21/09/2025
Understand Sciatica
📘 A Clinician's Guide to Sciatica: Assessment and Evidence-Based Management
▪️ Sciatica overview
🔹 Also known as lumbar radiculopathy or lumbosacral radicular syndrome
🔹 Annual incidence: 1%-5%
🔹 Accounts for 5%-10% of low back pain cases
🔹 Most prevalent in individuals aged 30-50
🔹 Prognosis generally favorable, but thorough assessment is crucial
🧠 Understanding the Etiology
▪️ Sciatica is a symptom, not a diagnosis
🔹 Characterized by pain radiating along the sciatic nerve’s path
🔹 Most often caused by compression of lumbosacral nerve roots (L4-L5 or L5-S1)
🔹 Most common cause: lumbar disk herniation
🔹 Must consider spinal and non-spinal etiologies
▪️ Spinal Causes
🔹 Herniated disk
🔹 Degenerative spine disease
🔹 Spondylolisthesis
🔹 Synovial cysts
🔹 Rare: tumors or fractures
▪️ Non-Spinal Causes
🔹 Piriformis syndrome
🔹 Pelvic conditions (e.g., endometriosis)
🔹 Pregnancy-related changes
🔹 Gluteal injection trauma
🔹 Hip fractures or dislocations
🩺 The Physiotherapy Assessment
1️⃣ Subjective Examination (History Taking)
▪️ Pain Characteristics
🔹 Unilateral radiating leg pain, worse than low back pain
🔹 Sharp or aching, dermatomal pattern in posterior leg
▪️ Aggravating Factors
🔹 Pain worsens with movement, lumbar spine flexion
🔹 Coughing, sneezing, or straining → suggests disk rupture
▪️ Neurological Symptoms
🔹 Paresthesia (numbness or tingling)
🔹 Subjective weakness
🔹 “Foot slapping” when walking → footdrop (L5 involvement)
▪️ Screening for Red Flags
🔹 Essential part of assessment
🔹 Urgent referral if serious pathology suspected
⚠️ Cauda Equina Syndrome
Bowel/bladder dysfunction
Saddle anesthesia
Progressive or severe bilateral leg weakness
Reduced a**l sphincter tone
⚠️ Fracture/Malignancy
History of trauma
Age >50
Unexplained weight loss
History of cancer
Fever or IV drug use
2️⃣ Objective Examination (Physical Assessment)
▪️ Neurological Examination
🔹 L4 involvement: Pain anterior thigh/medial leg; weakness knee extension & hip flexion; patellar reflex abnormality
🔹 L5 involvement: Pain posterolateral thigh/lateral leg; weakness foot dorsiflexion & hip abduction; footdrop; Trendelenburg gait
🔹 S1 involvement: Pain posterior thigh/leg & lateral foot; weakness plantar flexion; inability to walk on toes; Achilles reflex abnormality
▪️ Provocative Testing
🔹 Straight Leg Raise (SLR) / Lasègue Test: Pain between 30–70° → L5 or S1 compression; high sensitivity, low specificity
🔹 Crossed Straight Leg Raise / Fajersztajn’s Test: Raising unaffected leg reproduces pain; low sensitivity, high specificity for disk herniation
🔹 Slump Test: Seated with cervical flexion, knee extension, ankle dorsiflexion
🔹 Femoral Stretch Test: Prone knee flexion → anterior thigh pain; L2-L4 root compression
🛠️ Evidence-Based Management Strategies
▪️ Prognosis
🔹 About 75% resolve without specific treatment
▪️ Patient Education & Staying Active
🔹 Reassure good outcome possible
🔹 Encourage return to normal activities as tolerated
🔹 Bed rest not recommended
🔹 Advise light exercise (walking, swimming)
▪️ Exercise Therapy
🔹 Stabilization exercises (transversus abdominis, multifidus)
🔹 Directional preference exercises
🔹 Mobilization
🔹 Early referral to physiotherapy (within 3 days) improves outcomes
▪️ Manual Therapy
🔹 Spinal manipulation may help short-term pain relief
🔹 Chiropractic spinal manipulation reduces acute back & leg pain up to 180 days
🔹 When combined with home exercise: improved pain & disability at 12 weeks (not sustained at 52 weeks)
📌 When to Refer
▪️ Urgent Referral
🔹 Any red flag symptoms → emergency or spine specialist
▪️ Non-Urgent Referral
🔹 No improvement after 4-6 weeks conservative therapy
🔹 Severe, unresponsive pain/disability after 12 weeks
🔹 Surgery considered after ≥6 weeks failed conservative care (except urgent cases)
