Sciatica can be very difficult to accurately diagnose much less treat. The condition sciatica is caused by a perceived compression of the sciatic nerve by a herniated or bulging disc in the spine. The pain caused by this impingement then travels the path of the sciatic nerve all the way, in some instances, down to the feet. It is essential to perform a physical examination in cases of referred pain to isolate the problem as being one where a nerve is being injured or if it is a ligament that is injured. Often I find that the radiating pain is not because of radiculopathy or pinched nerve but because of a ligament that is loose or injured because ligaments refer pain the same way. This is why relying on an MRI as the sole diagnostic tool could lead to an unnecessary surgery. If the MRI were to show a degenerative condition, that would be cited as the cause of the radiating pain, even though that may have been a pre-existing condition that caused no pain. A physical examination and conservative treatments will help determine if this is a ligament injury or a nerve problem.
Let’s bring in other opinions.
A July 2020 paper in one of the world’s most prestigious medical journals the Lancet (1) discusses the problems of diagnosis and treatment of sciatica.
“Management of sciatica can be suboptimal and shows large variation in clinical practice. In general, we only have limited knowledge about the diagnosis of sciatica, the value of diagnostic interventions, the natural and clinical course of disease, predictors of outcome, and the efficacy of most therapeutic interventions. Compared to the amount of research on non-specific low back pain, research activities focused on sciatica are scarce.”
Because of this confusion at leading medical institutes and research centers as to how to diagnose and treat sciatica, when someone tell us they have sciatica and nothing has helped them, we explore their medical history a little further to see if they have a true sciatica that is difficult to fix without surgery or a psedo-sciatica that can be very responsive to conservative care and regenerative medicine treatments.
“Most participants found medication ineffective and reported significant side-effects.”
A June 2021 study (1) noted that for sciatica, medication is routinely the first line of management. It also noted to doctors that it is important to describe patients experiences of taking medication for sciatica, the reasons for commencing and reasons for cessation, the effects of the medication in symptom management and any other potential positive or deleterious effects. Why? Because they further noted that in a survey of the patients prescribed medications, “Most participants found medication ineffective and reported significant side-effects.” The recommendation to the doctors? “Clinicians should be cognizant of the fears that patients hold in terms of the cause and severity of sciatica, as well as fears of prescribed medication.”
Physical therapy for sciatica
A December 2022 study from the United Kingdom (x) assessed the effectiveness of physical therapy versus control interventions in people with sciatica. In reviewing data from 2699 patients included in 18 previously studies, the researchers found physical therapy did not offer any more pain alleviation or improved disability than the control interventions.
“I have been considering an epidural. I’m waiting to have a microdiscectomy. I have severe sciatica. Can you help? I need to get back to work.”
This is the type of email we get: “I have been considering an epidural. I’m waiting to have a microdiscectomy. I have severe sciatica. Can you help? I need to get back to work.” Typically someone with “severe true sciatica,” is not someone we can help with stem cell or PRP therapy.
- PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected into spine to stimulate healing and regeneration.
- Stem cell therapy involves the use of bone marrow derived stem cells. These stem cells are also injected into to the joint to stimulate healing and regeneration.
When an email like the one above comes in we have to take a realistic approach to how we would answer this person. We may ask initially:
Thank you for writing and we are sorry to hear about the challenges you are facing. Is the sciatica causing you pain in your back or hips or does it go down your legs and feet? How long have you been out of work because of this? What do you do for a living? How long have you been waiting for a surgery? We will reach out to you so we can start getting some information and an understanding of how to proceed in your case.
What we are trying to do with this email is get a realistic assessment. If this person has true sciatica with neurologic symptoms of radiating pain into the feet or bladder malfunctions they need to follow the recommendations of their neurologist, regenerative injection treatments will not help them reverse their sciatica problems.
But what about this person?
“My chiropractor did not think I had sciatica, he thought maybe piriformis syndrome?”
Here is the email: “Are you able to successfully treat sciatica type symptoms? I have NOT had an MRI and have only seen a chiropractor. He thought it could be sciatica or piriformis syndrome. I am sore on the outside of the buttocks, down the back and outside of the leg to the foot with some lower back pain but not always. It is triggered mainly when standing or walking and has progressively gotten worse.”
- Piriformis Syndrome is caused by the compression of the sciatic nerve by the piriformis muscle.
- Piriformis Syndrome mimics sciatica by causing in some people, numbness in the buttocks, hip, knee and into the feet and the pain travels down the sciatic nerve into the feet.
- Piriformis Syndrome pain can be made worse by running, walking, standing or sitting for long periods of time.
So in this patient, treatment of piriformis syndrome can alleviate the sciatica like symptoms.
Pseudo Sciatica – gluteus minimus trigger points
What else can be causing “sciatica-like symptoms,” or Pseudo “fake” sciatica? A group of researchers published this paper in October 2020 (3).
“Not all sciatica-like manifestations are of lumbar spine origin. Some of them are caused at points along the extra-spinal course of the sciatic nerve, making diagnosis difficult for the treating physician and delaying adequate treatment. While evaluating a patient with sciatica, straightforward diagnostic conclusions are impossible without first excluding sciatica mimics. Examples of benign extra-spinal sciatica are piriformis syndrome, walletosis, quadratus lumborum myofascial pain syndrome (a muscle problem) . . .”
A 2014 paper (4) points out that a trigger point or a “muscle knot,” of the gluteus minimus muscle (upper butt muscle) can be the cause of pseudo sciatica.
“Sciatica has classically been associated with irritation of the sciatic nerve by the vertebral disc and consequent inflammation. Some authors suggest that active trigger points in the gluteus minimus muscle can refer pain in similar way to sciatica.”
A 2016 paper agrees:
“Pseudo-sciatica is a diagnostic term sometimes used to describe sciatic nerve symptoms which are not caused by the typical spinal sources. . . Trigger points can form in the muscles of the hip and lower back and refer pain down the leg. Trigger points are ‘knots’ in the muscle which become inflamed and highly irritable. They are more often found in weak muscles or muscles that have been ‘overloaded’ and have fatigued .”(5)
“the most common indication for surgical treatment in patients over 65 years old”
A January 2023 study (x) looked at spinal stenosis and its implications in being “the most common indication for surgical treatment in patients over 65 years old” having spinal issues. The key to this study was to assesses the incidence and indications for revision surgery after previous spinal decompression and fusion for patients being treated with lumbar spinal stenosis.
The researchers looked at the outcomes of 1233 patients with lumbar spine stenosis who underwent spinal decompression and fusion surgery between 2014 and 2018. The number and causes of readmission were evaluated.
Of the 1233 patients, 164 were readmissions.
- Revision surgery at the same level was performed in 63 patients (38.4%), at the higher level – 72 (43.9%), at the lower level – in 29 (17.7%) patients.
- The most common indication for readmission was spondyloarthrosis with facet joint syndrome (94 (57.3%) patients) or adjacent segment degeneration.
- The second common complication was pseudoarthrosis or the failure of the spinal fusion to achieve the fusion (26 (15.9%) patients).
- The most common indication for readmission was adjacent segment degeneration.
1 Lebedev VB, Epifanov DS, Osipov II, Esin AI, Kinzyagulov BR, Zuev AA. [Revision surgery after previous spinal decompression and fusion for lumbar spinal stenosis]. Zh Vopr Neirokhir Im N N Burdenko. 2023;87(1):70-76. Russian. doi: 10.17116/neiro20238701170. PMID: 36763556.
“it may be possible for a patient to have spinal surgery while their pain is coming from a different source”
A July 2022 paper in the Journal of orthopaedic case reports (x) discusses how it may be possible for a patient to have spinal surgery while their pain is coming from a different source. Mainly fragility fractures of the pelvis. The paper’s authors wrote: “The clinical symptoms of fragility fractures of the pelvis are frequently vague and nonspecific. Moreover, the symptoms of fragility fractures of the pelvis can mimic lumbar spine pathologies. Therefore, accurate diagnosis of fragility fractures of the pelvis is often difficult and the fracture may be misdiagnosed as lumbar degenerative disease.”
Ohyama S, Inoue M, Nakajima T, Kubota G, Ohtori S, Aoki Y. Cooccurrence of Fragility Fracture of the Pelvis with Lumbar Degenerative Disease: A Case Report. Journal of Orthopaedic Case Reports. 2022 Jul;12(7):93.
Sacroiliac Ligament Laxity or Weakness
For some people a diagnosis of sciatica may be a misdiagnosis of sacroiliac joint dysfunction.
A study in the European spine journal (6) compared “the clinical features of patients with sacroiliac joint-related sciatica-like symptoms to those with sciatica from nerve root compression.” Patients with pain radiating below the buttocks with a duration of 4 weeks to 1 year were included. The researchers found: “Sciatica-like symptoms derived from the sacroiliac joint-related can clinically mimic a radiculopathy.”
So is it possible a ligament injury is causing sciatic like symptoms?
Doctors at the Mayo Clinic (7) have published a paper entitled: Comparative role of disc degeneration and ligament failure on functional mechanics of the lumbar spine. In this paper the Mayo Clinic researchers wanted to make a clear definition between two problems affecting low back pain patients.
- First, that pain could be coming from the discs.
- Second that pain could be coming from the spinal ligaments.
The Mayo researchers suggest that recognizing between the two could prevent an erroneously diagnosis of sciatica or back surgery.
- If a patient has instability, excessive movement, and decreased stiffness, doctors should examine for ligament damage.
- If the opposite, less movement, more stiffness, the doctor should look for disc disease.
The ligaments of sacroiliac joint, the anterior sacroiliac ligament, Interosseous sacroiliac ligament, Posterior sacroiliac ligament, Sacrotuberous ligament and Sacrospinous ligament may contribute to sciatic nerve entrapment when injured. How? By allowing hypermobility in the lumbar vertebrae. The vertebrae will slip out of place and possibly compress the sciatic nerve.
Our treatment options
In our practice, Bone Marrow Aspirate or bone marrow derived Stem Cell Therapy is a treatment for musculoskeletal disorders. We treat degenerative joint disease, degenerative disc disease of the spine, and tendon and ligament injury.
We are proud to have authored numerous research papers and forthcoming research papers on the use of stem cells in regenerative healing.
In our own published peer-review research appearing in the July 2018 in the Biomedical Journal of Scientific & Technical Research (BJSTR), July 2018, (8) we examined treating spinal ligaments with low back pain. Below is an explanatory adaption of the introductory paragraph of that study. It gives a good understanding of the importance of understanding that we should be looking at the ligament problems in back pain.
- An Orthopaedic Knowledge Update from the American Academy of Orthopedic Surgeons tells its surgeon members that muscle strains, ligament sprains, and muscle contusions account for up to 97% of low back pain in the adult population (9)
- Additionally, researchers wrote in the Spine Journal that spinal ligaments are often neglected compared to other pathology that account for low back pain (10). This could be due to the over-reliance of MRIs to guide physicians to correct diagnoses. They write: The influence of the posterior pelvic ring ligaments on pelvic stability is poorly understood. Low back pain and sacroiliac joint pain are described being related to these ligaments. When these ligaments are damaged or weakened, they serve as generators of low back pain. Possibly sciatic like symptoms.
PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration. PRP puts specific components in the blood to work. Blood is made up of four main components; plasma, red blood cells, white blood cells, and platelets. Each part plays a role in keeping your body functioning properly. Platelets act as wound and injury healers. They are first on the scene at an injury, clotting to stop any bleeding and immediately helping to regenerate new tissue in the wounded area.
Getting back to Piriformis syndrome: The piriformis muscle is in the buttocks, attaches to the pelvis and greater trochanter, and helps rotate the leg outward. The sciatic nerve is just beneath it. Occasionally the nerve is impinged beneath the piriformis muscle. When the muscle contracts, it pushes on the nerve, which causes the pain and its radiation down the leg. I rarely see true piriformis syndrome. Typically, the pain is at the enthesis of the piriformis or other buttocks muscles to the bone, and PRP usually heals that with one to three treatments.
Research has shown (11) PRP to be effective in treating degenerative disc disease (DDD) by addressing the problems of spinal ligament instability and by stimulating the regeneration of the discs indirectly (although discs were not directly injected, they showed an increase in disc height).
Although I don’t typically consider DDD to be a major player in neck or back pain, I do treat these areas daily. From my exam, it is typically not the discs that are the issue, but the ligaments at their connection to bone that cause the pain. This is called an enthesopathy. Typically, it is something that will respond well to PRP treatments.
1 Koes BW. Improving the management of sciatica. The Lancet Rheumatology. 2020 Jul 1;2(7):e372-3.
1 Reddington M, Baxter S, Walters SJ. A qualitative exploration of patient experiences of medication for sciatica. Musculoskeletal Science and Practice. 2021 Jun 21:102419.
3 Siddiq MA, Clegg D, Al Hasan S, Rasker JJ. Extra-spinal sciatica and sciatica mimics: a scoping review. The Korean Journal of Pain. 2020 Oct 1;33(4):305.
4 Skorupska E, Rychlik M, Pawelec W, Bednarek A, Samborski W. Trigger point-related sympathetic nerve activity in chronic sciatic leg pain: a case study. Acupuncture in Medicine. 2014 Oct;32(5):418-22.
5 Thiyagarajan S, Prabhu C. Pseudo Sciatica-It’s the Condition we really Treat Better than Medicine. J Nov Physiother. 2017;7(327):2.
6 Visser LH, Nijssen PG, Tijssen CC, Van Middendorp JJ, Schieving J. Sciatica-like symptoms and the sacroiliac joint: clinical features and differential diagnosis. European Spine Journal. 2013 Jul 1;22(7):1657-64.
8 Ellingson AM, Shaw MN, Giambini H, An KN. Comparative role of disc degeneration and ligament failure on functional mechanics of the lumbar spine. Computer methods in biomechanics and biomedical engineering. 2016 Jul 3;19(9):1009-18.
Darrow M, Brent Shaw BS. Treatment of Lower Back Pain with Bone Marrow Concentrate. Biomed J Sci&Tech Res 7 (2)-2018. BJSTR. MS. ID.;1461.
9 An HS, Jenis LG, Vaccaro AR (1999) Adult spine trauma. In Beaty JH (Eds.). Orthopaedic Knowledge Update 6. Rosemont, IL: American Academy of Orthopedic Surgeons pp. 653-671
10 Hammer N, Steinke H, Lingslebe U, Bechmann I, Josten C, Slowik V, Böhme J. Ligamentous influence in pelvic load distribution. The Spine Journal. 2013 Oct 1;13(10):1321-30.
11 Gullung GB, Woodall JW, Tucci MA, James J, Black DA, McGuire RA. Platelet-rich plasma effects on degenerative disc disease: analysis of histology and imaging in an animal model. Evidence-based spine-care journal. 2011 Nov;2(4):13. 2331 – 2528
12 Dove L, Jones G, Kelsey LA, Cairns MC, Schmid AB. How effective are physiotherapy interventions in treating people with sciatica? A systematic review and meta-analysis. European Spine Journal. 2022 Dec 29:1-7. [Google Scholar]