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Back & spine · treated under Musculoskeletal Physiotherapy

Sciatica

Also called Lumbar radiculopathy, Nerve root pain, Slipped disc pain.

Pain that travels down the leg from a nerve root in the lower back, nearly always a disc. It settles for most people with movement, not rest, and the disc shrinks on its own.

Written by , BPT, MPT · MIAP License No. 69386

Updated · Clinically reviewed by Dr. Sayyada on

A physiotherapist raising a patient's straight leg during an assessment

What it is

Sciatica is not a diagnosis; it is a description. It means pain along the sciatic nerve, the thick nerve formed from roots in the lower spine that runs through the buttock and down the back of the leg, caused by something irritating or compressing one of those roots. In about nine cases out of ten that something is a disc bulge or herniation pressing on a root [1]. The rest are narrowing of the spaces the roots pass through, which is the commoner cause after 60, and occasionally irritation lower down, in the buttock.

How common it is depends on how strictly it is defined. Studies report anywhere from 1% to 43% of people, because the word gets used for almost any leg pain [2]. Genuine nerve-root pain is a smaller group with a recognisable pattern, and telling the two apart is the first job of the assessment, because they follow different timelines and need different treatment.

How it presents

  • Pain that travels in a line down the leg, often below the knee, almost always on one side
  • A sharp, electric or burning quality rather than a dull ache, and often worse than any back pain
  • Pins and needles or numbness in a defined patch of skin on the leg or foot
  • Provoked by coughing, sneezing or straining
  • Worse with sitting and bending forward, easier standing or walking, when a disc is the cause; the reverse, worse walking and eased by sitting or leaning forward, points to narrowing in an older spine
  • Weakness in a minority: difficulty rising onto the toes, or a foot that lifts poorly

If the pain stops at the buttock and feels deep and achy, it is more likely referred from a joint or muscle than coming from the nerve. That is good news: referred pain usually settles faster, and it is not treated as a nerve problem.

Who gets it and why

A lumbar disc is a fibrous ring around a gel-like centre. When the ring weakens and the centre pushes out, it can press on the nerve root leaving the spine at that level and, just as importantly, set off an inflammatory reaction around the root. Both the pressure and the chemical irritation produce the leg pain, which is one reason the size of a bulge on a scan and the amount of pain match so poorly.

Discs bulge in people with no pain at all. In a review of imaging studies of people with no back or leg symptoms, a disc bulge was present in 30% of 20-year-olds and 84% of 80-year-olds, and a disc protrusion in 29% of 20-year-olds [4]. A bulge on your MRI is not proof that it is causing your symptoms, which is why the examination, not the scan, decides what is treated.

Risk factors

  • Age, with disc-related sciatica peaking between 45 and 64 [1]
  • Physical work with frequent lifting, especially bending and twisting, and whole-body vibration such as driving for a living [1]
  • Being tall, and smoking [1]
  • A recent episode of low back pain: most sciatica arrives on the back of a back that was already complaining
  • Prolonged sitting, which is not a cause of disc damage on its own but is reliably the position that provokes symptoms once it has happened

How it is diagnosed

Sciatica is diagnosed in the room, from the story and the examination: where the pain travels, what provokes it, and a set of tests that tension the nerve (raising the straight leg, for one), check the reflexes, and test the strength and sensation supplied by each nerve root. That combination tells us which root is involved and how irritable it is, and it separates nerve pain from the referred buttock and thigh pain that mimics it [1].

NICE guidance is explicit that imaging should not be offered routinely for low back pain with or without sciatica, and only where the result is likely to change management [3]. The reason is the review above: scans find bulges in most adults, painful or not [4]. A scan earns its place when symptoms are severe or progressive, when there is weakness, when the picture does not fit, or when an injection or surgery is being considered.

When imaging earns its place

Emergency imaging is a different matter. New numbness in the saddle area, any change in bladder or bowel control, or symptoms in both legs need same-day assessment and usually an urgent MRI, because a large central disc can compress the bundle of nerves at the base of the spine, and the outcome depends on how quickly it is decompressed [13].

What the evidence says

Treatment by treatment, with the studies behind each verdict numbered to the sources at the end of the page.

  • Staying active

    Core treatment

    The best-established principle in sciatica. In a trial of 183 people with acute symptoms, two weeks of bed rest produced no better outcome than simply carrying on as symptoms allowed, and 87% of both groups had improved by twelve weeks [7]. NICE advises people to keep active and continue normal activities as far as possible [3]. Movement hurts less than it seems it should, and it does the root no harm.

  • An exercise programme

    Core treatment

    Structured exercise gives a small extra reduction in leg pain over advice alone in the short term, and no difference by the longer term [8]. Its value is less the pain score than what it builds: the ability to bend and sit again, and a trunk and hips strong enough to make the next episode less likely. NICE recommends a group or individual exercise programme as the core of treatment [3].

  • Finding your direction

    Core treatment

    Many disc-related cases ease markedly with one specific repeated movement, most often extension, lying on the front and propping up onto the elbows; a minority prefer bending. The test is the leg, not the back: a movement that draws the pain up out of the leg towards the spine, even if the back aches a little more, is the right one. This is called centralisation, and the first session is largely spent finding it.

  • Time: the disc shrinks on its own

    Core treatment

    Herniated disc material is reabsorbed by the body over months. Pooled studies show regression in 96% of sequestrated fragments, 70% of extrusions and 41% of protrusions [5]. The larger and more alarming the herniation looks on the report, the more likely it is to shrink. This is not a treatment, but it is the reason the timelines below are what they are, and the reason a frightening scan is rarely a reason for surgery.

  • Nerve mobility exercises

    Helps alongside

    Gentle movements that slide the nerve through the tissues around it, started once the acute irritability has settled. Pooled trials show improvements in pain and disability for nerve-related low back pain [9]. They should feel like a mild stretch that eases within seconds, never a sharp or lingering one.

  • Hands-on treatment

    Helps alongside

    Spinal mobilisation and soft-tissue work are recommended by NICE only as part of a package with exercise, not on their own [3]. That is how we use them: to reduce pain and guarding enough to get the movement programme going and to make sitting and sleeping tolerable.

  • Pain relief

    Helps alongside

    NICE suggests an anti-inflammatory at the lowest effective dose for the shortest time, weighing stomach, kidney and heart risks, and advises against gabapentinoids, antiepileptics, oral steroids and benzodiazepines for sciatica, and against opioids for chronic sciatica [3]. Pregabalin, widely prescribed for nerve pain, did no better than placebo in a trial of 209 people with sciatica and caused more side effects, dizziness in particular [11].

  • Epidural steroid injection

    Second line

    Probably reduces leg pain and disability slightly in the short term, by an amount that may not be noticeable to the person having it, with no lasting benefit shown [10]. NICE reserves it for acute and severe sciatica [3]. Reasonable when pain is too severe to move at all, as a bridge into rehabilitation.

  • Surgery

    Second line

    In the Dutch trial that compared early surgery with continuing conservative care, surgery relieved leg pain faster, but by one year 95% of both groups considered themselves recovered, and 39% of the conservative group were the only ones who ever needed an operation [12]. Surgery is for severe pain that is not settling with time and treatment, or for progressive weakness, not a response to a scan.

  • Bed rest

    Avoid

    Beyond a day or two of the worst pain it does not help and it weakens everything that supports the spine [7]. Change position often, walk, and let the assessment find the movements that ease the leg.

Put together: keep moving, find the movement that draws the pain out of the leg, protect sitting and sleep with hands-on treatment and sensible pain relief, and give the disc the months it needs to be reabsorbed while the trunk and hips are rebuilt. Injections and surgery are for the minority whose pain is unmanageable or whose nerve is losing function, and the evidence says that for most people the destination at one year is the same either way [12].

How we treat it

At The Rym Space, Bagalur

  1. 1

    Assessment

    The story, then nerve tension tests, reflexes, strength and sensation, root by root. You leave knowing which root is involved, how irritable it is, and whether a doctor needs to be involved as well.

  2. 2

    A plan you start that day

    The movement that eases the leg, done little and often. Positions for sitting and sleeping, how to get out of a chair or a car without provoking it, and straight talk about pain relief and your scan.

  3. 3

    Week 1: bring the pain down

    3 to 5 sessions close together. Hands-on treatment to calm pain and guarding, the repeated movement that draws pain out of the leg, and a few basic exercises to repeat through the day. Walking is the main activity.

  4. 4

    Week 2 onwards: build strength

    Progressive strengthening for trunk, hips and legs, with sessions spacing out as the home programme takes over. Nerve mobility work once the leg tolerates it, and sitting rebuilt in steps.

  5. 5

    Return, or a change of plan

    Loading progressed to lifting, sport or whatever brought you in, with a maintenance programme you keep. No improvement by six to eight weeks, or any weakness, means medical review and imaging rather than more of the same.

What to expect, and when

Ranges, not promises. Where a figure comes from a study, the study is numbered.

First 2 weeks
The worst of it. Around two thirds of people report some improvement within two weeks, with or without rest [7]. The job now is finding the movements and positions that ease the leg, and walking.
By 6 to 12 weeks
Most acute sciatica is clearly better. In the bed-rest trial, 87% said they had improved by twelve weeks [7]. Improved is not gone: leg pain fades before the pins and needles do.
By 12 months
In a primary-care cohort of 609 people, 55% were improved at one year [6]. That is a stricter measure, a 30% drop in disability score, in patients who had often had the pain for months already, so it does not contradict the figure above. A longer history before seeking help, and expecting it to last, were the strongest predictors of not improving [6].
The disc itself
Herniated material is reabsorbed over months to a year or more. The larger the herniation, the more likely it is to regress [5].

Nerves recover more slowly than pain. Numbness, a weak calf or a dulled reflex can take months to return after the leg pain has gone, and a small patch of altered sensation that never quite goes is common and harmless. Weakness that is getting worse needs review, whatever the timeline says.

When to be seen sooner

Signs that this is something else, or that it needs looking at now rather than after a few weeks of self-care.

  • Numbness or altered sensation in the saddle area: the inner thighs, groin, buttocks or around the back passage. Same-day assessment, because a large central disc can compress the nerves at the base of the spine and the outcome depends on speed [13]
  • Any new difficulty passing urine, loss of control of bladder or bowel, or loss of sensation when you go
  • Sciatica in both legs at once, or rapidly worsening weakness in a leg or foot
  • A foot that slaps or drags when you walk, or new difficulty rising onto the toes
  • Leg pain after a significant fall or accident, or in someone with osteoporosis, until a fracture is excluded
  • Pain that is unrelenting at night, fever, unexplained weight loss, or a history of cancer
  • Pain that has not begun to improve by six to eight weeks despite treatment, which changes the plan rather than the urgency

Common questions

Do I need an MRI?
Not to start treatment. NICE advises against routine imaging because scans show disc bulges in most adults with no symptoms [3][4]. We ask for one when there is weakness, when symptoms are severe or not settling, or when an injection or surgery is on the table.
Is it a slipped disc?
Discs do not slip; they bulge or herniate, and about nine in ten cases of true sciatica come from one [1]. The reassuring part is that herniated material is reabsorbed by the body over time, and the larger fragments regress most reliably [5].
Should I rest until it settles?
No. Beyond a day or two of the worst pain, bed rest does not help and prolongs recovery [7]. Keep walking, change position often, and let the assessment find the movements that ease the leg.
Will I need surgery?
Most people do not. In the trial that compared early surgery with waiting, 39% of the waiting group eventually had an operation and the rest never did, and both groups were 95% recovered at one year [12]. Surgery is for severe pain that is not settling, or a nerve that is losing function.
Why do I still have pins and needles when the pain has gone?
Nerves recover more slowly than pain does. Altered sensation that is steady or improving is a healing nerve, not ongoing damage. Sensation or strength that is getting worse needs review.

Further reading

Sources

Guidelines, systematic reviews and trials only. Each number in the text links to the entry here.

  1. 1.Koes BW, van Tulder MW, Peul WC. Diagnosis and treatment of sciatica. BMJ. 2007;334(7607):1313-1317. pubmed.ncbi.nlm.nih.gov ↗
  2. 2.Konstantinou K, Dunn KM. Sciatica: review of epidemiological studies and prevalence estimates. Spine. 2008;33(22):2464-2472. pubmed.ncbi.nlm.nih.gov ↗
  3. 3.Bernstein IA, Malik Q, Carville S, Ward S. Low back pain and sciatica: summary of NICE guidance. BMJ. 2017;356:i6748. pubmed.ncbi.nlm.nih.gov ↗
  4. 4.Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. pubmed.ncbi.nlm.nih.gov ↗
  5. 5.Chiu CC, Chuang TY, Chang KH, Wu CH, Lin PW, Hsu WY. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabil. 2015;29(2):184-195. pubmed.ncbi.nlm.nih.gov ↗
  6. 6.Konstantinou K, Dunn KM, Ogollah R, et al. Prognosis of sciatica and back-related leg pain in primary care: the ATLAS cohort. Spine J. 2018;18(6):1030-1040. pubmed.ncbi.nlm.nih.gov ↗
  7. 7.Vroomen PC, de Krom MC, Wilmink JT, Kester AD, Knottnerus JA. Lack of effectiveness of bed rest for sciatica. N Engl J Med. 1999;340(6):418-423. pubmed.ncbi.nlm.nih.gov ↗
  8. 8.Fernandez M, Hartvigsen J, Ferreira ML, et al. Advice to stay active or structured exercise in the management of sciatica: a systematic review and meta-analysis. Spine. 2015;40(18):1457-1466. pubmed.ncbi.nlm.nih.gov ↗
  9. 9.Basson A, Olivier B, Ellis R, Coppieters M, Stewart A, Mudzi W. The effectiveness of neural mobilization for neuromusculoskeletal conditions: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2017;47(9):593-615. pubmed.ncbi.nlm.nih.gov ↗
  10. 10.Oliveira CB, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev. 2020;4:CD013577. pubmed.ncbi.nlm.nih.gov ↗
  11. 11.Mathieson S, Maher CG, McLachlan AJ, et al. Trial of pregabalin for acute and chronic sciatica. N Engl J Med. 2017;376(12):1111-1120. pubmed.ncbi.nlm.nih.gov ↗
  12. 12.Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007;356(22):2245-2256. pubmed.ncbi.nlm.nih.gov ↗
  13. 13.Gardner A, Gardner E, Morley T. Cauda equina syndrome: a review of the current clinical and medico-legal position. Eur Spine J. 2011;20(5):690-697. pubmed.ncbi.nlm.nih.gov ↗

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