Thursday, August 13, 2015

Sciatica and Conditions that Mimic Sciatica

I get questions on a regular basis asking if I treat sciatica. And then, I get further questions asking what I do for sciatica. The first question is easy. Yes, I treat sciatica. The second question is more difficult because, sciatica is not a very precise term and can involve many different but related syndromes. Strictly speaking, these involve irritation of the sciatic nerve, but there are many conditions such as muscle referrals that can be classified as ‘pseudo-sciatica’.

The Mayo Clinic defines sciatica thus:  “Sciatica refers to pain that radiates along the path of the sciatic nerve — which branches from your lower back through your hips and buttocks and down each leg. Typically, sciatica affects only one side of your body.”

A lateral view of the spine. The
intervertebral disc is highlighted red
and the intervertebral foramen
(where the spinal nerve exits) is
highlighted yellow. Disc herniations
mostly occur at the region where
the spinal nerve exits the foramen.
Pain radiating down the sciatic nerve has many causes, but I will highlight two. The most common cause is irritation at the level of the spinal nerve where it is exiting from the spinal cord. Conditions such as a herniated disc, degenerative disc disease and stenosis can compress part of the nerve. Depending on the spinal level affected, this could cause pain that radiates down the side of the thigh and the front/side of the leg to the top of the foot (this would involve compression of the L5 level); down the front/side of the thigh to the inside of the knee and to the big toe (this would involve L4); or down the back of the thigh (this would involve S1). All of these could be the result of trauma, inflammation, and/or aging and degeneration. I treat these by using acupuncture to release the deep back muscles at the level of spinal compression, balancing any postural disparities that might be contributing to compression on the nerve, and ‘opening the acupuncture channels’ which are along the pathway of the pain. In addition, I might use deep tissue massage techniques, stretches to free the nerves and restore proper gliding, and corrective exercise that can be used at home to expand the therapeutic outcome.

The second common cause involves an entrapment of the sciatic nerve by one of the muscles involved in turning the leg out. This muscle is called the piriformis and the condition is called piriformis syndrome. This would involve deep pain in the buttock region and pain radiation down the back of the thigh. This pain is often worse when sitting, climbing stairs, or running; usually there is reduced range of motion in the hip joint. Some authorities consider this syndrome to be common, while others perceive it as uncommon; this depends on how the syndrome is defined. In most people, the sciatic nerve sits below the piriformis, but in about 10% of the population, it actually penetrates through the piriformis muscle. These people would be predisposed to piriformis syndrome. In the Sports Medicine Acupuncture Certification Program in New York, we dissected a specimen that had just this situation. It was unknown to use if this individual had pain of this sort, but it was a much stronger likelihood. 
Sciatic nerve exiting below the
piriformis muscle. On some people,
it actually penetrates through the
muscle, predisposing them to symptoms.

While many physicians see piriformis syndrome as occurring only in this population, others (myself included) feel that a tight and contracted piriformis can also contribute, regardless of the position. I treat this condition with acupuncture to release the piriformis and balance the pelvis, and might also involve deep tissue massage, stretching and corrective exercises.

While these are the main conditions that put pressure on the sciatic nerve, there are many other syndromes that can mimic the pain of sciatica and can cause an incorrect diagnosis. In particular, hypersensitive painful spots called trigger points (TrPs) in the muscles on the side of the pelvis can radiate pain down the leg and mimic sciatica. In particular the gluteus minimus muscle which is deep in the outside of the hip region is a common culprit. Sacroiliac dysfunction and spinal arthritis (referred to as facet syndrome) are also pain syndromes that can refer into the buttocks and legs. Greater trochanteric bursitis can also radiate into the leg and be confused with sciatica. All of these conditions require proper assessment. In my practice, I take the time necessary to perform orthopedic evaluation and use other tools such as palpation to determine what is causing the symptoms experienced by the patient. I look at how the posture might be contributing to the condition. I assess range of motion, what muscles are strong and supporting the structure and which are inhibited and failing to provide support. And I use Traditional Chinese Medical diagnosis to assess imbalances in the channel system. All of these findings then are used to develop a unique treatment plan to relieve the pain of sciatica.

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