Many people will experience sciatic pain at some point throughout their lifetime. The pain starts in the glutes, clinical term for butt, and then travels down the back of the leg into the back of the knee and into the leg. It can be sharp or shooting, or even a dull aching pain that doesn’t subside. Weakness, difficulty moving from sitting to standing, and staying in the same position for a long time can also accompany sciatic pain.
Piriformis, the oversimplified cause
So you’ve been diagnosed with sciatica. Or maybe you have a pain in the butt that doesn’t extend quite far enough to be technically termed sciatica. One thing is for sure, you’re in pain. You ask the experts, and they say it’s caused by a muscle in the butt that is called the piriformis. It’s apparently pinching the sciatic nerve and causing the pain you are in. You’re prescribed some exercises and stretches to do, and maybe even have some therapy. The pain goes away.
But then the pain comes back. On and off, you seem to have this stubborn pain. Sometimes it’s shooting, sometimes it’s just a dull ache. Once you think it’s gone for good, you somehow have flared it up again.
What’s really going on?
Many people are familiar with the piriformis muscle. In the picture below, you can see how the piriformis attaches to the triangle shaped bone called the sacrum, and stretches over to attach onto the femur or the leg bone.
The piriformis stretches over the sciatic nerve, and when taut can cause sciatic pain.
The source of sciatic pain can actually be quite complex
Below, you can see the nervous supply to the leg. In the low back the spinal cord divides and branches off to go down each leg.
There are several ways that this nervous supply can be irritated and produce sciatic pain. The most common is to blame the piriformis muscle. In some cases this is the true cause, however most people present in my practice with a combined pelvic torsion, low back spinal (lumbar) dysfunction, leg length discrepancy, or sacral dysfunction. Any of these factors can be the true cause of the piriformis tensioning in the first place. They also present with weakness in the upper glute muscles on the side they are experiencing pain, which tells me that they have been overusing the piriformis muscle in daily walking, running, and other activities.
Treat the Source, not the Symptoms
The Lumbar Spine
Any dysfunction in the lumbar spine can cause narrowing of the bony passages that the nerve supply travels through. This can cause shooting pain below the source of nerve pinching or above. Conditions such as degenerative disc disease, bulging and herniated discs, arthritis, and previous low back injuries can all directly contribute to sciatic pain.
The nerves branch off underneath the bony bridge of the sacrum and begin their descent into the hip an down the leg. When the sacrum is torqued, stuck, or not moving on one side this can cause inflammation of the joint capsule and affect the amount of space that these nerves have to travel through, contributing to sciatic pain.
Hard falls, constant strain, and torsion can all cause the pelvis to be misaligned and twisted. This puts more biomechanical strain on one side versus the other side. If one side of the hip is higher or pulled more forward, it drags the leg with it, contributing to one leg being higher or lower than the other. Now there is uneven force applied up the pelvis in actions of walking and running, contributing to sciatica pain.
Weakness of the Upper Glute Muscles
When the upper glute muscles are weak, we rely on different muscle to achieve the same result. Try extending your leg straight backwards. Did your foot turn out or stay pointing straight? If it turned out, your recruiting your piriformis to do the same action as your glutes, causing it to work too hard and possibly irritating the sciatic nerve.
So what should you do?
A skilled physical therapist should be taking note of all of these possible causes of sciatica. They should be noting any of the contributing factors above, and able to take a good look at what the pelvis and surrounding structures are doing and how they are holding. There is usually an underlying cause or factor in why sciatica happened in the first place; simply treating the symptom won’t get to the root cause of the problem. That’s why I always assess the bony structure of the lumbar spine, sacrum, pelvis as well as note stance and gait as people walk into my office. This will usually lead me to a treatment plan that includes the low back, muscles of the hip, and muscles of the leg. Balancing the bony skeleton’s alignment through the lumbar spine and and pelvis is always one of my main goals for anyone who comes into my treatment room.
Alyssa is a Registered Massage Therapist, doula, and Co-Owner of More to Life Massage therapy. She is passionate about treating the pelvis and low back, as well as experienced in pregnancy and postpartum massage.