SCIATICA – THERE’S PROBABLY NOTHING STRUCTURALLY WRONG, LET’S JUST TAKE OUR FOOT OFF THE HOSE
Sciatica is a common problem. Of all chronic pain issues, it is definitely in the top three along with low back pain and knee pain. What we find most significant is that even with how common sciatica is, it is very poorly understood by the general public and the huge majority of professional advice, articles, and recommendations are incorrect in what they suggest as the causes and what they recommend as the solutions.
It is unsettling how practically all of the top google results when you search “sciatica treatment” suggest that you have a structural problem and recommend invasive and expensive procedures almost immediately. Sciatica is almost never difficult to fix.
At Human Movement Lab, a big part of what we want to contribute to is better education and understanding of all of the issues that affect so many of us. So let’s talk more about what sciatica actually is, what the most common incorrect recommendations are, and how it really is not a big deal and can be fixed quite quickly with the correct programming – not any programming, but correct programming.
Sciatica is a pain or uncomfortable sensation sometimes starting in the low back and sometimes starting in the hip/buttocks area and it often radiates down the leg. It may go all the way down to the calf, ankle, or foot, or it may just stay in the upper leg or buttock area. It can often feel worse when sitting, or the body position in which it feels worse can vary from person to person. It is not comfortable, can be very painful, is annoying, and most people that have the condition feel it most of the time, not just every once in a while.
The simple explanation of what causes sciatica is dysfunctional stability and mechanics in the hips and trunk – the hips don’t move properly, the trunk doesn’t reflexively stabilize properly, the hips and trunk are not coordinated to work together, and the spine moves too much and is put under stress that it would not be exposed to if trunk and hip mechanics were appropriate. None of these things are structural problems. They are movement and stability problems. The sciatic nerve originates in five different spinal nerves that give rise to the sciatic nerve, which goes down through the pelvis/hips and all the way down the leg. When these dysfunctional mechanics are present, the inappropriate movement in the trunk and hips causes pressure and pinching on this nerve either in the low back area or in the buttocks area – the equivalent of someone stepping on a hose. So if the sciatic nerve is getting “stepped on”, the solution is to just remove the pressure, not use injections or pain meds to numb the signal.
Another reality of dysfunctional hip mechanics is an inability to control the femur – the hips are basically just where the femurs insert into the pelvis – so the movement of the femurs within the pelvis is what hip function or dysfunction is. When the hips aren’t operating how they should, certain trunk and hip muscles are underactive and some are overactive. The most common overactive hip muscle is the piriformis, an external rotator right next to the sciatic nerve. The piriformis often gets very tight and sometimes larger than it should normally be since it is doing much more work than it is designed to do in an attempt to make up for the other underactive muscles. This tight and often larger than normal piriformis can put pressure on the sciatic nerve, along with the inappropriate movement of the hips. So the poor innocent sciatic nerve is just getting pinched and beat up for a few different reasons.
Sciatica pain can be quite serious, painful and problematic – but it doesn’t mean that there is anything structurally wrong – we just need to fix hip mechanics and trunk stability so that we take the foot off the hose. This is done by restoring hip and thoracic spine mobility, improving breathing, and improving trunk and hip stability and coordination starting at the most basic levels (below standing) and working up to a functional hip hinge motion in a standing position. In our experience, this fixes sciatica practically 100% of the time even with clients who have seen multiple other professionals about it before us.
Now let’s talk about the scary reality of what basically all of the top google results tell you when you search keywords “sciatica”, “sciatica relief” or “sciatica treatment”. Practically all of the top search results describe the symptoms accurately but are way off when it comes to what the likely causes are. They tend to suggest that it is some sort of structural issue – usually degenerative disc disease, a herniated lumbar disc, or spinal stenosis. These are the top three suggested explanations for sciatica.
Let’s talk about each one of these and why they are incorrect:
Degenerative disc disease is not really a disease but a process and the “degenerative” part just means that it will tend to get worse with age. But the name “degenerative disc disease” definitely sounds scary and serious. Everyone’s discs are constantly “degenerating” with time – 20 year olds, 40 year olds, 80 year olds. It is a normal thing. Countless studies have shown that if you randomly took 100 people and got an MRI of their spine, many of them will have scans that indicate that they have severe disc degeneration, but they have no pain or problems at all. And many people with MRI’s that look totally normal have very problematic and serious back pain or sciatica. There are many false positives with MRI’s, and many professionals that profit from expensive sciatica treatment attempts conveniently steer people towards invasive and costly procedures that are often unnecessary. We are not suggesting that MRI’s are not useful, just that they are often ordered as the very first thing, and really there should be several steps before scans that actually provide much more useful information and cost almost nothing. We are also not suggesting that these professionals are knowing misleading people – they do mean well, but when all you have is a hammer everything looks like a nail.
Degenerative disc disease definitions explain how the discs between vertebrae wear down over time due to the pressure put on them during daily movements, bending, and physical activity. It is more or less the paperclip theory – that with enough repeated bending and moving back and forth, the vertebrae wear down the discs and they become thinner and less resilient – but this explanation assumes that this “bending” is an unavoidable part of life. The reality is that the true cause of both sciatica and low back pain has everything to do with dysfunctional hip mechanics, and dysfunctional reflexive stability of the trunk. When the hips and trunk function appropriately, the hips move and the spine stay stable – so this bending is heavily reduced, and then there simply isn’t as much stress on the spine.
The hips and trunk work together as a unit – they almost never work independently of each other, so it is essential that they are coordinated and behave appropriately during daily activities. When the hips move the correct way, the trunk stays braced, stable, and neutral. When your hips flex as they do when you pet a dog or pick something up of the floor, there really should not be much movement in the lumbar spine. It is important for proper hip mechanics that we can disassociate movement of the hips from movement of the lumbar spine. The hips should be able to move while the lumbar spine stays neutral. When people have dysfunctional hip mechanics and trunk stability, every time their hips flex, their lumbar spine flexes or extends. So this diagnosis of “degenerative disc degeneration” is usually just poor hip mechanics – and fixing these non-structural movement and stability issues will fix the problem. If you stop the spine from moving under load way more than it is supposed to, then you slow or stop the “degeneration” – the paperclip bends much less often and preserves the integrity. An 80 year old with appropriate hip mobility, mechanics, and trunk stability will have a much healthier and pain free back than a 20 year old with poor hip and trunk function, even though it is very likely that the MRI of the 80 year old will look more degenerated.
A second common explanation of the cause of sciatica is a lumbar disc herniation. Many people, including doctors, clinicians and therapists use the terms “disc herniation”, “disc bulge”, and “slipped disc” interchangeably. Let’s think of a spinal disc as a jelly donut. The annulus is the outside of the donut, and the nucleus is the jelly inside. This can definitely be a real cause of sciatic discomfort, but it can almost always be fixed without injections or any surgery. Fixing trunk stability and hip mobility and mechanics will prevent the same problem from happening again once the disc has healed.
A disc bulge technically means that the disc is bulging out due to pressure from the vertebrae above and below but the nucleus (jelly) has not actually come outside of the donut, while a disc herniation means that the disc has been pinched so that the jelly has actually left the donut. A “slipped disc” can refer to either. Many of the top spine specialists in the world, such as Dr. Stu McGill and Dr. Richard Deyo will tell you that the huge majority of disc bulges and herniations will actually repair themselves. No intervention or procedure is necessary – but many (not all) professionals who make money on these procedures will tell you that you need to have these procedures done when you really don’t – or they will want to skip the more low cost and conservative treatment options that should happen first. A lot of people feel rushed or pressured into doing something invasive and expensive right away.
What is very important to understand is that the reason the discs were herniated or bulging in the first place is because there was inappropriate stress on the disc because the vertebrae were either too flexed or extended during the motion or activity that caused the problem. If all you do is rest, the injury will heal, but then you will probably move the wrong way again because you still have poor hip mechanics and trunk stability – so your risk has not really gone down. The important thing to do once the inflammation and swelling have gone down, is to correct hip mechanics and trunk stability in a safe and gradual way so that the trunk and spine stay stable and the motor control, stability, and proprioception of the trunk actually improve to the point that it won’t happen again. Rest and ice and medicine can help treat the symptoms, but they do nothing to treat the cause or reduce the likelihood of it happening again later.
The third most common explanation for sciatica is spinal stenosis – the narrowing of the bone channel that encases the spinal nerves and spinal cord. The idea with this diagnosis is that the pinching of the spinal nerves and cord is happening because the channel is just getting too narrow – but this is extremely unlikely compared to the possibility that, again, the person simply has dysfunctional hip mechanics and trunk stability which causes too much movement of the spine and not enough stability in the trunk – and this is actually why the spinal and/or sciatic nerves are getting pinched and irritated.
If the movement of the hips and stability of the trunk are improved, there is plenty of room in the bone channel. You can have the most spacious bone channel ever and you’re still going to irritate nerves if you have poor mechanics and reflexive stability. According to Dr. Stu McGill, a top back pain and spine specialist, diagnoses of spinal stenosis have increased dramatically in recent years and are just the latest fad among health professionals that profit from procedures following this diagnosis.
The common theme with all of the most common diagnoses of the causes of sciatica is that all of them steer patients towards significantly expensive and eventually invasive corrective procedures. Profitability is a big motivator, even if it is subconscious, and is why more effective and low cost treatment methods are frequently skipped over. This is really the biggest problem in healthcare in general – the correct solution is usually much less expensive than other options but involves time and effort so it isn’t given the priority and attention it deserves.