Sciatica: A Commonly Misdiagnosed Problem

What is True Sciatica?

True sciatica is caused by pressure on the sciatic nerve. This nerve, the largest in the body, travels from the lumbar spine through the buttocks, and down the back of the thigh, where it divides into two branches in the lower leg. Those suffering from true sciatica might experience sensations along this path including pain, tingling, or numbness which can travel down as far as the foot. The most common causes of pressure on the sciatic nerve are a bulging disc, which compresses the nerve near the spine, or soft tissue, such as the piriformis muscle in the buttocks, which can entrap the sciatic nerve.

True sciatica, then, is caused by compression or entrapment of the sciatic nerve which results in referred pain. This is called a nerve root referral.

True Sciatica or Trigger Point Referral?

When there is pain in the lower back, the buttocks or down the back of the leg, sometimes traveling as far as the foot, sciatica is often the first condition suspected. But in a high percentage of cases, this pain is not caused by compression or entrapment of the sciatic nerve but by chronically tight muscles, which can set up another type of referred pain: referred pain from myofascial trigger points.

Myofascial Trigger Points

The term "myofascial" is derived from myo which means muscle, and fascia which is the connective tissue that envelopes muscles, tendons, and joint capsules. In their 2-volume work, Myofascial Pain and Dysfunction: The Trigger Point Manual, Drs. Janet Travell and David Simons offer this definition:

Myofascial Trigger Point: A hyperirritable spot, usually within a taut band of skeletal muscle or in the muscle’s fascia, that is painful on compression and that can give rise to characteristic referred pain.

While referred pain is a common sensation caused by trigger points, other sensations can be elicited as well. Tingling, numbness, thermal sensations (hot/cold), achiness, or the feeling that the area “just isn’t right” are all possible symptoms of trigger point referrals.

A Common Trigger Point Referral

One of the most common muscle groups to develop trigger points are the gluteal muscles, especially the gluteus medius and minimus. The gluteal muscles can become chronically contracted due to:

• A sedentary lifestyle
• The absence of regular stretching following exercise
• Postural distortion which sets up compensatory muscular patterns

When muscles become chronically contracted, myofascial trigger points can develop. In the case of the gluteal muscles, the trigger points can cause referred sensation which will mimick symptoms of sciatica.

Why Are These Distinctions Important?

It’s important to make the distinction between true sciatica (nerve root referred pain) and pain that’s mimicking sciatica (trigger point referred pain) because otherwise we miss the most frequent cause of the problem: chronic contraction in the muscles.

Muscles receive little attention in modern medical school teaching and medical textbooks. Consequently, physicians give a disproportionate amount of attention to nerves, joints, bursae, and bones at the expense of the largest organ in the body: skeletal muscle. Inattention to what’s happening in the musculoskeletal system often results in medical confusion with respect to lower back pain and other chronic pain.

The common decree, “You have sciatica… get some physical therapy,” is often neither an accurate diagnosis, nor a sound therapeutic prescription. While physical therapy is tremendously effective for many types of treatment such as rehabilitation of an atrophied limb after a cast has come off or stabilizing a weak joint with strengthening exercises, it does not tend to deal effectively with chronic pain.

What To Do

Whatever therapeutic approach is chosen to relieve chronically contracted muscles and myofascial trigger points, it’s essential to follow the proper order of rehabilitation:

1) Relieve the spasms and hyper-constriction in the affected muscles
2) Restore proper biomechanics to the body
3) Restore flexibility to the tissues
4) Rebuild strength of the injured tissues
5) Rebuild endurance