separated by intervertebral disc. There are 5 vertebrae lumbar (hence the famous names L1, L2, L3, L4, L5).
On either side of the vertebrae there are nerve roots that emerge from the spinal cord (a part of the nervous system whose role is to transmit messages from the brain to the rest of the body). These nerve roots become nerves responsible for providing sensation in the legs, as well as the strength of certain key muscles.
The sciatic nerve is one such nerve.
Now you have to differentiate between a sciatica problem and sciatica. As surprising as it may seem, these two terms refer to symptoms, and not to a precise diagnosis.
Moreover, the word sciatica can be separated into "sciatica" and "algie", which means "pain in the region of the sciatic nerve". Thus, sciatica only refers to irritation of the sciatic nerve.
Sciatica covers an even broader spectrum. Indeed, a pain behind the thigh can come from several structures. To know 8 causes of pain radiating in the thigh (and what to do), see the following article.
In the next section, we'll identify ways to diagnose sciatica, then explain the causes and structures potentially responsible for your symptoms.
How to diagnose a sciatica problem?
Here are the structures that can cause pain behind the leg, and irritate the sciatic nerve:
Whether it's a disc protrusion ou herniated disc, the disc may irritate the nerve root (and indirectly the sciatic nerve), causing the pain to radiate to the leg.
If there iszygapophyseal osteoarthritis or a degenerative phenomenon, the nerve roots may be irritated. As the sciatic nerve is an extension of these nerve roots, symptoms follow behind the leg.
Moreover, thesacroiliac joint, when inflamed, can also reproduce sciatic-like pain (without involving irritation of the sciatic nerve as such!).
Certain muscles in the hip area can sometimes be contracted or spasmed. This can cause pain to radiate up the leg (note that the sciatic nerve does not necessarily need to be irritated in this case).
The muscle most frequently associated with sciatica is the piriformis muscle, in particular because the sciatic nerve passes through the fibers of this muscle located in the buttock. This refers to the piriformis syndrome.
Sciatic nerve and pregnancy (pregnant woman)
During the pregnancy, there are several anatomical and physiological changes that can lead to sciatica. It is not for nothing that it is estimated that between 50 and 80% pregnant women will develop a form of low back pain. Fortunately, this condition does not cause any harm to the baby.
Often, sciatica occurs during the third trimester. Most of the time, affected women feel pain on only one side, although it is possible to feel symptoms in both legs.
Some potential causes of sciatica during pregnancy include:
- Weight gain and increased water retention can put pressure on the sciatic nerve in the pelvis.
- The hormone relaxin is secreted during pregnancy, and causes the ligaments to relax. This can increase joint instability in the joints and lead to sciatica.
- The expanding uterus can put pressure on the sciatic nerve.
- The modifications at the level of the pelvis and the sacroiliac can cause contractures of the piriformis muscle, and lead to a piriformis syndrome potentially responsible for the symptoms of sciatica.
- The expansion of the belly and the breasts moves the center of gravity forward and accentuates the lumbar lordosis, which can lead to an imbalance resulting in sciatica.
- During the third trimester, the baby's head may rest directly on the nerve depending on the position of the head.
To know everything about sciatica during pregnancy (causes, consequences, treatments and prevention), see the following article.
Most of the time, sciatica disappears shortly after childbirth, when the body has returned to its normal physiology. If it persists – or affects daily activities – the intervention of a healthcare professional is strongly recommended.
Symptoms of the disease
Note that the buttock pain or behind the leg is not the only symptom related to sciatica. Often the patient may complain of numbness and/or tingling in the thigh, calf or foot.
There may also be a feeling of weakness, cramps, or heaviness in the lower limb. Some patients have the impression that their leg gives way when walking or during certain movements.
Generally speaking, the symptoms are increased when the patient sits for a long time or leans forward if the sciatica is of disc origin. Sneezing or coughing also increases the pain in many cases. If the sciatica is more related to thelumbar arthritis, for an spondylolisthesis or an narrow lumbar canal, the symptoms tend to appear when walking and standing.
Of course, this is not a general rule, and there may be exceptions. A qualified therapist, in the light of a complete clinical examination, will be able to formulate a diagnostic hypothesis based on your medical history and your symptoms. He may refer you to medical imaging if he deems it necessary.
Why does sciatica hurt at night?
It's not uncommon for sciatic-like pain to seem to get worse at night. Here are several potential reasons for this phenomenon:
- Lying down can be uncomfortable and irritate the sciatic nerve in some individuals
- The poor quality of the mattress can be responsible for pain
- The static position during sleep increases muscle and joint stiffness, hence the aggravated pain on waking
- Although there is no scientific evidence, it is possible that room temperature influences nerve-type pain (such as sciatica)
- During the night, the attention can be focused more on the pain, unlike during the day when daily activities keep us busy.
- If you are taking medication, the analgesic effect may wear off overnight, causing an increase in symptoms.
As sleep is very important for optimal healing, it is important to find strategies to sleep better at night. A health professional will be able to help you determine the cause of your lack of sleep, and find remedies adapted to your situation.
When to worry? : Paralyzing sciatica and others
In some cases, the pain in the buttock or leg may come from a serious harm. This can for example come from a vascular, infectious or even tumoral origin. If your condition worries you, see the following article to rule out serious spinal damage.
A particularly debilitating form of sciatica is crippling sciatica. This usually comes from a herniated disc compressing the sciatic nerve at its nerve roots.
As a reminder, the sciatic nerve emerges from the spinal nerves from L4 to S3, then descends into the buttock and the posterior thigh. It then divides at the knee into 2 terminal branches, the common fibular nerve (also called external popliteal sciatic nerve) and the tibial nerve.
Any damage to the sciatic nerve in its path can cause dysfunction. A particularly important muscle that is innervated by the sciatic nerve is the tibialis anterior, which allows the foot to be lifted (a movement called dorsiflexion).
Thus, crippling sciatica is characterized by a fairly significant attack of the sciatic nerve which causes paralysis of the muscles allowing to actively raise the foot (called " foot drop in technical terms). Obviously, this loss of motor control can greatly limit locomotion.
Causes: But how does sciatica appear in the first place?
When a patient consults for a problem of sciatica, it is usually following an episode where he has lifted a heavy load on the floor. Often, a bending of the trunk associated with a twist causes a sharp pain behind the thigh which radiates to the foot (moving house, big cleaning, sudden movement, etc.).
Obviously, there are other potential causes of sciatica. To truly understand the source of the problem, it is first necessary to identify the damaged structure that causes the pain radiation.
- In younger people, the origin is often traumatic or discal (for example, a disc herniation L5-S1 which irritates the L5 nerve root and causes symptoms down to the foot).
- In older people, a facet syndrome (irritation of the zygapophyseal joints of the back) and thelumbar arthritis are often involved.
Prognosis: How long does sciatica last?
In general, I often tell my patients that a sciatica problem can take up to two months to heal, especially if the pain radiates to the foot.
Moreover, it has been shown that irradiation is often synonymous with a poorer prognosis. Pain that radiates into the buttock is easier to treat than pain that goes down to the toes. Likewise, if one is able to centralize the symptoms (bring the pain down to the lower back) in the short term, the patient has a better chance of healing quickly.
To offer a more accurate prognosis, you must first know the exact cause of your problem. For example, a massive herniated disc compressing the S1 root and consistent with the clinical picture will be more complex to treat than a mild symptomatic foraminal osteoarthritis.
In addition, several personal and environmental factors can influence healing time. As surprising as it may seem, factors such as your state of mind (stress, depression, social isolation, etc.), your personal and professional relationships, and even your genetic makeup can influence your recovery period.
Treatment: How to treat sciatica? (7 strategies)
Once the source of the problem has been identified, it is easier to establish a treatment plan which will allow you to relieve your pain and resume the course of your activities. Here are some treatment options that may relieve your symptoms and improve your condition:
1. Ice or heat
To relieve sciatic-type pain (especially in the early stages), it may be appropriate to use ice or heat.
Often patients make the mistake of applying these modalities in the leg. You will have understood that since the source of the pain generally comes from the lumbar region, it is preferable to put heat or ice in the lower back.
Now, how can one choose between the two? In reality, there are no right answers, and each person may react differently and have certain preferences. To learn more about applying ice and heat to relieve your symptoms, see the following article.
Generally speaking, it is recommended to use ice for the first 24-48 hours due to its anti-inflammatory abilities. It can even be applied regularly to control the acute phase (15 minutes with a compress, repeated every 2 hours).
After a few days, heat can be applied to reduce muscle tension by using a heating bag or a towel infused with hot water.
Note: Whether for ice or heat, there are risks of thermal burns. For this reason, be sure not to apply the ice directly to the skin (use an intermediary like a towel instead). Also, the application of these modalities should not exceed 15-20 minutes at a time.
2. McKenzie Method
We mentioned that it was important to centralize sciatica symptoms whenever possible. A method used frequently in physiotherapy (physiotherapy) is the Mckenzie technique.
This is an approach where the patient is made to repeat movements (or adopt certain static postures for a while). Depending on the response to these movements or postures, we are able to identify directions of movement to relieve symptoms and treat sciatica.
For more details on this famous method, see our article on the McKenzie method.
3. Lumbar Traction
The lumbar pull-ups are often used in therapy (physio, osteo, chiropractic, etc.). Their purpose is to exert spinal decompression. This allows, among other things, to reduce stress on the discs, stretch the tendons and ligaments, and relieve compressed or irritated nerve roots.
However, one should be aware that these techniques have not been shown to be effective in the long term in scientific studies. As they generally provide a feeling of well-being, pull-ups can be useful in reducing symptoms temporarily (for example in an acute crisis, or to allow more activity with a more acceptable level of pain).
Ideally, the healthcare professional is the person of choice to perform safe and specific lumbar tractions. Furthermore, there are self-pulling techniques you can do at home who can relieve you in the meantime.
When a nerve root or the sciatic nerve is irritated, pain can ensue. intense burning type. Although it is always preferable to opt for more "natural" strategies such as ice or heat, sometimes you have to resort to to take pills.
As everyone reacts to medications differently, it is best to consult your doctor to determine the type, amount and dose. The drugs generally prescribed following an attack of acute sciatica are anti-inflammatories, painkillers, and muscle relaxants. Your doctor may also prescribe pregabalin (Lyrica), an antiepileptic drug used in the presence of neuropathic pain.
The first reflex when suffering from pain (especially when it comes to an attack of sciatica) is to rest until the pain disappears. Unfortunately, this is a monumental mistake committed by several patients.
Indeed, many scientific studies have shown that people who are inactive following an episode of low back pain take longer to heal, and have more long-term recurrence episodes. Although a relative rest can sometimes be beneficial (for example, reducing activities or lying down for a short time to reduce pain), complete bed rest should be avoided at all costs.
Now I can understand you not being educated on the best exercises to do. To do this, a qualified professional will be able to guide you and prescribe the best exercises for your condition. Often, your therapist will prescribe neural mobility exercises aimed at mobilizing a nerve to reduce symptoms.
In the meantime, here is a series of effective exercises against sciatica that are regularly prescribed in physiotherapy practices: 5 exercises to relieve the symptoms of sciatica (in video)
In certain specific cases, your doctor may offer you a cortisone infiltration to relieve your symptoms. There are different types such as epidural or facet block.
Obviously, your doctor is in the best position to determine what is best based on your diagnosis. For example, this may depend on whether your pain is caused by the disc or the joint.
Keep these two premises in mind. First, don't make the mistake some of my patients make when they have back pain. Indeed, I see people receiving infiltration at the lumbar level before even trying medication or consulting a therapist.
In general, injections should be considered only in cases of persistent, incapacitating pain that has not responded to conservative treatment for at least 6 weeks. Then, if you ever have to make up your mind to infiltrate, ask your doctor that it be done under radiological control (like an infiltration under scanner).
Although infiltrations in the doctor's office are appropriate, they will be more effective if done under radiological control. This means that the doctor will use a medical imaging to better target the place to poke.
7. Alternative medicine and natural products
Unfortunately, sometimes the methods recommended by the doctor do not bear fruit. In the presence of residual pain, many people opt for alternative treatments.
Although not necessarily supported by solid scientific evidence, these treatments sometimes offer significant relief of symptoms. Possible options include:
- grandma's remedies
- acupressure mat
- suction cup (cupping therapy)
- natural products
- Quinton plasma
- percutaneous hydrotomy
- therapeutic yoga
- craniosacral therapy
It is advisable to discuss with your doctor the use of any natural or alternative product, in particular to avoid any potentially harmful interaction with other medications.
Positions and movements to avoid in the presence of sciatica
In the previous section, we discussed 6 treatment strategies aimed at relieving sciatica. On the other hand, it is important to avoid aggravating your symptoms on a daily basis by adopting bad postures.
Positions to avoid with sciatica will vary from person to person. In the acute phase, it is generally recommended to maintain the Lumbar spine in a neutral position, i.e. extreme positions must be avoided (such as twisting or sudden movements). It is for this reason that some doctors prescribe lumbar belts to stabilize the lumbar region and the pelvis in the short term.
For the rest, this will depend on the " preferential direction“, that is to say the movements that relieve the pain (and on the contrary those that aggravate the symptoms).
Let’s explain this concept with an example: If sitting still causes lower back pain or radiation (sometimes associated with tingling or numbness in the foot), this will be a position to avoid. It will then be necessary to integrate exercises favoring lumbar extension, or to get up as regularly as possible.
If the seated position on the contrary allows a reduction of the symptoms, it will be necessary to recommend it, and to integrate exercises favoring the lumbar flexion. Often the person complains when standing for a while. It is therefore said that prolonged standing should be avoided in this case.
It is therefore understood that the positions to be avoided will be relative, and will have to be evaluated to optimize rehabilitation. A qualified therapist will be able to advise you on the best postures to use. In the meantime, remember to avoid holding positions that will aggravate symptoms over time.
Work stoppage and occupational disease
Following an episode of sciatica, it is not uncommon for the doctor to prescribe a work stoppage. The latter will depend on the severity of the symptoms, the condition of the patient and the physical demands of the job.
Sciatica, an occupational disease?
A disease is said to be occupational if it results from a direct exposure to a physical, chemical or biological hazard. It must also result from the conditions in which a worker exercises his professional activity, and must appear in one of the tables of the general or agricultural Social Security system.
The tables of occupational diseases 97 and 98 relate to back pain, and define a number of criteria which must all be met to allow recognition of the disease.
Here are the conditions that must be met for sciatica to be recognized as an occupational disease:
- It must be a chronic condition (defined by a duration of at least 3 months)
- If the pain radiates into the leg: sciatica or radiculalgia femoral crural must be caused by a herniated disc with a topography consistent with the root involvement. For sciatica, the herniated disc must be level L4-L5 or L5-S1. For crural radiculalgia, the herniated disc must be level L2-L3, or L3-L4, or L4-L5.
- The herniated disc must be explicitly qualified in the report of the radiological examination via a scanner ou IRM.
- The duration of exposure to the risk is 5 years, and the period of coverage must be a maximum of 6 months.
If you have pain behind your leg and suspect sciatica, I hope you are now more educated about your condition.
As you may have noticed, sciatica is a vague term that does not really explain your pain. To identify the source of the problem, it is necessary to identify the structure in question (often located at the lumbar level). From the moment a “problematic” disc, joint or muscle is identified, the management becomes more appropriate and effective.
Obviously, your best ally in this sometimes complex process remains the healthcare professional.
Good recovery !
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Patients with back pain, I only see that on a daily basis. The problem is that most people consult only when their pain becomes intolerable. My name is Anas and I am physiotherapist (physio). My mission ? Helping people who are in pain before their pain becomes chronic and requires surgery. It is for this reason that I created Lombafit, a site focused on the popularization of back pain by health professionals.