Overview
Sciatica is a symptom, not a diagnosis. The sciatic nerve is formed from the L4, L5 and S1 nerve roots as they leave the low back, and when one of those roots is compressed or inflamed, pain travels along the nerve into the buttock, the back of the thigh and below the knee into the calf and foot. The name describes where the pain is; the exam identifies the cause, and the cause decides treatment.
In patients under 50 the cause is nearly always a disc herniation. Over 50 it is more often narrowing of the canal where the root exits, from disc collapse, bone spurs and thickened ligament. Less often the nerve is irritated by a tight piriformis muscle in the buttock. Dr. O'Donnell manages sciatica non-operatively and refers to a spine surgeon when there is progressive weakness, cauda equina symptoms, or leg pain that has failed 6 to 12 weeks of care.
Common Symptoms
- Pain that starts in the buttock or low back and runs down the back or side of one leg, usually below the knee
- Burning, electric or cramping pain that is worse than any back pain present
- Tingling or numbness in the calf, the top or side of the foot, or the toes
- Weakness lifting the foot or big toe, or pushing off, sometimes noticed as a catching toe or a foot that slaps
- Pain worse with sitting, coughing and bending forward when a disc is the cause; worse with standing and walking and eased by sitting when the canal is narrowed
Pain in the buttock and thigh that stops above the knee, with a normal nerve exam, is usually a low back strain or hip problem. Back pain that has waxed and waned for years, with an occasional referred ache in the leg, fits degenerative disc disease.
Causes & Risk Factors
Under 50 the history is a lift, a twist or a long drive followed by leg pain that peaked over a day or two. Over 50 the onset is gradual, the leg aches after walking a certain distance, and the cause is degenerative narrowing. Piriformis syndrome occurs in runners and cyclists. Heavy lifting, smoking, prolonged sitting and prior back injury raise the risk.
How It Is Diagnosed
Dr. O'Donnell locates the root. The straight-leg raise reproduces leg pain between 30 and 70 degrees when a lower lumbar root is tensioned, and pain in the affected leg when the opposite leg is lifted (the crossed straight-leg raise) is close to diagnostic of a herniation. The slump test does the same seated. He then tests ankle and knee reflexes, strength in the big toe, ankle and knee, sensation over the foot, and heel and toe walking, which together identify whether L4, L5 or S1 is involved. The hip is examined with the FABER test and the piriformis palpated to exclude conditions that mimic sciatica.
X-rays show alignment, disc height and any slip of one vertebra on another. MRI is ordered when there is weakness, when pain has failed 6 weeks of care, or when an injection is planned, and shows which root is compressed and by what: disc, bone or ligament. Out-of-town patients can send imaging through mymedicalimages.com.
Treatment Options
Non-operative care
Most sciatica settles within 6 to 12 weeks, and the program is built to get through that window with as little nerve irritation as possible. The first two weeks are walking rather than bed rest, avoiding the positions that provoke the leg, an anti-inflammatory, and for severe pain a short oral steroid taper. Physical therapy starts early: directional-preference exercises, nerve glides, core activation, then the stabilization and hip-flexibility program, and for piriformis syndrome, targeted stretching and hip strengthening. An epidural steroid injection is arranged when pain remains severe at 2 to 4 weeks or prevents therapy; for canal narrowing in older patients, a bike or incline-walking program, which opens the canal, is the mainstay.
When a spine surgeon is involved
Dr. O'Donnell refers when weakness is progressing or severe, when cauda equina symptoms appear, or when leg-dominant pain has failed 6 to 12 weeks of care including an injection. For a herniation the surgeon's option is a microdiscectomy; for canal narrowing it is a decompression. Both relieve leg pain reliably in well-selected patients.
Recovery & What to Expect
Leg pain fades first, tingling next, and numbness and strength take the longest. The timeline below is a general one for sciatica managed without surgery.
| Phase | Timing | What happens |
|---|---|---|
| Reduce nerve irritation | Weeks 0–2 | Walking; positions of relief; anti-inflammatory or steroid taper; directional-preference exercises and nerve glides; no prolonged sitting or lifting |
| Reassess | Weeks 2–4 | Exam repeated; epidural injection if pain is still severe; core activation begun |
| Stabilize | Weeks 4–8 | Core stabilization progression; hip and hamstring flexibility; glute strengthening; bike or incline walking; MRI if not improving by week 6 |
| Return to activity | Weeks 8–12 | Progressive strengthening and lifting mechanics; return to sport on painless function; surgical opinion if leg pain persists |
Desk work continues with frequent standing; driving resumes when sitting is tolerable and the right foot is strong enough to brake; running returns around weeks 6 to 8 and lifting or contact sports at 3 months. The core program is the lumbar sprain protocol.
Frequently Asked Questions
How long does sciatica take to go away?
Most episodes improve substantially within 6 weeks and resolve by 12, with leg pain leaving before tingling and numbness. Sciatica from a disc herniation follows that course reliably; sciatica from canal narrowing in older patients tends to come and go with activity and is managed over the long term with a walking and core program.
What is the best position or activity for sciatica?
Walking, in short frequent bouts, is better than either bed rest or sitting. Most disc-related sciatica is eased by standing and by lying flat with a pillow under the knees and worsened by sitting; sciatica from canal narrowing is eased by sitting and leaning forward. Physical therapy identifies your direction of relief and builds the program around it.
Do I need an MRI for sciatica?
Not immediately. An MRI is ordered when there is weakness, when leg pain has not improved after 6 weeks of care, or when an epidural injection or a surgical opinion is being planned. Ordered earlier it usually shows the herniation that the exam already predicted and does not change the first 6 weeks of treatment.
When does sciatica need surgery?
When weakness is progressing or severe, when there are cauda equina symptoms such as saddle numbness or bladder change, or when leg-dominant pain has failed 6 to 12 weeks of care including an injection. Dr. O'Donnell refers those patients to a spine surgeon for a microdiscectomy or decompression. Leg pain that is improving, however slowly, is not an indication.
Is sciatica the same as a pinched nerve?
Sciatica is a pinched or inflamed nerve root in the low back felt along the sciatic nerve in the leg. The cause differs by age: a disc herniation in younger patients, narrowing of the nerve canal from wear in older ones, and occasionally a tight piriformis muscle in the buttock. The exam identifies which, and the treatment differs for each.
This page is for general education and is not a substitute for a medical evaluation. Treatment recommendations depend on your individual diagnosis and goals. Kevin O'Donnell, MD sees patients from Coral Gables, Miami, Brickell, Pinecrest and Coconut Grove at 475 Biltmore Way, and out-of-town patients by telemedicine.