Many people are confused about the definitions of nerve pain, and we don’t blame you. It can be confusing! This blog is meant to clear up some of that confusion. Below are some basic definitions:
Radicular pain = pain caused by a problem at the nerve root
Radiculopathy = weakness, numbness (loss of function) caused by a problem at the nerve root – = often together (“painful radiculopathy”) but not always!
Sciatica = old fashioned word for radicular pain
Referred pain = pain from a problem in a muscle, joint etc. that is felt in a different place to where the problem is
Mechanosensitivity = when a nerve is sensitive to movement
Sciatica Myths You Need to Know
The first line of treatment for sciatica (radicular pain) is conservative management. Not everyone needs surgery, but a small minority might need it more than they need physiotherapy. Surgery provides a rapid decrease in pain and disability at 3 and 6 months. 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.
“This Will Definitely Get Better’’
Unfortunately, there are a subset of people with radicular pain who may not completely improve even with surgery. It’s believed that one-third of patients with sciatica may develop persistent pain and disability. However, a large portion of people with radicular pain will improve with physiotherapy intervention however there is no guarantee that they will make a 100% recovery. If every patient is told that they will make a 100% recovery with radicular pain, then this is a myth. So too is blaming people for not doing enough.
“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. 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. Therefore, telling people not to rest is a myth. So too, is telling people to exercise their way to a pain-free life.
“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 a Physiotherapist. Searching ‘’best sciatica exercise’’, gives you 8 million results! Is it any wonder people are confused and frustrated by the time they see a Physio. 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. You don’t have to get bogged down to a rigid rehabilitation protocol. Instead, it opens a variety of potential activities that could be beneficial. The more meaningful the activity is to you (the patient), the more likely you are to adhere to it 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 for you (the patient). Therefore, the best form of exercise is that which you consistently do. The ‘’one specific exercise for sciatica’’ is a myth.
‘’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.
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. Classic symptoms of a lumbar nerve root pathology features include 1 sided buttock pain, pain with prolonged sitting, increased mechanosensitivity and pain on palpation over the greater sciatic notch.
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.
‘’Leg pain: It’s not always sciatica’’
Leg pain is a frequent complaint in physio clinics. All too often it’s brushed off as “sciatica”, but the poor sciatic nerve isn’t always the culprit. Leg pain can have somatic, neuropathic, vascular and systemic causes, which makes assessment complex to say the least!
Sciatica is the first thing a lot of people think about when experiencing leg pain. It isn’t as common as we think though, with only 2-3% of the population in the UK being diagnosed each year. Pain is most typically felt in the calf, then foot and lastly knee/thigh region. One of the key messages to give people with sciatica is that it needs time; 90% of people are thought to improve within 4 months, but one third of people continue to have symptoms after a year. So ‘’all leg pain is sciatica’’ – is a myth.