The word sciatica gets used for almost any pain that runs down the leg. Here's what's actually going on, why it matters, and what drives recovery.
Sciatica is probably the most misused word in musculoskeletal health. People use it to describe almost any pain that runs down the leg. Sometimes that's accurate. Often it isn't. And the distinction matters, because what drives the symptom determines what actually helps.
Let me explain what's actually going on.
The sciatic nerve is the largest nerve in the body. It forms from five nerve roots in the lower lumbar spine and sacrum, runs through the buttock, down the back of the thigh, and branches into the lower leg and foot. When something compresses or irritates those nerve roots, or the nerve itself along its path, you get the classic pattern: pain, burning, tingling, or numbness running from the lower back or buttock down into the leg.
That pattern is real and recognisable. The question is what's causing it.
The first is disc-related. The discs between the vertebrae of the lower lumbar spine act as shock absorbers. When a disc bulges or herniates, the displaced tissue can press against a nerve root. The result is often sharp, shooting pain, sometimes with weakness or altered sensation in the leg, that follows a specific nerve pathway. L4, L5 and S1 nerve roots are the most commonly involved, and each has its own referral pattern down the leg.
The second is piriformis syndrome, sometimes called deep gluteal syndrome. The piriformis is a small muscle deep in the buttock. The sciatic nerve runs close to it, and in some people, directly through it. When the piriformis is chronically tight or in spasm, often from prolonged sitting or hip mechanics that load it asymmetrically, it can compress the sciatic nerve from the outside rather than the spine itself. This is frequently missed, because the symptom looks identical to disc-related sciatica but the driver is entirely different.
A 2021 review in the Journal of Neurosurgery estimated that piriformis syndrome accounts for around six percent of sciatica cases, though clinical experience suggests the number is higher, because it's rarely assessed for unless disc pathology has already been ruled out.
If disc-related compression is the driver, the management involves reducing the load through the affected segment, restoring normal mechanics to the lumbar spine, and addressing the movement patterns that got the disc into that position in the first place.
If piriformis compression is the driver, the disc work is mostly irrelevant. The priority is restoring normal hip mechanics and releasing the piriformis compression directly.
Treating them the same way is like treating a broken window and a broken lock with the same tool. The symptom is similar. The solution isn't.
Most acute sciatica does improve. A landmark 1994 study published in the New England Journal of Medicine found that 90 percent of sciatica episodes from disc herniation resolved within twelve weeks without surgery. That's reassuring, and also slightly misleading, because resolved means the acute pain improved, not that the underlying structural pattern has been corrected.
The people who have one episode of sciatica and never have another are usually the ones whose mechanics were addressed, not just their symptoms. The people who have three or four episodes in five years are usually the ones who recovered from the pain and assumed the problem had resolved with it.
It hadn't.
If you're in the middle of a sciatica episode, the question worth asking isn't just how do I get through this. It's what's driving it, and what needs to change so it doesn't keep coming back.
Wild Chiropractic is a nervous system-led chiropractic practice in Shenton Park, Perth.
