How To Treat And Beat Sciatica
Sciatica, an intense pain down the leg or lower back, is a symptom; here's how to find and treat the cause
Outside's long reads email newsletter features our strongest writing, most ambitious reporting, and award-winning storytelling about the outdoors. Sign up today.
Every October, as hopeful runners around New York hit their peak training for the New York City Marathon, Dr. Loren Fishman’s office becomes flooded with people complaining of sciatica.
“Sciatica” is commonly used to refer to pain along the sciatic nerve, which runs from the lower back through the buttocks and down the leg. But sciatica itself is just a symptom, says Fishman, with a number of possible causes.
For most people in the general population who complain of sciatica pain the issue tends to be a herniated or ruptured disc. While that can also be a problem for runners, it’s much more common for pain in the lower back, buttocks, and back of the legs in a runner to be a result of piriformis syndrome, says Fishman.
A study of over two million people complaining of sciatica found that there were “as many, if not more, with piriformis syndrome as with herniated discs,” says Fishman.
The piriformis muscle is a small muscle deep in your hip that runs from the back of the pelvis to the top of the femur. It helps with hip rotation and it typically runs over or above the sciatic nerve. (In some people the nerve actually runs directly through the piriformis muscle.) The sciatic nerve is a very large, thick nerve that comes out of a bundle of nerves in the lower back and goes all the way down the leg. If the piriformis muscle becomes tightened or inflamed, it can catch or pinch the sciatic nerve—meaning your real problem is piriformis syndrome.
There are actually some very simple tests to find out if your pain is a result of piriformis syndrome or something else. Lay on your back and pull your knee toward your opposite shoulder. Hold it for about 30 seconds and if you have piriformis syndrome then you will likely experience tingling along the outside of your leg. Lying on your unaffected side and rotating the painful leg across your body with the knee bent or attempting to push your knees out against resistance while sitting, may both also cause pain if you have piriformis syndrome.
However, none of these self-diagnostic tests are conclusive. A simple test, invented by Fishman, uses EMG findings in similar poses to diagnose piriformis syndrome.
Once the problem is properly diagnosed, the treatment can be relatively straightforward.
But Dr. Steve Gangemi, known as “The Sock Doc,” says sciatica is actually “one of the most misdiagnosed” problems. The sciatic nerve does extend down the back of the leg, but it doesn’t have any sensory endings above the knee. “You can’t feel your sciatic nerve in your hamstring or butt,” Gangemi says. What people are actually feeling in their lower back or hamstrings is typically sclerotogenous referred pain.
For runners complaining of what Gangemi calls “sciatica-like pain,” i.e. pain in the lower back and back of the leg, he argues that it most commonly is an imbalance of the piriformis or glute max and medius muscles. That can cause inflammation, pain, or even pinching of that sciatic nerve.
Gangemi recommends that his patients with piriformis syndrome or glute imbalances use manual therapies to hit key trigger points in those muscles. Visiting a chiropractor or massage therapist can help with some of that bodywork, he says. Stretching, on the other hand, feels good, but it can actually continue the imbalance problem in the long run, according to Gangemi.
Sometimes people get better after just basic bodywork. Sometimes they have to pull back on running or figure out if they need to strengthen some muscles over others.
If you keep having pain, “then you’re not really addressing the problem,” says Gangemi. That problem may really be poor running mechanics, improper footwear, or overuse.
Over the years, Fishman says, he’s seen probably 17,000 people who thought they had piriformis syndrome. About half of them really did. For that half, he recommends a protocol that he developed over 35 years and that he believes cures about 80 percent of the sufferers.
It starts with a small injection of steroids and lidocain in the lower muscle to decrease the pain and bring down inflammation. Over a number of sessions, the injured then get treatment that includes ultrasound and manual release from a therapist, who presses horizontally on the muscle and then down.
“The therapist gets arthritis and the patient gets better,” says Fishman.
After the pain is gone and the runners are better, Fishman prescribes them a course of yoga exercises, including the twisted triangle, seated twist, and twisted half moon.
What about the other half of people who think they have piriformis syndrome but don’t? Or those who simply complain of sciatica? For them, the pain can be a result of any number of things: from arthritis to a pulled hamstring to spinal stenosis. That’s why sciatica continues to send hundreds of runners running to the doctor’s office.