Sciatic Nerve Entrapment A real pain in the butt
The sciatic nerve is the largest peripheral nerve in the body. Many folks will be acutely aware of its presence due to chronic symptoms that may be felt throughout the lower half of the body, typically from the hip region and down the back of the leg. These symptoms are commonly referred to as ‘Sciatica’.
The term Sciatica is a label and only describes a set of symptoms. Typically there could be pain, tightness, tingling, numbness or even burning that reaches as far as the toes. But the term sciatica is very vague. A diagnosis of sciatica lacks clinical detail and only tells us that there are symptoms, likely to be in either one or both legs.
Sciatica as a label tells us nothing about what is causing the symptoms and if there is actually any involvement of the sciatic nerve at all. So before we even consider how to treat sciatica, we must have a robust diagnosis and understand what is causing the symptoms.
Not all sciatica is ‘true sciatica’
True sciatica is when there is irritation of a spinal nerve root in the lower back, usually from an acute disc injury or advanced degeneration. When a nerve root in the lumbar spine becomes irritated or compressed, it can produce painful symptoms that may progress to numbness and weakness in more severe cases.
The problem with assuming that all sciatica is ‘true sciatica’, is that there are also other tissues and pathologies that can produce similar symptoms. True sciatica is when the spine is responsible for the symptoms, but it is also possible to experience similar symptoms that are not directly caused by the spine.
The sciatic nerve can still become irritated and produce painful, frustrating symptoms which are NOT due to a big disc injury or degeneration.
👉 A less-commonly diagnosed cause of sciatic symptoms is fibrous entrapment and irritation of the sciatic nerve as it passes through soft tissues at the back of the hip and thigh.
This peripheral nerve irritation is called Sciatic Nerve Entrapment and may occur with or without spinal pathology.
What is Sciatic Nerve Entrapment?
Sciatic Nerve Entrapment (SNE) is when the sciatic nerve becomes adhered to surrounding tissues, typically at the deep glute muscles in the back of the hip, causing a loss of the normal slide and glide that is required for healthy nerve function. The entrapment is caused by chronically-developed fibrotic adhesions that form around the nerve and tether it to the surrounding muscles.
When the nerve is entrapped and unable to move normally, it can produce sciatic-like symptoms.
A challenge for patients is that this condition is unlikely to be reported in diagnostic imaging. It’s not uncommon for a patient to present an MRI report which has been tagged as clear of any pathology, and lacking any explanation for their symptoms. Yet, they still experience ongoing lower back, hip and/or leg symptoms.
Typical symptoms of SNE
Many of the common SNE symptoms overlap with those caused by a disc injury or spinal degeneration, highlighting the value of a thorough diagnostic process.
⚠️Lower back pain
⚠️Buttock pain
⚠️Leg pain
⚠️Chronic tension/tightness; AKA tight hamstrings
⚠️Lower leg pain
⚠️Tingling
⚠️Pins & Needles
This is not a ‘new’ condition
Entrapment of the sciatic nerve is not a new clinical entity and has been described in published literature for many years. Neurosurgeons have also demonstrated its relevance by performing surgical decompression to reduce the fibrotic adhesions in cases of chronic sciatica and back pain where there was otherwise no explanation for the symptoms.
This condition is typically described in peer-reviewed publications as “Deep Gluteal Syndrome”.
This is a healthy sciatic nerve
This is an entrapped sciatic nerve, covered in adhesion
There is published research and video content online, describing the surgical procedures used to decompress the sciatic nerve when it is entrapped by fibrous adhesion ⬇️
Is this the same as Piriformis Syndrome?
No, it’s a similar set of symptoms, but the underlying pathology is different.
Piriformis Syndrome is classically described as when the sciatic nerve is compressed and irritated by a tight or over-used Piriformis muscle. This diagnosis can lead to interventions such as deep tissue massage, muscle compression with elbows, thumbs & instruments, dry needling and aggressive stretching routines.
The Piriformis muscle is located in the same region as the typical entrapment site in cases of SNE, however it’s not often that Piriformis is primarily responsible. Piriformis is often labelled the culprit in many cases of buttock and leg symptoms, however the real problem may be a nearby sciatic nerve entrapment.
It is possible to be born with a variation to Piriformis, where the sciatic nerve passes through the muscle, rather than going underneath it. However, this congenital variation is considered to be rare.
Common treatments for sciatica symptoms
Spinal Manipulation/Decompression
Corticosteroid injections
Muscle relaxants
Heat/Ice
Anti-inflammatories
Kinesio tape
Stretching
Foam rolling
Massage
Exercises
These interventions may provide some relief of symptoms, however none are likely to be effective at releasing an entrapped nerve. It is not uncommon for patients to describe chronic symptoms that have persisted for several years, despite trying many different treatment modalities.
SNE is a physical pathology where the sciatic nerve is adhered by fibrous bands, therefore requiring a physical solution that actually reduces the fibrotic adhesions and releases the nerve.
Peripheral nerves in the body are very sensitive and prefer to be left alone. When an adhesion develops over time and causes the nerve to lose it’s normal glide and slide motion, it responds with inflammation and symptoms. Therefore the adhesion should be reduced to restore health to the nerve.
What can we do about it?
If you are experiencing sciatica, or sciatic-like symptoms, it is critical to obtain a diagnosis that is specific to the tissues that are involved in the problem. A clinical diagnosis is reached by understanding the full detailed history of the problem and then conducting a comprehensive clinical examination to include or exclude the likely pathologies. In some cases, further investigation may be required, such as diagnostic imaging (MRI).
In our office, if we suspect that Sciatic Nerve Entrapment may be a feature of a new patient presentation, we will investigate it further through clinical examination and if present, we use conservative techniques to treat the fibrotic adhesions.
We utilise Manual Adhesion Release and Shockwave therapy techniques to non-surgically treat Sciatic Nerve Entrapment.
This approach is supported by current research, where a 2020 study demonstrated that non-surgical reduction of SNE at the deep gluteal space provided 67% sustained pain relief when compared to other treatments, in patients that had experienced pain for an average of two years.
How common is Sciatic Nerve Entrapment?
The clinical experience of our office suggests that SNE is a reasonably common pathology and can be a cause of sciatic-like symptoms, with or without the presence of a disc injury.
The most common symptoms that we see include hip and buttock pain, chronic tension/tightness throughout the hip and thigh, intermittent tingling/pins & needles throughout the leg. SNE is often also present in cases of chronic lower back pain that has so far been unresponsive to various treatment modalities.
This does therefore highlight the importance of a thorough diagnosis, as this condition should at least be excluded as a contributing factor in presentations with sciatic-like symptoms.
Final thoughts
“Sciatica” should not be used in the context of a robust clinical diagnosis. It is a label that describes a symptom set and is a starting point for further investigation and appropriate management.
While this article has highlighted the importance of considering Sciatic Nerve Entrapment in cases with sciatic-like symptoms, it is critical to note that this entity is not the only cause of symptoms and may be just one of several contributing factors, or may not be present at all.
As a patient, you should expect a detailed history-taking process followed by a comprehensive physical examination, where the findings are explained to you in a way that makes sense. If you are experiencing sciatic-like symptoms then it is worth asking your provider if they have at least considered if Sciatic Nerve Entrapment may be involved.
Dr. Christopher Aysom, Principal Clinician
BChiroSc, MChiro (Chiropractor)
Apex Soft Tissue & Spine
Pymble, NSW, Australia
https://apexsofttissue.com.au
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Deep gluteal syndrome (2015)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4718497/
Deep gluteal syndrome as a cause of posterior hip pain and sciatic-like pain (2020)
https://pubmed.ncbi.nlm.nih.gov/32349600/
Deep gluteal syndrome: anatomy, imaging, and management of sciatic nerve entrapments in the subgluteal space (2015)
https://pubmed.ncbi.nlm.nih.gov/25739706/
The endoscopic treatment of sciatic nerve entrapment/deep gluteal syndrome
https://pubmed.ncbi.nlm.nih.gov/21071168/
Sciatic Nerve Entrapment due to Fibrous Adhesion in the Deep Gluteal Space: Proposed Clinical Diagnostic Criteria and Therapy Using Manual Adhesion Release®
https://clinmedjournals.org/articles/jmdt/journal-of-musculoskeletal-disorders-and-treatment-jmdt-6-088.php?jid=jmdt
