Figuring out Sciatica……and other garbage diagnoses.

…..I understand that a stretched piriformis, intravertebral disk bulges, and hamstring irritation can elicit some form of sciatic pain.  Are there any other dysfunctions that could potentially contribute to this condition that you are aware of that I did not mention?
How would hamstring injury trigger sciatica?
…… Could excessive weight bearing and sitting produce these effects and how??
…… Can migration of the annulus be affected by repetitive spinal motion?

Big heel on those sorry sneakers. Dude should have back pain.

Sciatica is really a garbage diagnosis.   I learned this term from Coach Boyle to mean something used typically in the medical world that really can mean a number of different things.  Shoulder impingement is another garbage diagnosis.  There are like 25 things that can cause impingement and at least half that many different treatment approaches.

For sciatica, all it really means most of the time is that there is pain through the sciatic nerve distribution.  It may be more appropriate to mean that the sciatic nerve is irritated and causing pain. There are a number of areas that can cause this irritation via compression.  Someare mentioned above in the paraphrased question, but there are others.  Finding the location of lesion is where attacking sciatica usually boils down to.

Keep in mind the diagnosis itself, while soft, is often also totally wrong as well. I’ve seen anterior leg pain diagnosed as sciatica, which is ludicrous because the sciatic nerve runs down the back of the leg.  Conversely, not all pain going down the back of the leg is sciatic nerve-driven.  There are many legitimate trigger points that have referral patterns that mimic sciatic nerve irritation patterns.

I think the most common sciatic nerve local irritations are probably nerve root compression and peripheral entrapments through the lower quarter. Common sites of peripheral entrapments can be the piriformis, the superior gemmelus in some folks, the hamstrings, and/or ADDuctors.
Definitely consider the Glute Minimus as a trigger point referral source.  That is not a sciatic nerve irritation, but rather an illusory referral pattern that easily fools dumb physicians and rehab clinicians.  There are other trigger points as well that can fool you.  Also consider when you do believe that a trigger point is the

This is why you need to know how to do Dry Needling.

Keep in mind that these traditional diagnosis suggest a site (pain down the back of the leg) and a source (compression or trigger point).
But a cause in terms of a movement dysfunction is what is going to ultimately lead you to the sciatica solution.  This is where your SFMA or full body evaluation comes into play.

So if say, an ART scanning approach concludes an adhesion between the hamstrings and ADDuctors, it is necessary to treat that local dysfunction, but ultimately some movement disorder caused those muscles to become overworked, and that movement strategy is part of an endless list of contributors and priorities.
Basically what I’m saying is that anything can cause compression or dysfunction anywhere in the body.   Call it Anatomy Trains or Chain Reaction or Regional Interdependence or Movement Impairment Syndromes, they all mean the same thing.  This is why full-body screening and assessments are the key to uncovering the most underlying issues, regardless if they are painful or non-painful.
There are brilliant methods to get at the site and source of the sciatica, but you need to be in parallel in ignoring the body’s expression and find what the body isn’t telling you right off that bat as well.

In terms of the hamstrings’ involvement in sciatic nerve compression, if the injury scars over and causes adhesions, we should without a doubt attack the local issue, but also look to what led to the muscle strain in the first place.

Consider that synergistic dominance of the hamstrings is almost always tied to glute dysfunction. When the glutes don’t hold up their end of the bargain during hip extension, the hamstrings work overtime and eventually tear. The tear can be frank like a Grade II or III, or it can be the most mild of microtrauma that adds up and adds up and entraps the sciatic nerve if it is in the right place or influence.

The environment of the lower-crossed syndrome has multiple contributions that lead to this environment, and the best general suggestion is to check mobility before stability. If the movement is pain-free, check ASLR as a starting point, but also remember that all the moves of the FMS or SFMA matter equally from the start.

Inefficient weight bearing, yes, can cause spinal dysfunction and threats.
Seating up to 20 minutes will cause posterior bulging of the IV discs. This may or may not be perceived as pain or threatening.

Yeah, this isn't good.

I am not familiar with migration of the annulus in relation to spinal motion. I’m not saying it doesn’t happen, but I have never been under the impression that it is impactful.  Certainly pressure from nucleus will cause deterioration of the annulus.  That’s a problem, but I don’t know that the annulus is motile without being pressurized from the nucleus of the disc.
The reference you make may be consistent with Stanley Paris’ suggestion as to why The McKenzie Method works in treating back pain, which is actually very different to how the McKenzie folks believe.
I am confident that flexion yields nuclear migration posteriorly, and anteriorly with extension. I haven’t experienced anything in the literature or real world that would suggest otherwise. It’s the nucleus pulposis that is the player in discogenic back pain. Annular tears can also be perceived as threats, but I don’t think that comes from unbalanced repetitive motions or from environments where there are not bulges or herniations.
Back to sciatica, pressure from the annulus pushing into the nerve root is how you get to this problem.

My teacher for Musculoskeletal in tDPT called me a young Stanley Paris. Not sure if that's good or bad. Click on his face for his Bio and ConEd programs @ St. Augustine.

Without knowing an individual’s presentation, there may be some extra pieces of the puzzle, but the keys are always to stay pain-free and restore mobility prior to stability.
If they are pain-free, trust the FMS and run it through to the terminal fitness exercises. If your client is not pain-free, get them to someone that you can work with and tag team with what you are each skilled at.

There’s 2 ends to this or any rehabilitation.  Destroy the local irritation, but also reinvent a new motor pattern and lock it in.  This will have nothing to do with the painful diagnosis, but have everything to do with it.  Reread the above if that doesn’t make sense.
The local irritation of “sciatica” is reliable to find.  Isolate the issue and restore mobility.  In this case, mobility can be of the nerve in its sheath.  It can be through adhesions of the muscle itself or with others.  It can be of the joint.  Keep in mind, crap flows up and down.  The Joint by Joint will continue to influence neighboring joints especially when the problem is chronic and festering.  Reset the system.
The regional problem is probably going to lie in a hip/lumbar spine stiffness issue.  Integrate the new mobility with the core.  Reinforce the new environment maybe with a supportive sleeve for skin proprioception before you hammer big exercise into the system.
The interregional problem is the big movement that led to all of this in the first place.  Functional Movement is going to bring in the upper body with the lower body and the core.  Reload to the new skill set and capabilities.  Hit save by Breathing at terminal mobility positions.
Reinvent how someone moves.

So there are more than a couple important local issues to cull out what is causing sciatica.
And because of its nebulous definition, it is a good place to learn to appreciate movement disorders.
Treating pain and non-painful movement can very much be run in parallel.  Without the SFMA or something like it, this can be very challenging.
There must be an appreciation that everything matters.

This lets me finish your lousy and incomplete rehab.

  • June 11, 2011

Leave a Reply 7 comments

Joe B Reply

I am confused on why your focus is so much on the peripheral structures. A possible explanation on why patterns of sciatic nerve irritation vary could be a cortical processing error, the individualized nature of the neuromatrix or the suspician that tissues in the region have the potential to be damaged. Tissue damage is not necessary for pain and it appears you are only trying to pinpoint structures that refer sciatic symptoms. And could you define what a trigger point is and how it is related to pain?

Corey S Reply

Great column and understand your passionate voice for ‘garbage’ diagnoses well. The interdependence of the body through functional movement patterns is not well understood by the medical community and could be for several reasons. First being lack of biomechanical training/education; second, focus on medical problem solving rather than biomechanical analysis; lack of familiarity with orthopaedic examination (which has been well published). All the more reason to have physical therapists trained in multiple assessment strategies for movement dysfunction.

As an aside, I’d review the S1 or S2 course from the University of St. Augustine’s Continuing Education series. They will better explain the annular mechanics your speaking about in your column. I don’t think your explanation quite matches what Dr. Paris teaches and has researched.

Charlie Reply

Joe – Please don’t be confused. This post answered questions from a readers, so it included specific references.
I am pinpointing structures related to the questions.

But while you decide to bring up the Neuromatrix, which is likely the correct landscape in which to try to understand “pain,” is it not correct that traditional or causative symptoms are also a part of the Neuromatrix along with the symptoms that are less easy to explain?

Charlie Reply

Corey – I am not formally trained in any of the Paris methods, and I hope I didn’t attribute anything to his teachings. I am just aware that he challenges the McKenzie explanation.

Joe B Reply

Charlie, your response actually confuses me more. All pain originates as an interpretation (sometimes as a result of ascending pathways) by the brain and pain is a defensive response (if we are discussing more acute issues) to the potential for further dAmage to local tiasues. The neuromatrix is activated for this response. No pain is directly local…it is always a central response. Where i am confused is that you are stating the local irritation is reliable to find…literature has most definately indicated otherwise. It has also invalidated the concept of the triggerpoint ( which i have to admit I also belived to exist until recently…the interrater reliabiliy of detecting so-called trogger points is extremely low and even the belief of what one is is theoretical). I do believe that regional interdependence does exist as a neural phenomenon but it highly individualized likely to the individualized neuromatrix. Unfortunately biomechanics, despite still being taught, are holding many PTs back bc the theories to apprach are unreliable. I only make these comments bc I care about our profession and dont want to become known as quacks, due to theoretical hubris, like our chiropractic counterparts.

Charlie Reply

Joe – From what I have read and understand of the neuromatrix, there model is one that I agree with from the a bird’s eye view.
What I do not agree with, nor do I think is necessary to embrace how pain is integrated and modelled within that concept, is that biomechanics or soft tissue constructs do not exist or are not reliable.

100% agree that pain is a defense mechanism and can be elicited from a litany of stressors from any angle or form, including non-physical. 100% agree that no pain is local.
I do believe that a stressor can be local. The local stressor does not have to cause pain. And that in itself does not invalidate the reality of the local stressor or potential impact.
That potential impact may or may not activate the neuromatrix depending on the activity and the threshold that individual person exhibits at that time. Other stressors may yield an activity to cause pain. Is it the activity, the local stressor, or the ancillary stressors? Who knows?

I am not confident at all that “literature” invalidates local stressors such as trigger points.
When a “researcher” seeks to find something, they will find it. I am not impressed or moved to invalidate the fact that if I put a needle into what I believe to be a “trigger point,” that person’s pain is gone, AND they move better, AND they stay better. And this fact does not invalidate the ideals of the neuromatrix. This is not an either-or situation as I see it.

What is ultimately incidental, I 100% that a trigger point is theorectical, and I also believe that every premiere educator that hangs their hat on the trigger point would say the same.
It is okay for things to be theoretical. The result of moving to your predetermined ideal and without pain is the only confirmation we need to continue with the methods we choose.

100% agree that regional interdependence is a neural phenomenon. Everything the body does in terms of failure and adaptation is a neural phenomenon.

Biomechanics is not holding us back. Biomechanics ALONE is what is holding us back.
If biomechanics are ill, the neural phenomenon is not predictable. What assists in predictability, which these researchers are not cognizant of, is taking ill biomechanics to aggressive movement. This is not a part of the research that you are pushing. That is confusing to me.

Henry Reply

Thanks for that post Charlie. I enjoy reading your thoughts.

A few thoughts on my end…

– in my experience (although very brief) I find that discogenic pain/injury may cause inflamation around the associated nerve root creating “sciatic” type of pain without a buldge/herniation

– I used to think that ART actually did “release” adhesions between muscle layers but now I think it’s effect (and that of many soft tissue therapies including instrument assisted approaches) is primarily on fascia. I wonder as well about fascial contractures being the source of these “adhesions” versus scar tissue between layers… although fascia is technically the divider of layers so maybe one in the same? Toma”e”to, Toma”a”to?

– Like you, I too have received referrals for “sciatica” when in fact the patient reported pain on the lateral aspect of the leg from abductor trigger point referral, glut med/min tendonopathy and sometimes, bursitis… I’ve actually coined a term to help educate some of these referral sources… I’ve asked that they use “side-atica” if their impression/diagnosis isn’t exact but pain presents on lateral aspect… at least this way it can lead me to specific structures that may be causing their pain… start there and then correct movement pattern that resulted in that presentation. Regardless, I know that a full exam on my end is necessary and I use what others think as a guide-post. P.S. I agree, dry needling is a great approach for these types of complaints.

– get this… quick google search as I’m not Greek and I apologize to the Greeks of the world if this is wrong but according to (reliable source?) “The name “sciatic” came via Latin from the Greek “ischiadikos” which means “subject to trouble in the hips or loins.” I think this is more fitting as I find that the origin of “sciatic pain” is often from structures or dysfunction in the hips or loins… interesting I thought…

Great post and thanks for it!

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