ARE YOU REALLY HANDLING SCIATICA? OR ????? (A Breif Intro about Pseudo Sciatica / Retro-Trochantric

We are the generation of Digital World. Our Communication is DIGITAL, Our System is DIGITAL and our outcome expectations are also DIGITAL. Living in this kind of world, even we become DIGITALIZED. We belive what we see and we are not ready to listen, especially to the one who has come to us with PAIN. Funny part is we will ask that person to rate his/her pain in DIGITAL form (VAS). We always eager to know the intensity of pain but not the source of pain. This is the best criteria which applies for our day to day clinical practice where most of the radiating pains are misdiagnosed as Intraspinal SCIATICA.

Sciatica is defined as lumbar radicular pain along with clinical findings suggestive of nerve root compression.(1) Sciatica can result when the nerve roots in the lower spine are irritated or compressed. Most often, sciatica is caused when the L5 or S1 nerve root in the lower spine is irritated by a herniated disc, degenerative disc disease may irritate the nerve root and cause sciatica(2)(3)(4)(5). Like this many more influenced stuffs are misleaded the concept of Sciatica. But, being a Physical Therapist (A Movement Scientist) our way of examination and Analysis are enormous. A perfect Physical Therapist always feel the muscle, observe the Movement, control the Arthro-kinematics, change the abnormal force vectors across the joint, enhance the Neuro-kinetics, achieve the Functional limitations. With our gifted Kinesiology we can detect the hidden affected strutures which mimics like Intraspinal Sciatica.

Presenting some of those here:

1) PIRIFORMIS SYNDROME (PS):

Piriformis syndrome (PS) is an extraspinal nerve entrapment that comprises symptoms like pain in the region of the sacroiliac joint, greater sciatic notch, piriformis muscle (PM), and may radiate distally. Walking/stooping/lifting exacerbate the symptoms, signs include Piriformis muscle tenderness, Piriformis muscle stretch pain, positive straight leg raise sign, gluteal atrophy and weakness. Piriformis Syndrome accounts for 6–8% of low back pain cases. Proposed mechanisms for PS include Piriformis muscle contracture/spasm from trauma/overuse/hypertrophy.(6) Piriformis Syndrome is the one, which going eazily for misdiagnosis and leaves fatal effects. A 62-year-old man who had Foot drop with delayed diagnosis of Piriformis Syndrome,(7) also it was misdiagnosed as disc herniations and Chronic Ishemic Limb Disease.(8)(9)

2) PSEUDO SCIATICA (GLUTEUS MINIMUS TrP):

Is it really Sciatica or just a trigger point in your buttocks? In this issue we focus on the Gluteus Minimus, a muscle in your buttocks with a surprising referred pain pattern that mimics the pain of sciatica! Pain extends from the buttocks region down the back and side of the entire lower limb into the ankle. The referred pain caused by these trigger points affects almost the identical areas as Sciatica. For this reason we called this pain as “Pseudo Sciatica”. A quick assessment of this muscle can prevent misdiagnosis for low back and leg pain sufferers.

Knee Cross Over Test: Start by sitting upright. Then, without using your hands, raise one knee and attempt to cross it completely over the opposite knee.

If you fail to cross your knee over opposite knee, it indicates the tightness of Gluteus Minimus muscle.(10)

3) RETRO-TROCHANTRIC PAIN SYNDROME:

Deep Gluteal Syndrome (DGS) and Greater Trochantric Pain Syndrome (GTPS) are also the acronyms for Retro-Trochantric Pain Syndrome. It involves pain in the buttock caused from entrapment of the sciatic nerve in deep gluteal space. The boundaries of deep gluteal space are femoral neck anteriorly, gluteus maximus posteriorly, linea aspera of proximal femur laterally, sacrotuberous ligament medially, inferior margin of the sciatic notch superiorly and hamstring muscle inferiorly. The space contains piriformis, obturator internus/externus, gemelli, quadratus femoris, hamstring, gluteal nerves and lateral ascending vessels of the medial femoral circumflex artery. Any contents of deep gluteal space can cause sciatic nerve entrapment syndrome.(11)

In this space, with Piriformis muscle other rotators like Obturators and Gemelli muscles are also more prone for tightness. In one article they mentioned “Twelve patients, three male and nine female, mean age 47 (25-66) years, with pain in the buttock, radiating pain distal to the knee, were included in a prospective, randomized study for either surgical or conservative treatment. Six patients were operated in the hip region in an attempt to relieve pressure on the sciatic nerve. The piriformis muscle and tendon, as well as their relationship to the sciatic nerve, were found to be normal. However, the internal obturator tendon was found to be very tense, slightly hyperaemic and compressing the sciatic nerve; the nerve was slightly flattened where the obturator muscle was lying against it”.(12) Bulk of articles giving information about tightness of the hip rotators which causing Sciatic nerve entrapment.

4) SACROTUBEROUS LIGAMENT PAIN:

Many Ligaments around the S.I Joint and Hip joint are very sensitive and more prone for injury, Often the key ligament is the sacrotuberous, either at its origin at the lower sacrum, or along its insertion. It is a frequent culprit, but is so rarely properly examined. The problem is insertions of the sacrotuberous ligament are deep in the pelvis, where most practitioners are quite hesitant to touch. The sacrotuberous extends much further anterior than most texts show. When ligaments are tender, they are dysfunctional. The sacrotuberous often refers pain or abnormal sensation all the way to the ankle and foot.

Here is how to examine and treat the insertions of the sacrotuberous ligament. Tell the patient what you are going to do, and ask for explicit permission. Lay the patient on their involved side, bend the opposite leg up to 90-90, and rest the upper leg on a large pillow or bolster. Now, on the medial side of the lower thigh, slide your fingers anterior, starting at the ischial tuberosity and working your way anterior along the ischial ramus. You are pressing in an inferior direction. You want your fingers to be directly in contact with the bone, where the ligament inserts. Where the ligament is tender, apply manual Deep Transverse friction. It is too sensitive of an area, do not be too vigorous they can get very sore easily.

So, the success of your practice is influenced by your ability to educate your patients. Knowing the specific pain patterns of each muscle gives you the knowledge to efficiently assess, educate and design treatment plans tailored to your patient's complaints. So, always listen to the patient not to the youtube, Treat the source not the symptom.

Rahman Shiri et al. Obesity as a Risk Factor for Sciatica: A Meta-Analysis. Am. J. Epidemiol. (2014) 179 (8): 929-937.
Wegner I, et al. Traction for low-back pain with or without sciatica. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD003010. DOI: 10.1002/14651858.CD003010.pub5.
A.J.H. Verwoerd et al. Systematic review of prognostic factors predicting outcome in non-surgically treated patients with sciatica. Eur J Pain 17 (2013) 1126–1137
Boote, Jonathan, et al. "Physiotherapy for Patients with Sciatica Awaiting Lumbar Micro‐discectomy Surgery: A Nested, Qualitative Study of Patients' Views and Experiences." Physiotherapy Research International (2016).
El Barzouhi, Abdelilah, et al. "Magnetic resonance imaging in follow-up assessment of sciatica." New England Journal of Medicine 368.11 (2013): 999-1007.
Vas, Lakshmi, et al. "“Piriformis Syndrome”: Is It Only Piriformis?." Pain Medicine (2016): pnw037.
McCabe, Fergus J., and John P. McCabe. "An Unusual Presentation of Right-Sided Sciatica with Foot Drop." Case reports in orthopedics 2016 (2016).
Ya-lin, L. I. U. "Analysis of 23 cases of piriformis syndrome misdiagnosed as lumbar disc herniation." Modern Medicine & Health 7 (2006): 011.
Shouhui, Xu, and Tan Hongyan. "Clinical Analysis of Piriformis Syndrome Misdiagnosed as Chronic Ischemic Diseases of Limbs." JOURNAL OF SHENYANG MEDICAL COLLEGE 2 (2000): 010.
Sharon Sauer, CMTPT, LMT and Mary Biancalana, CMTPT, LMT Trigger Point Therapy for Low Back Pain. New Harbinger Publications: Oakland, CA 2010.
Park, Myung-sik, et al. "Clinical results of endoscopic sciatic nerve decompression for deep gluteal syndrome: mean 2-year follow-up." BMC musculoskeletal disorders 17.1 (2016): 1.
Meknas, M. Khaled. "Retro-trochanteric sciatica-like pain." (2010).