Sciatica and referred leg pain

The four things it usually turns out to be

A lumbar disc irritating a nerve root. The classic presentation: pain below the knee, often worse sitting, sometimes with pins and needles in a specific distribution, and frequently with a directional preference — a movement that centralises the pain towards the back and one that sends it further down.

Lateral stenosis or foraminal narrowing. More common with age, often worse standing and walking than sitting, which is the reverse of the disc pattern and is the single most useful thing in the history.

Gluteal tendinopathy or deep hip pain referring into the thigh, usually stopping above the knee and not accompanied by any neurological sign.

And referred pain from the lumbar joints themselves, which can produce a convincing buttock and thigh ache with no nerve involvement whatever.

What recovery actually looks like

Centralisation. The useful measure of progress in nerve root pain is not how much it hurts, it is how far down the leg it reaches. Pain that has retreated from the calf to the buttock is improving even if the buttock hurts as much as the calf did, and this surprises almost everybody.

It is also slow. Eight to sixteen visits is a typical course and the tail of it can run for months. Nerve tissue settles on its own timescale and no amount of treatment accelerates it past a certain point — what treatment does is keep you moving, keep the rest of you strong, and stop the compensations that outlast the original problem.

The treatment

Find the direction that eases it and use it, repeatedly, at home, several times a day. For a large share of disc-related presentations there is a movement preference and finding it is worth more than anything else in the first fortnight.

Nerve mobility work where the nerve itself has become mechanically sensitive — gentle, graded, and easy to overdo, which is why it is taught rather than handed over on a sheet.

Then loading, as tolerance returns, aimed at the whole chain rather than at the sore spot.

When we stop and refer

Progressive weakness. A foot that catches, a leg that gives way, a calf that will not push off — getting worse rather than staying put — means a physician.

Any change in bladder or bowel control, or numbness in the saddle area, means an emergency department today. Not tomorrow, not after the appointment. We will tell you so and help you get there.

And a course that has not moved at all by the visit-four reassessment goes back to a physician rather than into another block of appointments.