Not all sciatica is the same: the three main causes, and why it matters
By the team at Matrix Health & Performance, Ivanhoe East
If you have pain running down your leg and someone has called it sciatica, here is something most people are never told: sciatica is a label, not a diagnosis. The word simply means the sciatic nerve is irritated. It describes what is happening, not why.
That distinction matters more than it sounds, because there are three main causes of sciatica, and they are not treated the same way. If you do not work out which one is actually driving your symptoms, you are guessing at the treatment. So the single most useful thing we do at a first appointment is tell these three apart.
1. Disc-related nerve tension
This is the most common cause. A disc in the lower back irritates the nerve where it exits the spine, and that irritation refers pain down the leg. It often feels like a deep ache in the back or buttock that travels below the knee, sometimes with pins and needles or a sense of weakness, and it can be worse with sitting, bending, or coughing.
The important part: a disc bulge on a scan does not mean you are finished. Around a third of people with no pain at all have disc bulges they will never know about. The disc does not need to look perfect on imaging for you to feel and move well again. The focus is on taking pressure off the nerve, restoring movement through the lower back and hips, and gradually rebuilding your tolerance to sit, bend, and load without flaring it up.
2. Piriformis involvement
Here the driver is muscular rather than the disc. The piriformis, a muscle deep in the buttock, can compress or irritate the nerve as it passes nearby, producing very similar leg symptoms from a completely different source. The pain tends to sit more in the buttock itself and is often aggravated by prolonged sitting or certain hip movements.
Because the cause is different, the approach is different. Rather than focusing on the disc, we work on settling the tension through the deep hip muscles, understanding why that area became overactive in the first place, and restoring balanced movement through the hip and pelvis so the nerve is no longer being squeezed.
3. Narrowing where the nerve exits
The third cause is a narrowing of the space the nerve passes through, often from bony changes that develop gradually over time. This becomes more common as we get older. It typically feels worse with standing and walking, and is eased by sitting or leaning forward.
This one rarely means surgery, despite how it is sometimes framed. The aim is to create and maintain as much room and movement for the nerve as possible: improving mobility through the lower back, building the strength and endurance to stay active, and giving you clear strategies to manage day to day. Many people stay comfortable and mobile for years with the right plan.
Why telling them apart is the whole point
All three of these can feel like sciatica. From the outside they can look similar: pain down the leg, maybe some tingling, worse with certain positions. But a disc-driven problem, a muscular one, and a narrowing of the nerve space each respond to a different approach. Treat all sciatica the same and you will help some people and frustrate others.
That is why a proper assessment matters. At a first appointment we take a thorough history and run through orthopaedic and movement testing, matching your symptoms to what the testing shows, so we are treating the actual driver rather than chasing leg pain in the dark. Where a scan genuinely adds something, we will say so. Where it does not, we will save you the worry and the cost.
Where to start
If you have leg pain that has been dragging on, or you have had a scan that left you more worried than reassured, it is worth having it assessed properly. At your first appointment we will work out which of the three is driving your symptoms, treat it hands-on the same day, and give you a clear, realistic plan.
This article is general information, not medical advice. Individual circumstances vary, so if you are dealing with pain or an injury, get it assessed properly.
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