5 Sciatica Myths You Need to Know

Let’s start with a thought experiment.

It’s January 2021. You’re an office worker, sitting at a desk all day. COVID-19 is still here in full force, and you’ve been in lockdown for months. Your physical activity levels have plummeted. You’re also suffering with a broken heart, due to withdrawals from the only thing you’ve ever truly loved – the gym. In a state of panic and self-loathing, you jump on the home gym bandwagon and purchase yourself a barbell and some rusty plates from Facebook Marketplace.

It’s like Christmas morning when they arrive. You break out the barbell, whack on the new plates and start your session the way you finished your last. You’re on the 10th set of deadlifts and that’s when it happened. ‘’BANG’’ – The plates clatter off each other as you drop the barbell to the floor. Then you drop. Sheer agony. Pain from the middle of your right glute all the way to your right ankle. You don’t want to move an inch. Even breathing hurts. You think ‘’do I need an ambulance?’’.

You gather yourself and do what any sensible, exercise enthusiast would do – You call your physiotherapist. Your white polo wearing friend listens to you intently, empathises with your situation and provides you with the following diagnosis – ‘’sciatica’’. You’re delighted. Now you’ve a diagnosis and feel validated. However, you had some questions, and the physio summarised the session with the 5 following statements:

1) ‘’Surgery is never needed’’

2) ‘’This will definitely get better’’

3) ‘’If you don’t start moving, you won’t get better’’

4) ‘’The Secret Exercise You Must Do’’

5) ‘’Ah, just what I suspected, it’s your Piriformis’’

But has your well-meaning physio friend provided you with facts or myths? Let’s look at each point and see what the evidence says.

1) “Surgery is Never Needed’’

The first line of treatment for radicular pain is conservative management. This confirms our biases as physiotherapists, but when is conservative care not indicated? Not everyone needs surgery, but a small minority might need it more than they need physiotherapy. It’s therefore vital that we don’t paint all patients with the conservative management brush and deny them the option of onwards referral (if they need it). Of course, with cases of progressive neurological deficits, persistent symptoms, and lack of response to conservative care, referral for surgical opinion is recommended (1).

But what about someone who just has radicular pain with no loss of nerve function? When considering who should be managed conservatively or operatively, we must consider the individual’s circumstance. Radicular pain can cause immense suffering and suicidal ideation (2). If the patient isn’t improving, is it possible that your conservative management may be unnecessarily prolonging their suffering?

Recent systematic reviews have shown that surgery provides a rapid decrease in pain and disability at 3 and 6 months (3). However, physiotherapy and surgical management have similar long-term outcomes. One would understandably ask ‘’why opt for surgery in the short term if outcomes are the same in the long term?’’. This comes down to shared decision making, considering patient preferences and if short term pain reduction via surgical intervention is something they want (or need). So, is it fair to say that surgery is never needed? This is a myth.

2) “This Will Definitely Get Better’’

If you’re a physiotherapist, then you likely got into the profession to help people. Part of helping people is about providing compassionate care, and empathising with the human in front of you. It’s no surprise then, when we meet people suffering with severe radicular pain, that we would do anything to provide them with hope and optimism about their recovery. But at what stage does this enthusiasm become non-evidenced based? In our enthusiasm, we may provide prognostic advice that does not align with the evidence.

Unfortunately, there are a subset of people with radicular pain who may not completely improve. Schmid and colleagues stated that one-third of patients with sciatica will develop persistent pain and disability lasting 1-4 years (1). This isn’t an argument for not providing your patient with hope and optimism. Instead, this is about providing accurate prognostic advice informed by the evidence. Not only is it more ethical, but it might also save you a difficult encounter when the patient returns 1 year later, frustrated that they haven’t improved as per your prediction.

If you are telling every patient with radicular pain that they will make a 100% recovery, this is a myth. So too is blaming people for not doing enough.

3) “If You Don’t Start Moving, You Won’t Get Better.’’

It is vital that we don’t confuse the management of acute radicular pain with other conditions such as non-specific low back pain. Promoting ‘’motion is lotion’’ is great advice for some people, but for acute radicular pain, motion may be too painful.

Patients present to us frustrated, vulnerable and often exhausted by pain. Is it fair for us physiotherapists to add to the patient’s exhaustion by providing them with a list of things to do? Is there evidence to suggest that doing less would be detrimental to their recovery?

This is why I’m an advocate for the ‘’rest is best’’ approach with acute radicular pain. There is wisdom in knowing when to do nothing, and sometimes radicular pain warrants a rest and relaxation approach. This may be counterintuitive to patients (and physiotherapists) but may enhance their recovery and remove feelings of guilt associated with rest. Anecdotally, some patients feel empowered when a healthcare professional has reassured them that periods of rest may enhance recovery.

Di Mattia and colleagues (2018) stated that short recovery periods in bed as a pain management strategy may not be contraindicated due to the lack of benefit from other options (4). Therefore, telling people not to rest is a myth. So too, is telling people to exercise their way to a pain-free life.

4) “Try this one Exercise’’

Periods of rest doesn’t mean you’re surrendering to a life of physical inactivity. Patients know this and chances are they’ll have paid Dr. Google a visit prior to seeing you. Searching ‘’best sciatica exercise’’, gives you 8 million results! Is it any wonder your patients are confused and frustrated by the time they see you? With everyone claiming to have all the answers, how do you respond when asked what the best exercise is?

Unfortunately, there isn’t one! Specific exercise does not seem to show any added benefit compared to general physical activity (5). This doesn’t mean that there is nothing you can do to help. It just means that you don’t have to always periodise your rehabilitation protocol with rigid sets and reps. Instead, it opens a variety of potential activities that could be beneficial. Maybe instead of prescribing a neural glide to address neural mechanosensitivity, you work with the patient to find what is most meaningful to them. The more meaningful the activity is to the patient, the more likely they are to adhere in the long term.

In contrast, some people will want specificity and structure with their rehabilitation, and that’s great. Again, it comes down to individual patient preference and providing an evidence-based narrative around the treatment you provide. Therefore, the best form of exercise is that which you consistently do. The ‘’one specific exercise for sciatica’’ is a myth. Now onto our 5ᵗʰ and final point.

5) “Ah, just what I suspected, it’s your Piriformis’’

We’ve heard it all before; ‘’Your piriformis is trapping your sciatic nerve’’, ‘’you’ve a tight piriformis’’ or (my favourite) ‘’your glutes are too big and it’s putting pressure on the nerve’’. The piriformis has been blamed for decades and in recent years it has been replaced by Deep Gluteal Syndrome. This is an umbrella term for pain in the posterior hip and has grown in popularity because it doesn’t victimise any one specific structure. However, hang around on social media long enough and you’ll see plenty of debates about its under-diagnosis and overdiagnosis.

Part of the problem is that there are no strict diagnostic criteria for Piriformis Syndrome or Deep Gluteal Syndrome (6). However, recent evidence suggests that the most consistent features include unilateral buttock pain, pain with prolonged sitting, increased mechanosensitivity and pain on palpation over the greater sciatic notch. Unfortunately, these are also classic symptoms of a lumbar nerve root pathology. Just because it’s felt in the glute, doesn’t mean the source of the problem is the glute. It may be more plausible that it is simply referred from the lumbar spine (7).

Does that mean that every diagnosis of piriformis syndrome is a myth? I think it’s certainly possible that something in the deep gluteal space could compress the sciatic nerve, but probably not to the extent that it has been diagnosed. If you want to get into the details of deep gluteal syndrome, check out Tom Jesson’s sub-stack for an excellent, balanced appraisal of the evidence.

Conclusion

If you found these myths interesting and want to dig deeper into the science behind radicular pain, then I’d highly recommend checking out Tom Jesson’s “Sciatica: The Clinician’s Guide”. It wasn’t until I read this guide and kept up to date with Tom’s sciatica newsletter that I realised how little I knew about sciatica. It will take your clinical reasoning to the next level and help you, help your patients!