Sciatica is pain from the sciatic nerve that starts in the lower back and travels down the leg. Depending on the cause of the sciatic pain, we have treatments and exercises to help people suffering from it.

Is it true that the sciatic nerve is the largest nerve in the body? Where is it located?

Dr. Gregg Rubinstein: It absolutely is and when you think about it, if anyone has ever seen a model of the spine, we can see that in between the two bones that come together there are nerves that exit and there is basically 33 bones and the nerves are numbered one all the way down through. The last three to four nerves all branch out, join together, conjoin and then split again and form the sciatic nerve which is the biggest nerve in the body.

It typically starts from the lower lumbar segments, L3, 4, 5 and S1 and branches out and then it travels a path from the lower back slightly laterally or to the side, down through the buttocks and typically goes straight down the leg. A lot of people will experience sciatica in their lifetime. It is usually starting in the lower back and then it travels down the leg.

Sciatica is the term used to describe the pain from the sciatic nerve. Can you describe some of the symptoms of sciatica that people experience?

Dr. Gregg Rubinstein: Absolutely. The general rule of thumb, what you are going to see is pain that originates in the lower back and they will feel pain close to the spine or what we call proximal. Then as you travel away down the nerve path, usually what they will get is something called paresthesia which can be numbness or tingling all the way down. That can be experienced into the toe. What you will see is pain close to the origin of the nerve where it is getting pinched and then it can travel down the back of the leg and as you go farther away it is usually perceived as numbness or tingling farther down the nerve axon.

What are the most common causes of sciatica?

Dr. Gregg Rubinstein: Well, there are three basic causes of sciatica. One could be when the disks herniate, swell up or bulge they will actually move out into the area where the nerve lives and compress the nerve and put pressure on the nerve. That irritation is what causes the pain that travels down the sciatic nerve. Essentially it is the pinched nerve. That can happen from the disks or if there is enough misalignment in the spine, which we call subluxation where the bones actually move out of their alignment.  It can actually compress the nerve physically just from the bones being out of alignment and it does not necessarily have to be the disks swelling up and pressing on it.

Those are the easiest ones for chiropractors to handle because once we correct the alignment, get the pressure off the nerves, a lot of times those symptoms will abate. It is a little bit different when the disk is herniated because the disk occupies space and it can become swollen and inflamed. When we improve the alignment and get pressure off the disk, then the swelling of the disk goes down, sometimes you can even create a negative pressure in the disk by distracting or opening up the spine manually and allowing some of that disk material to create a vacuum and pull it back in away from the nerve where it is getting irritated. Chiropractors can be very effective in handling people with sciatica.

The other cause is something called a piriformis syndrome. Now a piriformis is a muscle that is internal external rotator of the hip. In probably, I forget the exact number, but I think it might be 20% of the people, the sciatic nerve actually pierces through that muscle. If that muscle should tighten up or spasm, it can choke off or irritate that sciatic nerve and create sciatica from what is called a piriformis syndrome. Those are the most common three situations that would lead to sciatic nerve irritation or what most people call sciatica.

Why does sciatic pain come and go?

Dr. Gregg Rubinstein: Well, that is a really good question. Typically in the patient who has a disk injury where the disks are getting inflamed and swollen there can be certain activities that you do, like jumping rope or running that causes a lot of compression and every step the spine compresses which can then irritate the disk and then the disk can swell up. When it is in an inflamed state it will occupy enough space and irritate the nerve.

Then when that disk is not as swollen and not as irritated it shrinks down just like anything that is inflamed once it is gone through its course of inflammation, it will shrink back to normal size and it will not irritate the nerve so much and they might not have pain. Sometimes the bones can be realigned or readjusted and we can get some of that pressure off the nerve and then eight months later they might go ice skating, take fall, land of their butt and end up having another episode.

Or they might sit for 12 hours on a trans-Atlantic flight and then all of a sudden have another episode of sciatica because anything that compresses the spine for long periods of time and one of the things that people forget is that when you sit, you put more direct pressure on your spine than you do when you’re standing. Sitting for long periods of time can aggravate the disk, create more inflammation and swelling and then cause another flare up of sciatica.

These things have a tendency to come and go or wax and wane depending on the cause and it varies from person to person how many episodes they will get, how severe they are. There are a lot of different factors that contribute to that. Just suffice it to say that the more inflamed and the more pressure there is on the spine, the more likely we are going to see sciatic type symptoms in the patient.

Is exercise better for relieving sciatic pain than rest?

Dr. Gregg Rubinstein: You can not say that one is necessarily better than the other, but specific exercises coupled with rest will be better. Some people can not move at all when they are in a full on episode of sciatica. Some people can bend forward with ease and some people can bend backwards with ease. It depends on what type of injury they have. If someone has a herniated disk and the disk is herniated posterior or backwards and they bend backwards, they are going to compress that disk even more. That is going to be worse.

That person would benefit from doing what we call flexion exercises or what is called Williams Flexion Exercises, which are designed to open up the back of the spine to create more room. There are other people who respond to something called a McKenzie Protocol which is more extension or back bends. That depends again, which way, if it is an anterior or lateral herniation then chances are they are going to respond better to an extension protocol. Really what you need to do is you need to examine the patient carefully and do your range of motion testing. If they do better in flexion, then you would probably start with a flexion protocol. If that tends to aggravate things, then you would try the extension protocol.

Different exercises will be better for different people depending on the cause. If someone is having a piriformis syndrome then obviously you will need to do massage work, realign the pelvis and stretch out the piriformis muscle to get it to relax more and then that is going to help that person. In that case, a person stretching would probably be better than just plain old rest. If the disk is swollen we need rest because that is going to allow our body to heal, it is going to allow the body to decrease the inflammation and then you need to figure out which specific exercises are going to be the best ones for that specific patient because unfortunately the exercises required to help someone with sciatica is not one size fits all. You need to do a little bit of examination and sometimes there is even a little bit of trial and error.

Sometimes you could think someone might benefit from the flexion protocol. You start them on that, they get worse and then you might have to switch them up to the extension protocol. Rest is very beneficial, exercise is very beneficial, but if you find someone is doing exercise and they are getting worse then you might want, just prescribe rest only until they heal up and get better from that. It varies from person to person. There is no clear concise answer. It is really best to work with a professional on that to get the best advice on that. I would not want people just doing at home exercises and diagnosing themselves without proper help on that. Sometimes it can go the other way.

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