Sciatica: Causes, Symptoms and Conservative Care Options

Few kinds of pain are as distracting as sciatica. It can start as a dull ache in the lower back or buttock and then shoot down the back of the leg like an electric current, sometimes all the way to the foot. Many people describe burning, tingling or numbness along with the pain, and sitting or coughing can make it worse. The good news is that most cases of sciatica improve with time and conservative care. This guide explains what sciatica is, what usually causes it, how it is evaluated and which non-surgical options can help you get moving again.

What Is Sciatica?

Sciatica is not a diagnosis by itself. It is a description of symptoms caused by irritation or compression of one or more of the nerve roots that form the sciatic nerve. These roots leave the lower spine (the lumbar and sacral levels) and join together in the pelvis to form the largest nerve in the body. The sciatic nerve then travels through the buttock and down the back of the thigh before dividing into branches that supply the lower leg and foot.

Because the nerve covers such a long path, the location of symptoms often gives a clue about which nerve root is involved. Pain that travels to the top of the foot and the big toe suggests a different level than pain that travels to the outside of the foot and the little toe. Clinicians call this pattern of leg pain from a nerve root lumbar radiculopathy.

Common Causes of Sciatica

Several conditions can irritate the sciatic nerve roots. The most common include:

• Lumbar disc herniation. The soft inner material of an intervertebral disc can push through its tougher outer ring and press on a nearby nerve root. Chemical irritation from the disc material also plays a role. This is the most frequent cause in adults under about 50. Read more in our guide to herniated disc treatment without surgery.
• Lumbar spinal stenosis. Age-related thickening of ligaments, bone spurs and disc bulging can narrow the spaces where nerves travel. Stenosis-related leg pain often worsens with standing and walking and eases when sitting or bending forward.
• Spondylolisthesis. When one vertebra slips forward on the one below, the opening for the nerve root can narrow.
• Piriformis and deep gluteal irritation. In some people the sciatic nerve is irritated where it passes through the deep muscles of the buttock. This is sometimes called piriformis syndrome, and it remains a diagnosis of exclusion.
• Less common causes. Rarely, infection, tumors, fractures or blood-vessel problems can produce similar symptoms. These possibilities are the reason a careful history and examination matter.

Pain from the sacroiliac joint or from the small facet joints of the spine can also spread into the buttock and thigh. That kind of referred pain usually stops above the knee and does not cause true numbness or weakness, which helps a clinician tell it apart from nerve-root sciatica.

Typical Symptoms

• Pain that radiates from the low back or buttock down one leg, often below the knee
• Leg pain that is worse than the back pain
• Numbness, tingling or a "pins and needles" feeling along the same path
• Pain that increases with prolonged sitting, coughing, sneezing or straining
• Mild weakness in the foot or ankle in some cases

Sciatica usually affects one side. Symptoms in both legs, or symptoms that are getting steadily worse, deserve prompt medical attention.

Warning Signs That Need Urgent Care

Most sciatica is not dangerous, but a small number of people develop a serious compression of the nerves at the bottom of the spinal canal called cauda equina syndrome. Go to an emergency department right away if back or leg pain comes with any of the following:

• New numbness in the groin, genitals, inner thighs or around the back passage ("saddle" numbness)
• New difficulty starting to urinate, loss of the feeling of passing urine, or leaking urine
• Loss of bowel control
• Rapidly increasing weakness in one or both legs

Fever, unexplained weight loss, a history of cancer or a significant fall or accident are also reasons to be seen quickly. Our article on back pain red flags explains these warning signs in more detail.

How Sciatica Is Evaluated

A chiropractic physician, primary care doctor or physical therapist will start with a detailed history: how the pain started, what makes it better or worse, and whether there are any red flags. The physical examination usually includes:

• Observation of posture and how you move and walk
• Straight-leg raise and related nerve tension tests
• Reflex testing at the knee and ankle
• Muscle strength testing of the hip, knee, ankle and toes
• Sensation testing to map areas of numbness

Imaging such as X-ray or MRI is not needed for most people during the first several weeks. Guidelines generally reserve MRI for people with red flags, significant or progressive weakness, or symptoms that have not improved after a reasonable period of conservative care and who might be candidates for an injection or surgery. Many people without any pain have disc bulges on MRI, so imaging findings always need to be matched to the examination.

Conservative Care Options

The natural history of sciatica is generally favorable: many people improve substantially within a few weeks to a few months. Conservative care aims to reduce pain, keep you active and speed that recovery.

Stay as active as you comfortably can

Prolonged bed rest is no longer recommended. Short walks, gentle movement and continuing everyday activities, adjusted to your pain, tend to lead to better outcomes than lying still. Change position often and avoid sitting for long periods without a break.

Heat, ice and short-term pain relief

Many people find a heating pad or a cold pack helpful for short periods. Over-the-counter pain relievers may help some people, but talk with your doctor or pharmacist about which medicine is appropriate for you, especially if you have stomach, kidney or heart concerns or take other medications.

Spinal manipulation and mobilization

Chiropractic physicians may use gentle spinal manipulation or mobilization, along with soft-tissue work, to reduce pain and improve movement. Clinical practice guidelines, including the American College of Physicians' 2017 guideline for low back pain, list spinal manipulation among the non-drug options clinicians and patients may consider. Treatment for sciatica is adapted to the individual, and a skilled practitioner will avoid techniques that clearly aggravate leg symptoms.

Exercise and nerve mobility work

A tailored exercise program is one of the most useful long-term tools. This may include directional preference exercises (movements that centralize or reduce leg pain), core and hip strengthening, and gentle nerve gliding exercises. Your clinician can show you which movements help and which to avoid. For ideas you can use at home, see our guide to sleeping positions for back pain and our ergonomic desk setup tips.

When other treatments are considered

If severe pain continues despite several weeks of good conservative care, your medical doctor may discuss prescription medication, an epidural steroid injection or a referral to a spine surgeon. Surgery is usually considered for people with progressive weakness, cauda equina syndrome, or persistent disabling leg pain with a matching finding on MRI. Many people who choose conservative care do well, and the decision is a personal one made with a specialist.

Preventing a Recurrence

• Build and maintain strength in the trunk and hips with regular exercise
• Take movement breaks when sitting for long periods
• Lift with your legs, keep loads close to your body and avoid twisting while lifting
• Maintain a healthy body weight and stay physically active
• If you smoke, consider quitting; smoking is associated with poorer spinal health

When to See a Chiropractor or Doctor

Consider booking an evaluation if leg pain lasts more than a few days, keeps returning, interferes with sleep or work, or comes with numbness or weakness. A licensed chiropractic physician can examine you, explain the likely source of your pain, provide hands-on care and exercises, and refer you to a medical doctor when your history or examination calls for it. As Dr. Lehman describes in his article on low back pain and chiropractic treatment, a good initial assessment is designed to rule out serious causes before treatment begins.

Conclusion

Sciatica is a symptom of an irritated nerve root, most often from a disc herniation or narrowing in the lower spine. Although it can be very painful, it usually improves with time, activity and conservative care such as manual therapy and targeted exercise. Know the red flags, stay as active as you can, and seek a professional evaluation if your pain is severe, persistent or accompanied by weakness or changes in bladder or bowel control.

Medical disclaimer: This article is for general education and is not a substitute for personalized advice from a licensed health care provider. If you have severe, worsening or unusual symptoms, seek medical care promptly.