Sciatica & Piriformis Syndrome

What is sciatica?

Sciatica is a relatively common condition, but the term ‘sciatica’ is often used, somewhat confusingly, to describe a symptom or symptoms rather than an actual diagnosis.

The sciatic nerve is the longest nerve in the body and one of five major nerves in the hip region.

Sciatic pain can be felt anywhere along the path of the sciatic nerve, or branches of the nerve.

Prevention

We can’t guarantee complete prevention from suffering from sciatica, but you can decrease your chances of suffering from a few simple tips:

• Posture – this is your number one defense in the fight against back pain. If you can improve your overall posture (and awareness of posture) then you will undoubtedly place your disks in a better position for long periods of the day and decrease your chances of disks pressing on the sciatic nerve.

• Applying ‘good posture’ to all your activities. When standing, sitting, walking, and lifting. This will reinforce good habits and help to prevent potential sciatic nerve pain

• Strengthening abdominals, back, and core. Pilates is key to this and if done correctly will absolutely lead to strength and endurance gains in these preferred areas. A strong back and core will go a long way towards sciatica prevention.

• Exercise with a good mobility section and warm-up as well as an effective cool-down and stretch will keep you supple and your spine safe. Exercise is known to reduce the deterioration of vertebral disks, which means they are less likely to become herniated, therefore reducing the risk of sciatica.

Signs and symptoms of sciatica

Signs and symptoms of sciatica can vary in nature and severity. Generally, pain may be felt from the lower back, down the back of the thigh and lower limb to as far down as the foot, depending on where the sciatic nerve is being compressed.

Symptoms will normally affect only one side of the body with the leg pain being worse than any back pain.

Buttock pain is usually worse on sitting and you may experience sharp, shooting pain which is more noticeable when standing up. You may experience tingling, pins, and needles, a burning sensation, or numbness along the course of the nerve.

You may experience weakness or a feeling of heaviness in the affected leg or foot, making it difficult to move.

Causes of sciatica

Symptoms of sciatica occur when the sciatic nerve root is irritated or compressed as it exits the spine between the fourth lumbar and third sacral vertebrae. This is most commonly due to a herniated or ‘slipped’ disc, or less commonly when the sciatic nerve itself is compressed.

Other than a herniated disc, irritation or compression may be due to degenerative disc disease, spinal stenosis, spondylolisthesis, or piriformis syndrome.

If you experience any of the symptoms of sciatica should be checked out by a GP, physiotherapist. They will determine the cause of the symptoms by taking a thorough history, categorizing lower back pain, and performing several physical tests.

Treatment of sciatica

Treatment of sciatica will depend on the cause of the symptoms. Acute episodes of sciatica generally resolve in a few weeks with conservative, non-surgical, treatment.

Disc herniation

Many people have heard the term ‘slipped disc’, but this is a somewhat misleading lay term as the disc does not actually ‘slip’, but instead it herniates.

Description
A disc herniation occurs when the softer center of the disc, the nucleus pulposus, protrudes through the annulus fibrosis, the tougher exterior of the disc.

Occurrence
It is more common in the lumbar than the cervical spine and can occur in any direction. However, most disc herniation occurs in a posterior direction towards the spinal column and nerves as the posterior portion of the annulus is the thinnest part.

Acute pain
Severe, acute pain can result from pressure exerted on spinal nerves. In the case of the sciatic nerve, it will cause the symptoms of sciatica.

Signs and symptoms of a disc herniation 

Signs and symptoms of herniation can vary greatly depending on its area and size. If there is no pressure against the nerves, as might be the case in the initial degenerative stage, then there may be localized aching or pain or no pain at all.

Q) What are the symptoms if there is pressure?
A) If there is pressure against a nerve, depending on where the disc is herniated there may be pins and needles, electric shock type pain, numbness, or weakness in the arms or legs.

Q) Where do most disc herniation occur?
A) Disc herniation most commonly occurs between the fourth and fifth lumbar vertebrae and the fifth lumbar and first sacral vertebrae as this is the area of the spine that takes most of the body weight.

Q) Can herniations occur in any direction?
A) Yes. Disc herniation is more common in the lumbar than the cervical spine and can occur in any direction. However, it is most likely to occur in a posterolateral direction producing unilateral symptoms.

Causes and risk factors

A number of factors increase the risk of disc herniation.

Occupation
Certain types of occupation or lifestyle activities that include heavy lifting, or prolonged sitting, such as desk jobs and driving, can be increased risk factors.

Rotation and flexion 
Combined movements of rotation and flexion stretch all of the annular fibers at the same time, making the disc more prone to injury.

Health choices
Health choices such as smoking or being overweight are also contributory factors

Traumatic injury 
Traumatic injury or a history of back injury may cause tiny tears or cracks in the outer layer (annulus or capsule) of the disc.

Vigorous exercise 
Years of vigorous exercise and exercises such as weight lifting can increase the wear and tear of the disc.

Most people with disc herniation will recover within 4–6 weeks and may not seek medical attention. Those that do seek medical help will be given a thorough assessment by a health professional. Special tests will be performed to detect a herniation, test muscle strength, sensation, and reflexes. If the symptoms do not settle or if there is a need for further investigation an MRI and/or CT scan may be performed.

Treatment of disc herniation

Treatment of herniation will depend on the severity of the symptoms.

Rest 
Initially, you may be advised to rest from aggravating activities, such as prolonged sitting, bending, lifting, and reaching. Symptoms generally settle within a few days as the protrusion retreats.

Medication
If the pain is severe, complete rest may be required initially. However, once symptoms have settled people are encouraged to keep moving and perform the gentle exercise. Medication may be required such as NSAIDs or paracetamol. The GP may prescribe stronger pain relief such as codeine if the pain is severe.

Discectomy
If the symptoms are severe or long-lasting a discectomy may be performed to remove the section of a disc that is bulging.

Muscle relaxants
Muscle relaxants such as Diazepam may also be prescribed in cases with severe muscle spasms and stiffness.

Physiotherapy and exercise programs
Physiotherapy treatment and exercise programming can help relieve symptoms.

Usually, sciatic pain will settle within a couple of days, after which time exercise and movement are encouraged to prevent deconditioning of muscles and other spinal structures. It also helps keep the discs healthy, as movement provides nutrients and fluid to the discs. It is important to know the underlying cause of sciatica. This will determine what specific movements and exercises to carry out and which to avoid.

Exercise for sciatica pain caused by disc herniation

Exercises that centralise symptoms  –
Pilates exercises encouraging lumbar extension include:

• Half or Full Cobra
• Cat Stretch in extension

Exercises once symptoms settle  –
As symptoms settle and centralise the emphasis is on strengthening the core and lower back muscles and stretching tight structures with exercises such as:

• Swan Dive
• Swimming
• Single then double knee folds
• Shoulder Bridge
• Pelvic tilts to gently stretch and mobilise the lower back, as long as they do not exacerbate symptoms
• Gluteal and hamstring stretches

Exercise for sciatica caused by spinal stenosis

Exercises for sciatica caused by spinal stenosis are those that encourage opening the passageway through which the spinal cord passes, thereby relieving impingement or irritation. These exercises focus on stretching the lower back extensors and strengthening the spine flexors.

Suitable Pilates exercises include:

• Child’s Pose
• Knees to Chest Stretch
• Cat Stretch inflection
• Curl Ups and spinal flexion exercises such as The Hundred
• One Leg Stretch
• Double Leg Stretch
• Scissors
• Roll-Up

Piriformis syndrome

Piriformis syndrome is the name given to conditions involving the piriformis muscle. In a small number of people, the sciatic nerve passes through the piriformis rather than underneath it on its course through the pelvis. The sciatic nerve can be impinged by the piriformis muscle and the piriformis muscle itself can be strained.

Signs and symptoms
Sciatica symptoms such as pain and tingling in the buttock and radiating down the leg can be caused if the sciatic nerve is compressed by the piriformis.

The piriformis may be strained due to tightening or shortening of the muscle as a result of trauma or overuse. The symptoms in this instance tend to be deep aching in the buttock aggravated by sitting or walking upstairs.

Description and function
The piriformis is a short, flat band of muscle involved in lateral rotation of the femur from the anatomical position and abduction in a seated position, as when someone gets out of a car. It also stabilises the pelvis when rotating the trunk or if you are trying to maintain balance while standing on a moving train or bus, for instance.

Causes and risk factors
The piriformis is used heavily in everyday activities so it’s not surprising it can be easily irritated. Long-distance running and walking, running uphill, poor biomechanics, poor posture, sitting for long periods, bed rest, and direct trauma can cause the piriformis muscle to become tight or irritated.

Treatment
Treatment generally includes stretching exercises for the piriformis and other tight muscles such as the gluteals and hamstrings. A physiotherapist will use soft tissue techniques such as massage and stretch.

Exercises for piriformis syndrome

The main consideration of exercises for piriformis syndrome is to stretch the piriformis muscle to relieve pain along the sciatic nerve. There are several ways to stretch the piriformis including:

• Prone lying glute stretch
• Supine glute stretch
• Supine lying opposite knee to chest and shoulder

Prevention and management

You will benefit from keeping the lower back and abdominal muscles strong and the lower back mobile. This can be achieved through regular exercise such as Pilates.
Maintaining a good posture, changing position regularly, lifting and carrying correctly, and maintaining a healthy weight will also help.

What’s next?

Join a Pilates class (online or in-person) or a 1-2-1 session may beneficial to discuss a program to practice at home to speed up recovery as well as discuss alternatives for any exercise that may not be suitable in class.

Please feel free to read more information on our back pain page.

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