Conditions · Sciatica
Sciatica —
or something like it?
"Sciatica" has become the word for almost any pain that travels down a leg, and that is where a lot of the confusion starts. True sciatica means irritation of the sciatic nerve or the nerve roots that form it. A great deal of leg pain that gets called sciatica is nothing of the kind — it is pain referred from the joints of the lower back, or from the hip. The body reports it as coming from further down the leg.
Both are real, and both hurt. But they behave differently, they examine differently, and they need handling differently. So getting the label right isn't pedantry. It is the difference between treating your problem and treating a word.
01 · The differential
Three different things, one name.
This is the distinction I spend most of a first appointment establishing, because it decides everything that follows.
True nerve-root pain
Irritation of a nerve root in the lower back. It usually travels below the knee in a recognisable band, often with pins and needles, numbness or weakness in a pattern that follows the nerve. Frequently worse on coughing, sneezing or straining. This is the one that genuinely earns the name.
Referred from the lower back
Pain from the joints of the lower back reported by the body as leg pain. It tends to be a deeper, more diffuse ache, usually stopping around the thigh or knee, without the pins and needles or the clear band. Extremely common, and routinely mislabelled as sciatica.
Referred from the hip or deep gluteal muscles
Hip joint problems and the deep muscles of the buttock both refer pain into the back of the thigh, and both can produce something a patient reasonably describes as sciatica. The tell is usually what provokes it and what the examination finds at the hip rather than the spine.
02 · Why it matters
The label changes the plan.
If leg pain is referred from a stiff lower back or a hip that has lost rotation, then the lower back or the hip is what needs attention — and treatment aimed at a nerve that isn't the problem tends to disappoint on both sides.
If it is genuine nerve-root involvement, that changes the pace, what I would and wouldn't do, how closely I want to watch it, and how quickly I would refer for imaging or a specialist opinion if it isn't behaving.
It also explains why so many people arrive having been told they have sciatica for years without much changing. The word was settled on early. The examination that would have separated them never happened.
03 · The appointment
How it's told apart.
A first appointment runs 45 minutes, and the history does a lot of the work. I want to know exactly where the pain goes, how far down, whether it stops at the knee, whether there is pins and needles or numbness, what provokes it, whether coughing or straining makes it worse, and how it started.
Then comes the examination: lower back movement and what limits it, neurological testing of reflexes, sensation and muscle power, nerve tension testing, an examination of the hip and pelvis on that side, and testing of the deep gluteal muscles. Where the picture is genuinely a nerve-root one, I use specific manual techniques alongside a rehabilitation exercise programme. I say clearly what I expect each part to do.
And if the examination points somewhere I can't help, you'll hear that on the day.
04 · The limits
The symptoms that can't wait.
Leg pain has one genuine emergency attached to it, and everyone with back or leg pain should know the signs regardless of who they are seeing.
Go to A&E now
Difficulty controlling your bladder or bowels, numbness around the saddle area or between the legs, weakness developing in both legs, or numbness that is spreading. These are emergency symptoms and need assessment today.
Needs imaging or a specialist
Weakness in the leg or foot that is getting worse, symptoms progressing over weeks rather than settling, or a picture the examination cannot account for. I refer rather than continue and hope.
Following an accident
Leg pain that began with significant trauma needs medical assessment before manual treatment, and I'll say so.
Patients who came in with this
…I started to see Richard at the beginning of this year because I had sciatica down my left side every day for 6 months! It takes time and investment but it is worth it. I do the stretches that Richard taught me and I will go back for sessions because we need to keep on top of these things.
Where to see me
Two London clinics, same practitioner at both. A new patient appointment is 45 minutes and includes your first treatment where that’s appropriate.