By Jordan D. Metzl, MD
April 10, 2007 -- Doug, a forty-year-old triathlete, comes hobbling into the office last week. “Dr. Metzl”, he says, “this sciatica is driving me nuts! I can’t sleep, it hurts when I sit, I can’t move very well, and most of all, I can’t work out.”
“Hang in there, buddy”, I said to Doug. “The first thing we have to do is to try and figure out what the problem is, and then we can fix it.”
“Okay, Doc”, he said, “but please hurry. I am a bear to live with when I can’t work out. This morning I nearly kicked my dog.”
Sciatica, or sciatic pain, refers to an irritation of the sciatic nerve. The sciatic nerve is a large, rope-like nerve which is comprised of several nerve roots in the lumbar spine. Technically, the sciatic nerve (or sciatic pain), refers to an irritation of this nerve once the nerve roots have joined together.
When a patient such as Doug comes into the office, the first thing a doc will do is take a patient history. “Doug, please describe your pain”, I asked him.
Patients will often describe a shooting pain down the back of the leg which sometimes worsens with sitting, and sometimes worsens with bending the back forward. The quality of the pain, how far down it extends down the leg, and which types of things make it worse are all things that need consideration.
In general, sciatic pain comes from two sources, the spine or the hip. With lumbar type sciatic pain, the nerve roots (small branches of the spinal cord that exit at each level), are often pinched at a specific level in the spine by a bulging or herniated disc. These types of disc injuries (discogenic back pain), cause irritation, and when the nerve is compressed by the bulging disc fragment, it may impair the nerve and cause severe pain. (Please see “When to Worry About Back Pain” column for more info).
Clues to discogenic pain being the cause of the sciatic pain are if the pain radiates down into the toes; if the pain radiates down both legs (meaning the nerve is being compressed within the spinal canal, pushing on both nerve roots); and if the pain worsens when the patient bends forward. Discogenic-type sciatic pain is the more serious of the two types to treat, and often requires some combination of medication, physical therapy, and often an injection of cortisone. In severe cases, surgery can be required.
The other type of sciatic pain, which emanates from the hip, is quite different than discogenic pain. With this second type, sciatic pain comes from a tight piriformis muscle (one of the deep butt muscles), which actually pinches the nerve as it passes through the muscle. This is known as a compression of the sciatic nerve, and it causes pain when sitting on the affected side.
Piriformis-type or hip-type sciatic pain, causes symptoms only on one side, and rarely travels below the upper leg. This type of pain generally does not travel into the toes and often feels better when the piriformis muscle is stretched. It is usually much easier to treat – often with medication and physical therapy, which focuses on hip muscle stretching. The hip variety of sciatic pain is quite common in triathletes who don’t stretch their hip muscles enough, especially when increasing bike mileage.
Now let’s get back to Doug.
His pain was shooting, one sided, and didn’t hurt when he bent forward. When he was lying on his stomach, he cited an exact point of pain just in the middle of his butt – the exact location where the sciatic nerve courses through the piriformis muscle.
Doug’s diagnosis: Sciatic pain stemming from compression of the sciatic nerve at the level of the piriformis muscle. With a week of anti-inflamatory medicine and some physical therapy to stretch the hip, Doug was as good as new in a few weeks.
Pin-pointing the type of sciatic pain is the first step. After that, treatment is typically easy.
Jordan D. Metzl, MD, is a nationally recognized sports medicine specialist at Hospital for Special Surgery in New York City. In addition to his medical practice, Dr. Metzl is a 25 time marathon runner and four- time Ironman finisher.