All About the Treatment of Low Back Pain & Sciatica!
What is Sciatica?
Sciatica is a condition that affects about 40% of the population at some point in time and is the NUMBER ONE most common condition I see in my office. When a patient is suffering from sciatica, it is due to irritation and/or compression of the sciatic nerve, which is your largest nerve in the body.
Sciatica by definition is a result of a disc bulge or herniation that puts pressure onto the nerve root. Think of it like a jelly donut… When you step a bit on that donut, the fluid or jelly migrates to the back. As the fluid begins to go further back it can bulge or herniate (break through the disc). In both cases, you can have symptoms of sciatica but often times a disc herniation is more inflammatory and painful.
The disc within the spine really does two different things. First, they are a shock absorber (and they provide some movement) in the spine that helps to transfer energy. Secondly, they provide as a spacer to help create space for the nerve.
Discs are made of up two separate parts; a outer annulus and an inner nucleus. The outer annulus is a tough fibrous outer wall that has concentric rings much like an onion that helps to keep the contents of the disc inside! This layered ring structure helps to provide a lot of strength and when it is ruptured the contents on the side can begin to leak out or bulge and create low back pain.
The inner nucleus is softer gel like center that provides cushion and helps prevent against other forces within the spine.
Interestingly enough is that the inside ⅔ of the annular layers do not have nerve innervation and the outer ⅓ does. This means that you can literally tear some of the rings on the inside or hurt them without having low back pain. Once your start to penetrate to the outer ⅓ areas then you begin to risk pain into the back or irritation to a nerve root (sciatica).
When a disc herniates, that is when the softer jelly material leaks out of the disc and you can likely experience inflammation and low back pain. Disc herniations and injuries to the disc are some of the most common reasons you may be experiencing lower back pain.
Symptoms of Sciatica?
Symptoms can vary from person to person and pain even can change daily in patients suffering from sciatica. Some of the most common symptoms a person may feel with sciatica is low back pain, burning, numbness, tingling that goes down the butt or gluteal area, pain or discomfort down the hamstrings, and it can even extend to the calf or heel.
A nerve is designed for getting sensation from our environment and transferring that information to our brain so that we can make a decision. For example, if it is very cold out, our nerve will get that information and send it to the brain and we then make a decision to put on a jacket or blanket.
When nerves are irritated their sensations are altered, thus giving us altered information about the environment as well. Symptoms that a nerve is irritated can be numbness or tingling into the area. Often time’s patients will have difficulty with sensation and during an exam they may report an increase in sensation (hyperesthesia) or too little sensation (hypoesthesia). This often happens over certain areas of the thigh or parts of the leg that the nerve innervates.
One of the biggest problems with sciatica as I mentioned is not only the pain but also loss of neural information. This loss of information means your body will not respond properly as well. Think of it like this… When there is loss of sensory information going in to the body, there will be a loss of motor output (meaning how your body reacts to the environment). This is often seen in patients with sciatica who have altered movement patterns because of the injury to the nerve. When this goes on for some duration of time it can lead to even more dysfunction in the movement patterns.
Leg pain with sciatica?
The leg pain that some patients feel can be intense burning or searing pain and is not fun! Since the nerve goes from the spine all the way down into the heel we can often times make an assumption that the further the pain goes into the leg, the more irritated the nerve is. In addition, since it is more irritated in terms of intensity, it may give the doctor a hint that this has been occurring for a longer period of time, there is more inflammation, and thus it may take longer to treat.
One of the most common symptoms of leg and thigh pain is constant hamstring tightness and calf tightness. Patients often stretch these areas of tightness repeatedly and often state “I have always had tight hamstrings.” In addition, patients will notice an inability to bend and touch their toes with their fingers. If they can, they will say, “it takes me a few minutes but once I warm up I can do it.” The sciatic nerve goes down the back of the gluteal muscle, into the hamstring and then splits just above the knee. The remaining branches go to different areas of the legs and all these nerves control the muscles.
Think about it this way, if a nerve or set of nerves are inflamed from a disc herniation then it will cause these muscles to go into a spasm, guard, and protect the body from further injury. So essentially, that chronic “tightness” you are feeling in the back of the leg or thigh is not really muscle tightness, but rather nerve irritation that creates the sensation of tightness.
Most patients will go ahead and continue to stretch this tightness with little to minimal effectiveness. Often time’s patients will states that they stretch for 20-30 minutes and the relief is very minimal (5-10 minutes or less). This means that it is not the best use of your time and the condition is not a muscle (or at least we should consider that something else is involved) and since there is such little relief with such effort, we need to consider the neurology involved.
Spasms are common
When dealing with sciatica many patients will find that they are having constant low back pain and spasms. These spasms often occur into the thigh and calf and are known as muscle fasciculation. Spasms can range from painful to annoying or even give rise to a “creepy crawler” sensation and are often due to the irritated nerve. In a “true” muscle spasm, there may be some benefit to stretching but with sciatica and sciatica related back spasms the body is often protecting itself from further injury to the neurology. Stretching the spasms are typically not beneficial. We’ll go over that later.
Other Syndromes and Sciatica
Search Dr. Google and you cannot look into sciatica without finding information on Piriformis Syndrome or IT Band Syndrome, or some other back, hip, or pelvic related issue. The truth is that these syndromes often occur in clusters or groupings and are often inter-related.
For example, if you have tight hip flexors you likely also are dealing with a groin or hip impingement issue. If you have a groin or hip issue, you may be dealing with a lower back, SI, or even a knee complaint.
People like to think that they have multiple injuries going on at once and people often isolate them and pick them apart as if they are different.
.As mentioned before, piriformis syndrome with has pain in the butt and can also refer pain down into the leg or into the hip. Many will say they have piriformis syndrome, and IT band syndrome but with chronic hamstring tightness.
Does this make sense?
What people with injuries don’t seem to do (not their job) is to ask how these can be related? What caused these issues to occur in the first place? If you are reading this and made it this far then you understand and you also understand that your body is intelligent and compensates for problems. One problem can lead to another down the chain.
Other Possible Conditions?
As we just covered, there can be syndromes that mask your true condition. If someone is having sciatica like pain but does not have low back pain then can it still be sciatica?
YES, you can still have no low back pain but have sciatica! In some cases patients will lack pain into the lower back as the nerve and sciatic pain is more intense. As the pain clears up or centralizes (opposite of peripheralization) the back pain can come on.
In addition, we do come up with a differential diagnosis meaning what else can be occurring. In the body you can also have peripheral nerve entrapments. This is when the nerve can be stuck or not gliding properly through its structures and soft tissue. The result is friction or tension on a nerve and when the patient goes through a motion, the nerve gets caught and becomes symptomatic.
In many of these cases, mobility work and soft tissue work tend to clear them up in a few to several visits.
What is the Treatment For Low Back Pain and Sciatica?
Overall, back pain is treated very poorly, that’s how! Low back pain and sciatica are the MOST common injuries a doctor sees; yet we are so bad at treating it. It literally is an economic drain on the entire world. We spend about $100 BILLION per year on this condition and each person suffering tends to spend more than $4,000 out of your pocket. The big issue is that our outcomes are not good either.
Why are we so bad at treating low back pain?
How could that be? We have some of the most advanced imaging and treatments available yet we still suck at managing this condition? Here may be some of the reasons why!
- Chiropractic can help patients feel better and the most common issue a Chiropractor will tell you is that you have a joint that is not moving well and is “misaligned.” We know alignment in the body is important but when it comes to the spine, searching for a misalignment is extremely subjective. As a matter of fact, it is so subjective that inter-examiner (doctor to doctor) reliability is low.
- Physical therapy can be great to get a rehabilitation process going and get patients strong again right? Yes, that is true but only 87% of people engage in a formal rehab program. So patients are rarely interested in putting in the work but also physical therapy and rehab is often not specific to the person’s condition and back pain issue. Most professionals don’t spend time mastering or dedicating themselves to one area of the body. Health professionals often see patients with elbow pain, hip, shoulder, and although they get exposure to these areas, most pros don’t ever truly learn how to help since their knowledge is so broad.
- MRI and X-Ray scans can tell you exactly what you are dealing with right? MRI and x-rays for the lower back (or any body part) is essentially getting a scan or a blue print of how your spine looks. It is most definitely a valuable tool but it DOES not tell you how your body functions as a whole. Radiologists are often conflicted with the same results and again, reliability is low. Finally, research has shown that many patients may have a “problem in the lower back” but do not have pain. This means you cannot always correlate pain with the damage. (Why an MRI may not help & when should you consider getting an MRI?)
- Most medical doctors are there for help and can help manage pain very well with medications. I often refer to them when needed but many do not realize that constantly managing lower back pain with medications is just the relief phase! That is fine with me but low back pain is complex and once medication management is done, MD’s often just don’t have the time and training to heal back pain.
- Orthopedics and specialists are extraordinary in there craft and skill. I truly admire what they do!!! Many orthopedics attempt to relate structure and function together. “This disc bulge or herniation is the reason you have the pain.” It is a very mechanical view of how a person works and as mentioned before, you can have “damage to your lower back” and be pain free and vice versa. The whole mechanical approach to pain is not 100% certain and surgical intervention is very costly to the patient and society.
- Massage is a great way to enhance blood flow to tissues and free it up of restrictions. Not to mention the stress release you get! A herniated disc or sciatica is not going to get “pushed” into place by relieving the tension the muscles. Although it feels good and does help with pain relief, it does minimal to help train your body to move better and tightness within the muscles are neurological, not from the muscles themselves.
- Low back pain is not all in your head! There is something we now recognize which is called the mind body connection. While I believe the mind does allow us to heal, any doctor or professional says that it is “All in your head” likely just does not want to deal with you because they don’t know how to manage your pain or condition anymore and that’s okay! Now, I have referred many patients to therapy and it does help but almost NOTHING is truly ALL in YOUR HEAD and often times there is a cause for this.
- Education rarely happens in the healthcare setting and for many reasons. First, many providers just do not spend enough time with each patient to give the information necessary. Secondly, what information may be given is just s small fraction of the big picture. There is just no way for a clinician to dump all the information they know into a single patient visit. For patients to truly get well, education is needed so that they can piece together the puzzel of low back pain.
- Pseudo-treatments exist on the market. I have literally heard about things from putting your feet into warm milk and ginger, buying posture braces, all the way to potential things that may help like CBD oils, patches, and other things. All I am saying is that if you are really looking for help, do not fall victim to those who are praying on you as an easy sale and start with mainstream treatments and care options.
Okay, I get it! So what are the causes of my low back pain and sciatica?
“I think its my bed and the way I sleep? My mattress is old! I went to pick up my child and my back went out!”
These are some of the real things that patients say to me but they are NOT the cause of your back pain!
The way most people hurt their low back is by moving poorly for a long duration of time. Things like poor posture, bad lifting, sitting too long, not moving. Most people like to blame their lower back pain to an isolated or single incident. “I hurt it when it bent over and picked up my kid” “I heard a pop and my back went out when I was doing house chores”
While these injuries and isolated incidents may have been a factor, the true driving factor is your movement. The problem is when people really fixate on that one incident that hurt their back and then they avoid that activity forever. This only furthers the problem as patients begin to move less and less thus increasing their LACK of mobility and quality movements. This leads to the fear avoidance cycle and is very present in all injuries to some extent but is very common in chronic pain. If you want to learn more about how this cycle affects your body, watch the video!
How the Low Back Gets Injured?
The most common way to get your lower back injured or herniated is by flexion and loading. An example of this would be improper lifting techniques and lifting something too heavy off the ground while rounding the spine. While this is not the only way to injure the lower back, it is the most common. Flexion with loading is not bad in itself but it does add compression to the disc and can cause it to push backwards which can then affect the nerve root and cause the symptoms.
You can also see how if you go ahead and do this activity without a good warm up, or if you add a lot of stress to your body with excessive sitting and poor posture, you can increase the chances of this happening.
Common mistakes when dealing with sciatica?
- Not asking for help – Too many people suffer back pain for too long and without getting any help! Even as an expert in the field, it is often difficult to self manage your own pain. If you are suffering this condition, not getting better, don’t try to self manage your back pain without any lasting results. Go see an expert and seek professional advice. TRUST ME & learn from my own mistakes as a patient!
Seriously, this is the biggest mistake people make. Don’t wait any longer. Schedule an appointment Now!
- Stretching – If you have tried stretching it has not worked by now, then its not going to! This is particularly true with most conditions and the truth is stretch rarely fixes an injury. In contrast, it is strengthening and rehabilitation that will work better! The problem is that rehabilitation requires time, dedication, effort, and education that most people are not willing to sacrifice. These protocols should be the #1 go-to effort to reduce all injuries as they are the most cost effective! Think about it, an MRI costs about $1,500 -$3,000 and you can likely find a expert provider to give you COMPLETE care for that price.
- Rehabilitation – With rehabilitation, some people progress themselves too fast too soon. The fact of a matter is that flare-ups are common and sometimes can be expected, but that does not mean you are getting worse. Many people with rehab give up too soon and don’t give it a course of care. You truly need to exhaust your efforts and try your best. Ask yourself this one question, “Did you really put in the effort to get better?”
How Do I Know If My Low Back Pain or Sciatica is Something Else?
In evidence based practices the doctor should examine you and you should be giving them answers as well. In most cases, there is not really a major problem like cancer, tumor, infection in the spine (although that could happen).
But… if you are worried, most professionals should cover red flags during the initial treatment and be monitoring your progress. Red flags are exactly what you think they are! They are potential indicators that you need to see your doctor more urgently. If you have one or more of the following I would urge you to go and see your MD immediately.
- Loss of bowl or bladder control
- Bilateral limb weakness
- Foot Drop
- Trauma to the area
- Progressive neurological weakness
- Trauma associated with low back pain
- Unexplained weight loss
- Saddle anesthesia
- No or very little improvement with 6-8 weeks of conservative care
How Long Does Back Pain Take to Get Rid Of?
Truth: There is no straight answer for this one.
Each person is different and there are most definitely things that speed up or slow down the healing process. About 90% or more people with lower back pain will experience some form of recurring back pain, so does it ever really go away?
It can, but the recurring back pain should get less with time and if there is pain, you should be able to manage it well with the skills you learn while getting treatment for it.
Since there is no true answer I will give you my experience and opinion based on thousands of low back pain cases.
It may take about 1-3 weeks for your pain to significantly decrease to the point where you can get some good quality exercise and rehabilitation in. Depending on the persons history, activity levels, and other factors, to do a lot of the foundational training it can take another 4-6 weeks. Keep in mind there may be a week or so of flare-ups so maybe add an additional 2 weeks of care.
At this point you are anywhere between 6 weeks as minimum and 11 weeks to get out of pain, and all the foundational work complete. I would then say that your foundational work never really ends. You can implement these exercises as a warm up, cool down, or a workout in the gym so that you can maintain your spinal health and reduce low back pain chances.
At this point, you should really do another 4-6 weeks weeks of quality training with the doctor, trainer, strength coach, therapist, or whoever you are working with. This is more advanced strengthening that helps develop specific programs to help you get back to the things you love and are geared specifically for you!
So to get out of back pain, get the foundation set, and gain real strength, it will likely take you between 10 weeks and 20 weeks depending on your goals. I have seen less and I have also seen more but if you truly want to learn about your injury, get out of pain, and manage this issue long term this is what it will take.
The Three Phases of Care for Treating Injuries
There are essentially 3 phases I view to get out of pain for all injuries.
- Pain Relief Phase – This is the phase of care where the primary focus is to help relieve your pain and ease you into positions and postures that reduce your pain.
- Corrective Phase – The beginning phase that starts to get your body moving better and focuses on getting stronger and correcting the problem by promoting better movement patterns.
- Performance/Training Phase – The phase of care where your rehab looks similar to strength training. During this phase you will focus on optimal strengthening to help you return to activities specific to your goals.
All these phases of care are designed to help you get out of pain, correct the problem and get back to the activities that you enjoy doing. While many people think that it is a step-by-step or pyramid process, it is rather a process that overlaps each other and uses each phase to progress to the next. Using a phase of care program like this helps each person to get out of pain more predictably while reducing the occurrences of lower back pain.
What are some exercises and things I can do to get my back pain better?
Relief Phase Exercises Extension Exercises
Corrective Exercise Phase
Want More Low Back Information and Support?