Sciatica pain: not all leg pain is sciatica

“I have sciatica” is a phrase that is heard frequently. The term is used in everyday life to describe almost any pain that travels from the lower back or hips to the leg. The problem is that “sciatic pain” is not a diagnosis: it is a description of a symptom. And many of the pains that people call sciatica actually have another origin.

Understanding the difference is essential because the treatment depends on the cause, and not just the location where the pain is felt.

What is the sciatic nerve?

The sciatic nerve is the largest nerve in the body. It is formed by the junction of nerve roots that exit from the lumbar spine and the sacrum (from L4 to S3), passes through the groin region, descends along the back of the thigh and splits, usually above the knee, into two branches that continue to the leg and foot.

What is sciatica pain?

Sciatic pain is pain that extends along the path of the sciatic nerve or one of the nerve roots that form it. In clinical terms, the most rigorous designation is lumbosacral radicular pain, because in the vast majority of cases the problem lies in the nerve root near the spine, and not in the nerve along the leg.

Typically, sciatic pain:

• It affects only one leg
• It descends below the knee, often to the foot, following a well-defined path.
• It is felt in the leg with the same or greater intensity than in the back
• It is described as a pain in a “shock,” a burn, or an “electric shock.”
• It may be accompanied by tingling, numbness, loss of strength or decreased reflexes

When these neurological signs are present, it is referred to as radiculopathy, meaning that the nerve root is not only irritated but also exhibits changes in its function.

What is the most common cause?

In about 90% of the cases, sciatic pain is associated with a lumbar disc herniation that affects a nerve root, mainly at the L4-L5 and L5-S1 levels (Koes et al., 2007). Other possible causes include narrowing of the channels through which the nerves pass (stenosis), degenerative changes in the spine, or, more rarely, the slipping of a vertebra (spondylolisthesis).

It is important to know that pain is not solely the result of mechanical compression. The material of the herniated disc also causes an inflammatory reaction around the nerve root, which plays an important role in the symptoms (Ropper & Zafonte, 2015). This helps to explain why the pain may improve even when the hernia remains visible on the scans.

Does a hernia always explain the pain during an examination?

No. Changes such as protrusions and herniated discs are very common in people without any pain, and their prevalence increases with age (Brinjikji et al., 2015). Therefore, an imaging examination only makes sense when it is interpreted in conjunction with the symptoms and clinical evaluation. Finding a herniation on magnetic resonance imaging does not, by itself, mean that it is the cause of the pain.

So, all the pain in the back of the leg is sciatica?

No. Several structures can cause pain in the groin and the back of the thigh without there being involvement of a nerve root. This is the so-called referred somatic pain, sometimes popularly referred to as “pseudocathartic”. Among the most frequent causes are:

• Lumbar spine joints (facetal joints)
• Sacroiliac joint
• Muscles of the gluteal region, Including the so-called deep gluteal syndrome, in which the sciatic nerve can be irritated during its passage through the groin
• Tendinopathy of the sciatic muscles, near the ischium (the bone where we sit)
• Pain in the lateral region of the hip, in the trochanter area
• Hip joint articulation, which can refer to pain in the groin and thigh

The referred somatic pain usually has characteristics different from sciatic pain: it is more diffuse, difficult to locate precisely, it usually occurs above the knee and is not accompanied by changes in sensitivity, strength or reflexes.

There are also other less frequent situations that can also cause leg pain and require medical attention, such as peripheral arterial disease, in which pain occurs when walking and eases when stopping due to lack of circulation, and rarer causes such as tumors, infections, or certain gynecological conditions.

How is sciatica pain different from other types of pain?

Through a careful clinical evaluation, which includes:

• A detailed conversation about the onset, course, type of pain, and factors that worsen or relieve it
• Tests of spinal mobility, hip mobility and sacroiliac joint mobility
• Neurodynamic tests, which assess the sensitivity of the nervous system to movement, such as the extended leg lift test (Lasègue test) or the slump test
• Evaluation of sensitivity, muscle strength and reflexes
• Specific tests for the other structures that can cause leg pain

In most cases, imaging tests are not necessary in the first few weeks. Magnetic resonance imaging is indicated primarily when there are warning signs or when symptoms do not improve with conservative treatment and another intervention is considered (NICE, 2020).

When should you seek urgent medical help?

Some situations require immediate medical evaluation:

• Numbness in the genital area, the buttocks or the inner thighs (“heel area”)
• Difficulty urinating, loss of control over urination or stool
• Cranial pain in both legs simultaneously
• Progressive loss of strength, such as difficulty lifting the tip of the foot
• Fever, unexplained weight loss or a history of cancer
• Pain after a fall or major trauma

The first three signs may indicate a syndrome of the equine tail, a rare condition that requires urgent treatment.

What is the usual evolution of sciatica pain?

In most people, the evolution is favorable. A large proportion improves significantly within the first weeks to months with conservative treatment (Koes et al., 2007). Even when there is a herniated disc, it is common for the size to decrease over time.

How is it treated?

Treatment should be directed towards the cause identified in the assessment and adjusted to each individual. According to current clinical recommendations (NICE, 2020), the initial approach includes:

Staying active

Prolonged rest in bed is not recommended. Maintaining daily activities adapted to the pain promotes recovery.

Therapeutic exercise

Guided and progressive exercise is one of the foundations of treatment, helping to restore mobility, strength, and confidence in movement.

Manual therapy

Manual therapy, performed within the framework of Physiotherapy or Osteopathy, can be used to relieve pain and improve mobility, always integrated into a plan that includes exercise.

Education

Understanding what is happening, that most cases progress favorably and that pain does not necessarily mean injury, reduces fear and helps the person resume their activities.

Medication

The decision about medication rests with the doctor. It is important to know that in sciatica pain, the effect of many analgesics and anti-inflammatory drugs is limited, and that some frequently used medications are not recommended by current clinical guidelines.

Other options

When the pain is intense and persistent despite conservative treatment, infiltration or surgery may be considered by medical indication. Surgery tends to relieve pain more quickly, but in the long term the results are similar to those of conservative treatment in most people (Peul et al., 2007). In the presence of severe or progressive neurological signs, surgical evaluation is a priority.

During pregnancy, is leg pain sciatica?

In most cases, no. True sciatica caused by a herniated disc is uncommon during pregnancy. The pain in the groin and the back of the thigh that many pregnant women experience is usually related to the pain in the pelvic girdle, which involves the joints of the pelvis. This distinction is important because the approach is different, and pelvic physiotherapy can play a relevant role here.

The approach in Integrative Medicine

Sciatic pain is a symptom, not a diagnosis. It indicates that a nerve root or the sciatic nerve are involved, but it does not say where or why. On the other hand, many pains in the groin and leg are not sciatica and have their origin in joints, muscles, or tendons. Only a careful evaluation allows us to distinguish these situations and define the appropriate treatment.

In other words: sciatica pain isn’t everything, and not everything is sciatica pain.

In Integrative Medicine, each case begins with a detailed clinical evaluation, which seeks to identify the source of the pain, detect warning signs, and understand the factors that may be contributing to the problem, such as sleep, stress, physical activity, and the life context, based on principles of Clinical Psychoneuroimmunology. The follow-up combines Osteopathy and Physiotherapy and, when indicated, can be combined with Clinical Pilates for progressive recovery and the prevention of relapses, and with the doctor whenever necessary.

If you experience pain in the lumbar region, the groin or the leg, an individualized assessment allows us to understand the source of your pain and define a plan tailored to your needs. Schedule your consultation at Integrativa.