SCIATICA

“The back pain that travels to your legs”

- Dr. Shweta Soni

Contents:
Physiotherapy
management based
on best available
Introduction of evidences and
sciatica clinical guidelines

Assessment/Diagnosis
 Most frequent radicular
Introduction: pain syndrome of spinal
origin

Relieved by lying Sciatica is a symptom,

down NOT A DIAGNOSIS

Occurs due to
Exacerbated by
irritation of a spinal
standing, sitting,
nerve root associated
exertion, coughing
with disc herniation at
and sneezing
L4-L5 or L5-S1

Exertion or a forced Pain usually begins in

movement results in the lower back radiating
acute low back pain, to the sacroiliac regions,
followed by referral to buttocks, thighs, calf
the leg and foot
Epidemiology:
The lifetime incidence of sciatica is estimated to be between 13-40%

Clinically significant sciatica is much less common and occurs in only 4-6% of
people over the course of life time

True sciatica actually develops in only 35% of patients with disc herniation
Course of sciatic
nerve:
Termination: at
the apex of
popliteal fossa, it Origin:
terminates by lumbosacral
bifurcating into the plexus
tibial and common
fibular nerves

It than enters the

Traverse: first
posterior thigh
enters in gluteal
by passing deep
region via
to the long head
greater sciatic
of biceps
foramen
femoris

Then it emerges
inferiorly to the
piriformis
muscle
 Topography (The physical features of
a sciatica)
• It’s referral pattern follows that of L5 or S1 territory
• L5: buttock, anterior aspect of thigh,
lateral malleolus, dorsum of foot,
great toe or the medial 3 toes
• S1: buttock, posterior aspect of high,
knee, leg & heel to the sole or lateral
side of the foot up-to the fifth toe
• In the distal limb, pain may be
replaced by tingling or numbness
 Symptoms and sign:
• Radiating pain from buttock down the back of leg
• Cramping sensation in the thigh
• Tingling or numbness in legs
• Burning sensation in legs and thigh area
• Muscle weakness is present in severe cases
• Most often symptoms are seen only on one side
• If symptoms present in both sides the disc bulge is more severe

• Worse when you cough or sneeze and prolonged sitting can aggravate
symptoms, numbness, tingling or muscle weakness in the affected leg or foot
Causes:

Nerve root
Inflammatory
compression
Inflammatory:
Sciatic neuritis:
inflammation of sciatic
nerve

Arachnoiditis:
inflammation of arachnoid
layer of spinal cord
covering
Nerve root compression:
Compression in the
intervertebral foramen due
Compression in the
to root canal stenosis
vertebral canal by disc,
because of OA,
tumor and TB spine
spondylolisthesis, facet
arthropathy and tumors

Compression in the buttock

or pelvis by abscess,
tumors and hematoma
Disk herniation: in approximately
90% of cases, sciatica is caused by
disc herniation at different level of
lumbosacral vertebrae(most
common L5-S1)
• Spinal stenosis:
• it is narrowing of passage where the spinal cord travels down the spine
that results in too much pressure on spinal cord
• Most common cause is age related change in spine
• Spondylolisthesis: it occurs when a vertebrae slips out of position, it is
a cause of spinal stenosis, most commonly caused by age related or
degenerative bear of spinal joints
Piriformis syndrome:
• Neuromuscular syndrome that occurs when the
sciatic nerve is compressed/irritated by the
piriformis muscle causing pain, tingling and
numbness in the buttocks and along the path of
sciatic nerve
• Wallet sciatica/fat wallet syndrome
• Caused/aggravated by sitting with a large wallet in
the affected side’s rear pocket
Pregnancy: it may
occur during pregnancy
as a result of weight of
fetus pressing on the
sciatic nerve during
sitting or leg spasms
Other causes:
• Medical condition like diabetes
• Infection in spine
• Injury to spine or surrounding muscle and ligaments
• Tumor within spine
• Spinal trauma: forceful impact caused by car accidents, falls or other
bows causes damage to spine
 Risk factors:
• Age related changes: herniated and bone spurs are most common cause of
sciatica
• Obesity: excess body weight may contribute to the spinal changes that
trigger sciatica
• Diabetes: blood sugar level increases risk of nerve damage
• Occupation: a job that requires twisting of back, carry heavy loads or drive
a motor vehicle for long periods may play a role in sciatica
• Prolonged sitting: people who sit for prolonged period or have sedentary
life style are more likely to develop sciatica than active people
When to consult a physiotherapy?

Sudden pain

Severe pain in your low back or leg

Numbness or muscle weakness in your leg

The pain following any injury, such as a traffic accident

Trouble controlling your bowels or bladder

When to seek medical advice?
Difficulty passing or controlling urine
Poor control or your bowel
Numbness around your back passage or genitals
Numbness, pins and needles or weakness in both legs
Unsteadiness when walking
Unexplained loss of weight
Night sweats, chills, fevers, nausea/ vomiting or
Unrelenting night pain
When spinal surgery recommended?

People who have That’s associated

Bowel or
severe sciatica with significant
bladder changes
<6-9 months leg weakness
 Test and diagnosis:

• Straight leg raising test (SLR):

• Patient in supine position
• Examiner lifts the leg gradually with the knee kept straight
• Between 30 and 70 degree nerve comes into contact with the
prolapsed disc and the patient complaints of pain
Straight leg raising test is positive: it’s
lasegue’s sign
• Modification of SLR test
• Hip is flexed and knee is also flexed at 90 degree
• The knee is then gradually extended by the examiner
• If patient will experience pain in the posterior thigh or leg the sign is
present
Signs of lumbar root compression
Clinical forms of sciatica:
Hyperalgic sciatica Paralytic sciatica
• Characterized by severe pain • Slight motor deficit can be detected
• Patient prefers to remain in bed and is • More frequent in L5 sciatica
hesitant even to move slightly • Most often paralytic L5 sciatica leads
to foot drop, which forces the patient
to modify the gait pattern

Myalgic sciatica: • Seen most commonly in disc herniations affecting S1 level

• Neuralgic pain is associated with intense and often
continuous muscular pains and cramps affecting the biceps
femoris, triceps surae and occasionally the gluteal muscles
• Mild motor deficit
• Fasciculations are seen
Diagnostic image:
• X-ray: spinal curvatures, vertebral disc changes and fractures in spine
• MRI: study of choice for recurrent herniated from peri neural fibrosis
• CT scan: to create images of structures of back, morphological
abnormalities in relation to a herniated disc, relative impact on
adjacent soft tissues, any neuroforaminal or extra foraminal
encroachment
• Electromyography: to examine how well electrical impulses travel
through sciatic nerve
Discography:
• Often neglected modality
• Excellent means of assessing disc pathology
Psuedosciatic syndromes:
• Periarthritis of hip: can stimulate sciatic pain
 Outcome measures:

The total score

ranges from 0 to 24,
with higher scores
indicating worse
symptoms.
Neuropathic Pain Symptom
Inventory:
 Clinical recommendation: (2008)

• Consistent, good-quality patient-oriented evidence

• If red-flag findings are absent, a patient with sciatica should try

conservative management for up to six weeks before obtaining
imaging and considering surgical approaches

Gregory DS, Seto CK, Wortley GC, Shugart CM. Acute lumbar disk pain: navigating evaluation and
treatment choices. Am Fam Physician. 2008 Oct 1;78(7):835-42. PMID: 18841731.
 Recommendation for sciatica patient: (April
2020)

Raymond WJG Osteo; Physiotherapy management of sciatic. Journal of physiotherapy Vol;66,issue

02. April 2020 Available on: [Link]
Goals for physiotherapist:
• Restore pain free functional movement patterns
• Relive back, buttock, thigh and leg pain
• Reduce muscle spasm
• Restore function of the lumbar spine and the SI joint
• Improve mobility of the lower back
• Foster a better healing environment in the lower back
• Promote neurological adaptations to reduce the perception of pain
• Prevent future pain flare-ups and reduce fear associated with
movement
Rehabilitation program:
• Correct your posture
• Strengthening exercises
• Stability and flexibility exercise
Common techniques:
• Extension and flexion back exercises:
• Help relive pain by promoting movement of the spine
• Often individuals with lower back pain and sciatica feel relief with specific
directional movement of the spine
• A physical therapist typically evaluates an individual’s directional
preference before prescribing specific directional exercises, as these are
tailored to the individual patient and symptoms
• These exercises include backward (extension)and forward (flexion) bending
• This directional movements is an imp component of the Mckenzie method
also known as mechanical diagnosis and therapy (MDT)
The MDT (Mechanical diagnosis and
therapy)
• Is a technique that involves a series of active directional movements to
identify and treat a pain source in the spine, muscles and/or joint
• The technique focusses on moving the radiating pain closer to the center
of the body through exercises
• Examples: moving leg pain closer to the spine.
• The theory of this approach is that centralizing the pain indicates
improvements in symptoms
• The goal is to reduce radiating symptoms originating from the spine
• A therapist who practices this technique usually has special training in
the Mckenzie method
Treatment:
• A physiotherapist is expertise in diagnosing and treating the root cause of your back
pain
• Various line of treatments are used by physiotherapists
• Hot pack
• Stretching
• Exercises
• Electrical modalities
• Advanced physiotherapy
• Dry needling
• Taping
• Cupping
Strengthening exercises:
• Include bodyweight and resistance exercises to strengthen the muscle
of the abdomen, low back, hips and legs
• Isometric exercises: involve contracting muscles without moving the
joints
• Examples of isometric exercises include a plank or a bridge hold
• These exercises can help strengthen muscles when symptoms are more
acute
• Isotonic exercises: include contraction of a muscle to resist a constant
load, such as resistance bands and weight training, to help increase
muscle strength through constant resistance to specific motions
Important note:
• More repetition= higher muscular endurance
• Repetition with holding= will increase power of your muscle
• NOTE: endurance in important than power because performing many
repetitions with a lighter weight trains the muscle to sustain
contractions over a longer period with help us in daily activities
RANGE OF MOTION AND STRETCHING
EXERCISES:
Posture and lifestyle modifications:

• In addition to physical therapy and exercises, committing to correct

and ergonomically supported posture while sitting, standing and
walking is essential in treating and preventing sciatica

• Daily routines such as following ergonomically safe lifting techniques

and using good sleep postures are also important to follow
• Sleep or rest on a firm surface. Find a position of comfort.
• The most commonly suggested positions are side-lying with a pillow between
your knees or on your back with a pillow under your knees.
• Avoid slouching when you walk or
stand. Stand up straight

• Walk erect and tall.

INCORRECT STANDING POSTURES CORRECT STANDING POSTURES
PROLONGED ACTIVITY IN A FLEXED
• Do not slouch sit! Sit with a small rolled-up towel, foam cushion, or pillow in
your low-back area, just above your belt.
• Sit with your buttocks all the way back in the chair.
INCORRECT SITTING POSTURES CORRECT SITTING
POSTURES
Functional training:
• Includes reintroducing movements such as lifting, carrying and
bending or squatting
• The use of proper technique and healthy movement patterns are
incorporated to reduce pain and prevent re-injury
INCORRECT LIFTING
TECHNIQUES:

DO NOT:
• Lift with your legs straight and
your back flexed/bent.
• Lift objects that are too heavy over
your head.
• Ever lift and twist at the same
time.
• Lift an object that is too heavy or
awkwardly shaped without help.
CORRECT LIFTING
TECHNIQUES:
DO:
• Lift with your legs, keeping
your back straight.
• Use a footstool for objects
that need to be placed or
retrieved from high
locations.
• Use two people for heavy
or awkward objects.
Nerve glides (nerve mobilization):
• Involves active and passive techniques on a
symptomatic nerve when it is placed into and out
of tension to facilitate movement and reduce
symptoms
Joint mobilization:
• Is a manual therapy technique in which the therapist applies pressure
to a joint to mobilize it and produce a therapeutic effect
Joint manipulations:
• Is a manual technique in which the therapist applies a quick, thrust
force at the end range of motion of a joint to promote pain relief and
restore normal movement
Dry needling:
• Is a technique in which a certified healthcare provider uses a small
needle to target a trigger point in a muscle
• This technique is performed to release hyper-irritable and/or hyper-
contracted muscle tissue to reduce pain
Muscle energy technique:
• Is a form of manual therapy that involves the patient performing gentle
muscle contractions in conjunction with the therapist moving the
painful joints through a specific range of motion
• This technique may help reduce pain and restore function

[Link]
Physiotherapy aids and modalities
Heat pack Cold pack

May relieve pain by reducing muscle May relieve pain by causing a

stiffness numbing effect
Heat helps blood vessels to dilate Cooling effect typically constrict
Improve blood flow blood vessels beneath the skin
Reduce muscle tension Helping to reduce pain and swelling
Promote relaxation Cold packs also slow down the
Prepare muscle for physiotherapeutic chemical reactions that cause
approaches inflammation and pain
 Transcutaneous electric nerve stimulation (TENS):
• A TENS unit applies electric current directly to sensory nerves,
creating a tingling sensation that may reduce the feeling of pain
• This reduction in pain may help to improve a patient’s tolerance for
active movements that facilitate healing
Neuromuscular electric muscle
stimulation:
• By using different wavelengths and amplitudes is
a therapeutic method of inducing muscle
contraction
• In certain cases, when nerve involvement is
severe and a patient is unable to voluntarily
contract muscles in their hip or leg, or muscle
contraction is weak, electrical stimulation can
help facilitate these contractions to improve
functions
• Various types of Electric muscle stimulators are
now available
Tractions:
• Mechanical traction gently pulls the vertebrae apart to relieve the
compression of spinal tissues
• In sciatica traction may help with
• Temporarily widen spaces in the intervertebral foramina to relieve
compression of the spinal nerve
• Provide muscle stretch to relieve spasm
• Relieve pressure ion injured discs, reducing nerve symptoms
• A therapist may apply traction manually or use mechanical traction
Identification of Best Evidence for Rehabilitation to
Develop the WHO’s Package of Interventions for
Rehabilitation: (Dec 2023)
CPG: clinical practice guideline, LBP: low back pain, PIR: Package of
 Exercise for Neuropathic Pain: A Systematic Review
and Expert Consensus (November 2021)

Symptom-guided exercises, such

as postural instructions,
stabilizing exercises for deep
muscles, and dynamic exercises
for surface muscles in the trunk
region, had a trend to a larger
reduction of leg pain than the
sham exercise group that
performed low-intensity and no
back-related training (Level of
evidence I)
Zhang YH, Hu HY, Xiong YC, Peng C, Hu L, Kong YZ, Wang YL, Guo JB, Bi S, Li TS, Ao LJ, Wang CH, Bai YL, Fang L, Ma C, Liao LR, Liu H, Zhu Y, Zhang ZJ, Liu CL,
Fang GE, Wang XQ. Exercise for Neuropathic Pain: A Systematic Review and Expert Consensus. Front Med (Lausanne). 2021 Nov 24;8:756940. doi:
Reference of guidelines for low back
pain with or without sciatica:
• Low back pain and sciatica in over 16s: assessment and management
NICE guideline Published: 30 November 2016
[Link]/guidance/ng59
Complications:
Sciatica can potentially cause permanent nerve damage

Loss of feeling in affected leg

Weakness in affected leg

Loss of bowel or bladder function

Prevention:

Maintain proper
Exercises Use good body
posture when
regularly mechanics
you sit
Always follow currently published evidences
and updated clinical guidelines to make
rehabilitation program for your patients
- THANK YOU