Sciatica is a specific type of nerve pain caused by irritation or compression of the sciatic nerve, the largest and longest nerve in the body. True sciatica results in pain that travels from the lower back or buttock all the way down the leg, often past the knee and sometimes into the foot.
Despite how often the term is used, most people who report “sciatica” don’t actually have it. In reality, many cases of leg pain, especially those that stop at the thigh or don’t follow a distinct nerve distribution, are due to other musculoskeletal or referred pain sources.
The Anatomy Behind Sciatica
The sciatic nerve originates from the lumbar and sacral spinal nerve roots (L4-S3). These roots merge to form the sciatic nerve, which exits the pelvis through the greater sciatic foramen, runs beneath the piriformis muscle, and travels down the back of the leg.
When the nerve becomes compressed or irritated—usually by a disc herniation, spinal stenosis, or inflammation—this can trigger a cascade of symptoms along its path:
- Sharp, shooting, or burning pain down the leg
- Numbness or tingling
- Muscle weakness
- Pain worsened by sitting or bending forward
This is true radiculopathy, a term used to describe nerve root irritation or compression.
Common Causes of True Sciatica
Sciatica isn’t a diagnosis—it’s a symptom of an underlying issue. The most common causes include:
- Lumbar disc herniation: The most frequent cause, where a disc presses on a nerve root.
- Lumbar spinal stenosis: Narrowing of the spinal canal that compresses nerves.
- Spondylolisthesis: Forward slippage of a vertebra that pinches the nerve.
- Piriformis syndrome: A less common cause, where the muscle compresses the nerve.
- Inflammation or infection: Rare, but inflammatory conditions like sacroiliitis can mimic nerve pain.
Conditions That Mimic Sciatica
Many patients with low back pain and pain radiating into the buttock or thigh assume they have sciatica. However, this is often not the case.
Here are several common mimics of true sciatica:
1. Referred Pain from Facet Joints or SI Joint
Pain from spinal facet joints or the sacroiliac joint can refer pain into the buttock or upper thigh. However, this pain does not follow a nerve root pattern and often lacks numbness or tingling.
2. Hamstring or Gluteal Strain
Soft tissue injuries in the posterior hip or thigh can mimic sciatica but are usually local to the site of injury and don’t extend below the knee.
3. Greater Trochanteric Pain Syndrome
Pain on the outside of the hip from irritated tendons or bursae can refer discomfort down the leg, but this is musculoskeletal in nature, not nerve-related.
4. Peripheral Nerve Entrapment
Conditions like meralgia paresthetica or peroneal nerve compression can cause leg numbness or tingling, but the symptoms follow peripheral nerve distributions, not the sciatic nerve.
Why Most Leg Pain Isn’t Sciatica
Many people describe any pain that runs down the leg as sciatica. However, true sciatica:
- Almost always includes pain below the knee
- Often comes with numbness, tingling, or weakness
- Follows a clear dermatomal pattern
- Is confirmed with neurological signs on exam
Back pain that radiates into the buttock or thigh without these features is more likely referred pain or a muscular issue.
How Sciatica Is Diagnosed
A proper diagnosis begins with a comprehensive evaluation, including:
- Patient history: Onset, pattern of pain, aggravating factors
- Physical exam: Neurological testing (strength, reflexes, sensation)
- Orthopedic tests: Straight leg raise or slump test
- Imaging: Only when warranted (e.g., persistent or worsening symptoms after 6 weeks, red flags, or surgical planning)
MRI is often used to confirm nerve root compression, but imaging should always be interpreted in the context of clinical findings. Many people with disc bulges on MRI have no pain at all.
Best Evidence-Based Treatments for Sciatica
Most cases of sciatica do not require surgery and improve with conservative care.
1. Education and Activity Modification
Patients should be reassured that sciatica typically resolves. Avoiding prolonged sitting or forward bending can help in the acute phase, but movement is medicine—bed rest is not recommended.
2. Exercise Therapy
Tailored exercises based on the patient’s presentation are critical. The McKenzie Method, which uses repeated motions to centralize symptoms, is particularly effective for disc-related sciatica.
A 2020 systematic review in Spine found that exercise therapy improves pain and function in patients with sciatica, especially when matched to the individual’s directional preference.
3. Manual Therapy
Spinal mobilization or manipulation, particularly of the lumbar spine and pelvis, can reduce nerve irritation and improve mobility. Myofascial release and soft tissue techniques also help with pain management.
4. Dry Needling and Shockwave Therapy
In cases where muscular or fascial components are involved, dry needling can reduce muscle tone and irritation around the nerve. Focused shockwave therapy may help in chronic sciatic-like pain where soft tissue or deep muscle tension contributes.
5. Medications (Short-Term Use)
NSAIDs can be helpful for inflammation and pain relief in the short term. Oral steroids or nerve pain medications (like gabapentin) may be used selectively. However, these are not long-term solutions.
6. Injections and Surgery
Epidural steroid injections are sometimes used when conservative care fails, particularly for acute disc herniation. Surgery (like discectomy) is reserved for severe cases with motor loss, unrelenting pain, or failure to improve after 3+ months of conservative care.
Final Thoughts
Not all leg pain is sciatica.
Understanding the difference between true sciatica and conditions that mimic it is essential for getting the right treatment. At our clinic, we specialize in diagnosing the root cause of your pain and guiding you through evidence-based, non-invasive solutions that work.
Schedule Your Evaluation
If you’re experiencing leg pain, numbness, or low back discomfort, don’t rely on guesswork or outdated advice. At Central Ohio Spine and Joint, we use advanced evaluation techniques—including movement screening and functional assessment—to identify the cause of your symptoms and build a personalized plan.
Schedule your consult today and get started on the path to lasting relief.
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