SCIATICA

ANATOMY
Sciatic nerve is the longest and thickest nerve in the body. It is
the largest branch of lumbosacral plexus.
 NERVES ROOT: L4-S3
 COURSE: It exists the pelvis through the sciatic notch (the
greater sciatic foramen) along with the superficial gluteal nerve,
inferior gluteal nerve and posterior cutaneous nerve of thigh and
enters the gluteal region. It emerges inferiorly to piriformis
muscle and descends downwards in inferolateral direction. As the
nerve passes through the gluteal region, it crosses the posterior
surface of superior gemellus, obturator internus, inferior
gemellus. Then it enters the posterior aspect of thigh by passing
deep to the long head of biceps femoris. In posterior thigh, the
nerve gives branches to hamstring and adductor magnus muscles.
On reaching the apex of popliteal fossa it terminates by
bifurcating into two branches- Tibial nerve and common peroneal
nerve.
 SENSORY SUPPLY: No direct sensory innervation.
Indirectly supplies the skin of the lateral aspect of leg, heel and
both plantar and dorsal surfaces of foot via its terminal branches.
 MOTOR SUPPLY: It supplies the muscles of posterior
thigh and hamstring portion of adductor magnus. Indirectly
supplies the muscles of leg and foot via the terminal branches.

DEFINITION OF SCIATICA
Sciatica is a set of symptoms in which the patient experiences pain and/or paresthesia in the distribution of the
sciatic nerve or an associated lumbosacral nerve root.

ETIOLOGY OF SCIATICA
It is caused by the irritation or compression of sciatic nerve.
 INFLAMMATORY CAUSES
 Sciatic neuritis
 Arachnoiditis
 COMPRESSIVE CAUSES
 Compression in the vertebral canal by disc, tumour, tuberculosis
 Compression in the intervertebral foramen due to root canal stenosis because of OA, spondylolisthesis,
facet arthropathy or tumours
 Compression in the buttock or pelvis by abscess, tumour, haematoma
 Entrapment in front of the sacroiliac joint, under the piriformis, over the quadrates femoris, under the
gluteus maximus or between the hamstring muscles.
 Malposition of body
 Sitting over the edge of hard surface (E.g. Bed Frame)
 During pregnancy as a result of the weight of the fetus pressing on the sciatic nerve during sitting.

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PATHOGENESIS
Gradual compression of nerve over a prolonged period leads to ischemia of nerve characterized by a variety of
symptoms that depends on the nerve injured, site of compression and the duration of injury. Progressive
compression leads to the demyelination of nerve that may compromise the function of normal nerve and may
result in distal axonal degeneration if left untreated.
CLINICAL FEATURE
 Lower back pain usually affects one side of the body
 Pain in the back of the leg-radiating type usually originates in the low back or buttock and continues along
the course of sciatic nerve
 Pain is relieved when patient lie down or walking and becomes worst in standing or sitting
 Burning, tingling, numbness along the back of the thigh and leg
 Shooting pain
 Cramps on prolonged standing- neural claudication
 Sensory dysfunction, paresthesia over the leg and foot below knee
 Weakness of hamstring, all the muscles below knee
 Ankle jerk is lost or diminished
 Gait dysfunction

PT ASSESSMENT
 DEMOGRAPHIC DATA
 NAME
 AGE: Older adults above 55 to 60 years are mostly affected. It can strike even during childhood.
 GENDER: It affects men and women equally.
 OCCUPATION: It has been shown in machine operators, truck drivers, and jobs where workers are subject
to physically awkward position.
 CHIEF COMPLAIN:
Patients complain about low back pain, which is usually less severe than the leg pain. Patients may also
report sensory symptoms.
 HISTORY TAKING
 HISTORY OF PRESENT ILLNESS
The presenting symptoms may involve the low back or buttock and continues along the course of
sciatic nerve. The is vary depending on the causative factor. With the compressive factor, the onset will be acute.
Inflammatory factors have a subacute course extending over days to weeks.
 HISTORY OF PAIN:
Pain often has a deep, burning, or drawing character that may be associated with jabbing or shooting
pains. Pain in the back of the leg-radiating type usually originates in the low back or buttock and continues along
the course of sciatic nerve. Pain is relieved when patient lie down or walking and becomes worst in standing or
sitting.
 HISTORY OF PAST ILLNESS:

Take a note on any trauma, or spinal injury that may compress the nerve. Take a note on diabetes.
 PERSONAL HISTORY
Addiction of smoking/ alcohol is noted.
 OCCUPATIONAL HISTORY:
It has been shown in machine operators, truck drivers, and jobs where workers are subject to
physically awkward position.

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  OBSERVATION
 Check for the attitude of the lower limb.
 Observe for wasting of the muscles
 Observe for any skin changes. It indicates either prolonged inactivity or involvement of fiber in the
peripheral nerve regulating autonomic function
 Check whether any swelling in he involved area or any gross swelling which may be relevant.
 Observe for any scars or unhealed wounds or skin infections in the limb.
 PALPATION
 Check for the temperature (Local) over the area of affection and compare with the normal
 Palpate the edema, if present
 Check for the tenderness over the area of affection.
 EXAMINATION
 SENSORY EXAMINATION
All sensory modalities should be tested. Including pinprick, light, touch, proprioception, Vibration,
Graphesthesia and temperature. If Sensory deficits are detected, the extent and pattern of the loss should be
determined.
 MOTOR EXAMINATION
Muscle strength should be graded by MMT of hamstring, all the muscles below knee. To examine the
tone, quick passive movement is done. The muscles become hypertonic.
 REFLEX TESTING
The ankle jerk is lost or diminished.
 GAIT EXAMINATION
Ask the patient to walk a few steps to see if nerve damage has affected gait pattern. Ataxias, high
stepping gaits, etc may be seen.
 SPECIAL TEST
 Slump Test
 SLR Test
 INVESTIGATION
 NCV STUDIES:
NCV test is used to measure the speed of conduction of an electrical impulse through nerve that may
be slowed down
 EMG STUDIES
It is useful to determine the extent and severity of nerve lesion.
 X-RAY
X-ray of the lumbosacral spine may evaluate for fracture or spondylolisthesis.

PT MANAGEMENT
 ACUTE PHASE: [ BETWEEN ONE AND TWO WEEKS]

GOAL INTERVENTION
 TENS- High TENS can be given to relieve radiating pains.
 Ultrasound- Pulsed Ultrasound below 1W/cm 2 can be used. It can penetrate to loosen
RELIEF PAIN adhesions deeply set like at the hip joint.
 LASER Therapy- Low laser therapy; spectrum at 635nm increase the circulation locally to
reduce muscle spasm.

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 Edema occurs due to gravity dependent position of limb coupled with lack of muscular tone.
PREVENTION OF EDEMA  Extremity elevation along with effleurage massage is given to dispel the edema
 Crepe bandage and elevation is also given to prevent edema
 Galvanic current given as they are of longer pulse duration. Artificially contracting
MAINTAIN THE PROPERTIES muscles will ensure a proper blood supply as well as help in maintenance of excitation,
OF THE MUSCLE contraction and coupling.
PREVENT ANY ABNORMAL  Splinting or bracing may be necessary to prevent deformities due to strength imbalances
ATTITUDE OF THE AFFECTED E.g. use of a plantarflexion splint to prevent foot drop. AFO may be given for comfortable
PART ambulation.

 C HRONIC STAGE:
GOAL INTERVENTION
 Sensory reeducation- It include touching different textured objects, massage, vibration,
pressure, determining joint position, identifying different temperature and electrical
stimulation. It helps to therapist to retrain sensory pathways or stimulate unused pathways.
Desensitization- As nerves regenerate, the person experiences increased sensitivity
SENSORY RETRAINING (hypersensitivity) in the area that had previously been without sensation. Use a graded series of
modalities and procedures that produce the least painful response to the stimuli that produce
the most painful response. Once the affected area begins to acclimate to initial stimulus, the
next stimulus is incorporated. Desensitization program may progress from a very soft material
stimulus (i.e. silk) to a rougher material (i.e. wool) or textured fabric (i.e. Velcro).
 It typically begins with the use of the tilt table because it helps prevent deterioration in
orthostatic tolerance. This can also be started in bed by having the patient sit upright for
extended periods, as tolerated. There is a cardiovascular and autonomic adaptation as the
GAIT & BALANCE patient is gradually elevated to the upright position.
RETRAINING  Patients are next allowed to stand in a standing table, which improves their muscular
endurance and permits them to work on other tasks. Then the patient is advanced to the
parallel bars, with the close assistance of the therapist.
 Next the patient can be advanced to ambulation with assistive devices then ambulation
without assistive devices.
FUNCTIONAL Lower limbs activities like level walking, staircase climbing etc. needs to be given.
RETRAINING
 HERNIATED DISC M ANAGEMENT - Extension exercises or press ups are prescribed
 SPINAL STENOSIS MANAGEMENT - Flexion exercises of the lower back are suggested. Flexing the
lower spine opens the spinal canal and allows the irritation to resolve. Stretching exercises for
the back are done. For strengthening the abdominal muscles hook lying march and curl ups an
MANAGEMENT OF be practiced.
UNDERLYING CAUSE  D EGENERATIVE DISC DISEASE MANAGEMENT : A dynamic lumbar stabilization program is

recommended. Through this program the patient finds the most comfortable position for the
lumbar spine and pelvis and attempts to maintain this position during activities. When
performed correctly,this exercise can improve the proprioception of the lumbar spine and
reduce the excess motion at the spinal segments. This reduces the amount of irritation at these
segments relieving pain and protecting the area from further damage.
 P IRIFORMIS SYNDROME MANAGEMENT - Stretching the muscle, hamstring muscles and hip

extensor muscles may decrease pain and improve the ROM. Muscle energy technique can also
be used in this case.

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