Are You Sure It’s “Just Sciatica”? Expert Case Study Insights
When patients walk into a physiotherapy clinic complaining of sharp, radiating pain down their leg, many assume they already know the diagnosis: sciatica. It’s common for patients to believe they have sciatica when, in fact, their symptoms don’t align with a typical sciatica presentation. While sciatica is a frequent diagnosis, its symptoms can mimic those of other conditions, such as somatic, referred spine-related leg pain, hip pathologies, peripheral artery disease, or peripheral neuropathies – so even us physios can get it wrong! How can we be sure it’s truly sciatica?
Luckily, Charlie Clements created a Case Study on this very topic – in this blog we’ll be sharing key lessons from his case presentation. We’ll discuss what “sciatica” actually is, the assessment process, how to rule out the differential diagnoses, and, importantly, when to escalate a patient’s care. Along the way, we’ll uncover valuable insights every clinician should know to confidently diagnose and manage sciatica.
If you’d like to see exactly how expert physio Charlie Clements treated a real patient of his with sciatica, check out his full Case Study HERE. With Case Studies you can step inside the minds of experts and apply their strategies to get better results with your patients. Learn more here.
What is “sciatica”, really?
People tend to label most spine or nerve-related leg pain sciatica, but this may be a mistake. How likely is it that the sciatic nerve is the sole culprit responsible for that radiating leg pain? Let’s consider a disc herniation that irritates a nerve root, like S1. That nerve root branches off into multiple nerves – not just the sciatic nerve! So why call this sciatica?
Here’s a quote from Charlie’s presentation:
“Usually, leg pain that comes from the spine is often going to be very heterogeneous in terms of how it presents… Very, very rarely is it going to just be an isolated mononeuropathy solely affecting that sciatic nerve”.
So, instead of “sciatica”, we can refer to nerve root-related pain coming from the lumbar spine as “lumbar radicular pain” – just like we don’t habitually call a cervical nerve root pathology “radial nerve pain”! Alternatively, if you choose to continue using the term “sciatica”, just understand that this does not automatically mean we are dealing with an issue that solely impacts the sciatic nerve.
In Charlie’s Case Study, the patient presented with back pain, along with sharp, radiating leg pain, raising the suspicion of radicular pain. So, how can we confirm this suspicion?
Misdiagnosis: A common pitfall
Lumbar radicular pain is often misdiagnosed because its symptoms overlap with other conditions. Let’s allow Charlie to explain what the common characteristics of radicular leg pain are and how they differ from somatic-referred pain and radiculopathy in the below clip taken from his Case Study:
Alright, so radicular pain is typically neuropathic, distal to the knee, and more intense than the back pain. Does this presentation confirm we are dealing with “sciatica”? Not necessarily. There are some other differential diagnoses we need to consider, including:
- Hip joint pathologies like osteoarthritis, can refer pain down the leg, leading to confusion.
- Peripheral neuropathies can cause neuropathic pains distal to the knee and can be worse in intensity than an ongoing back pain – but in this case, the back pain may be completely unrelated to the neuropathy!
- Peripheral Artery Disease (PAD) can certainly cause a burning sensation in the legs, though this would not be neuropathic in nature.
In the Case Study, Charlie outlines the subjective and objective findings that increased his confidence that his patient was suffering from a true painful lumbar radiculopathy rather than any of the above, so be sure to check it out!
When to escalate care
An accurate diagnosis is important, but no two patients with a nerve-root pathology are the same. While many cases of sciatica can be managed conservatively, there are instances where escalation to a specialist or further medical intervention is necessary. Knowing when to escalate care is critical to ensuring patient safety and optimal outcomes.
By this point, we should have already ruled out red flags. Here are some to always keep in mind:
- Cauda equina syndrome: Symptoms such as saddle anesthesia, loss of bowel or bladder control, or severe bilateral leg weakness are medical emergencies requiring immediate referral for surgical evaluation.
- History of trauma: If you suspect there may be a fracture due to trauma, a prompt investigation is likely required.
- Cancer: A history of malignancy, unexplained weight loss, or fever may indicate a serious underlying condition like cancer. A familial history of cancer can increase your suspicion.
If red flags have been ruled out and you are confident in a lumbar radicular pain and/or radiculopathy diagnosis, consider escalating care in these scenarios:
- Progressive neurological symptoms: If the patient reports worsening weakness, numbness, or tingling in the leg or foot, it may indicate increasing nerve damage requiring urgent attention.
- Severe, unrelenting pain: If the patient experiences intense pain that does not respond to conservative treatment or medication, further diagnostic testing or specialist care may be needed.
- Lack of improvement: If there is no improvement after 12 weeks since the onset of pain, especially if the patient has been engaging with conservative treatment, referring the patient for imaging or a consultation with a specialist may be prudent.
Here’s Charlie explaining two different mnemonics to help clinicians decide whether referral is needed in this snippet from his Case Study:
By recognising these signs and acting promptly, clinicians can ensure that their patients receive the appropriate level of care.
Wrapping up
When diagnosing and managing sciatica, or more accurately, lumbar radicular pain, clinicians must remain vigilant for differential diagnoses, ensure their assessments are thorough, and recognise when escalation is necessary.
Charlie Clements’ Case highlights the importance of remaining evidence-based while tailoring care to each patient’s unique presentation. Watch the full Case Study to sharpen your diagnostic skills, improve your ability to identify red flags, learn the psychosocial considerations for this population, and understand the evidence around exercise therapy, injections, and surgery.
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