Sciatica — not all back and leg pain is sciatica

Written by Dr Steven Hewitt — Chiropractor · AHPRA: CHI0001115420 · Last reviewed: October 2026

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What Is Sciatica?

Clinically, sciatica means pain caused by an irritated nerve root in the lower back [1]. The pain follows the path of the nerve down the leg, usually below the knee, and may come with numbness, pins and needles or weakness. The most common cause is a disc herniation; narrowing of the space around the nerve is another.

The word itself is a poor guide. An international working group of pain specialists concluded in 2023 that it is inaccurate, because the sciatic nerve itself is usually not where the problem lies, and that it is used inconsistently, with no agreed definition [2]. In everyday use it gets applied to almost any pain in the buttock or leg that comes with back pain, and not all of that is sciatica. In a UK study of 609 people seeing their GP with back-related leg pain, about three in four were diagnosed with sciatica; for the other one in four, the leg pain was referred from the back with no nerve root involved [3]. The causes most often mistaken for sciatica:

• Referred pain. Pain from the joints, ligaments, muscles or fascia of the lower back and pelvis is felt in the buttock and thigh without any nerve being irritated. It is usually a deeper, vaguer ache, and it tends to stop above the knee.
• A nerve irritated below the spine. The sciatic nerve itself can be irritated in the buttock, among the hip rotators, well away from the spine [4].
• Small nerves trapped in fascia. Sensory nerves crossing the back of the pelvic rim can be trapped where they pass through fascia, producing buttock and thigh pain sometimes called “pseudo-sciatica” [5], [6].
• The hip or sacroiliac joint. Either can be the main source of pain in people who were sure it was their back [7].

The first job of an assessment is therefore to work out which of these it is. Screening for the rare but urgent causes comes first, and the features to know are in the frequently asked questions below.

Telling them apart

In a study of nearly 400 people seeing their family doctor with back-related leg pain, four features best identified nerve root sciatica: pain below the knee, leg pain worse than back pain, a positive nerve tension test, and a change on neurological testing [8]. None of them needs a scan.

These are first clues, not a diagnosis. More than one is often present at once.

Who Typically Experiences This?

The person whose leg went after a bend and a lift

Back pain after lifting, twisting or a long day in the garden, and then, a day or two later, pain spreading into the buttock and down the leg. Often the leg becomes worse than the back. This is the classic presentation of a disc irritating a nerve root, and in our clinical experience the most frightening part for most people is not knowing what is happening or whether it will settle.

The desk worker whose leg aches after sitting

Buttock and thigh pain that builds through a seated day and eases on standing or walking. Sitting compresses the buttock directly and holds the hip and lower back in one position for hours. This presentation needs separating carefully, because a disc, the deep gluteal space and the hamstring tendon can all be provoked by sitting, and each is approached differently.

The older walker whose legs give out partway round the block

Heaviness, aching or tingling in one or both legs that comes on with walking or standing and eases with a sit-down, or by leaning on a shopping trolley. That relationship with posture is characteristic of narrowing of the spinal canal [9], [10]. It is common in people over 60, it is not the same problem as a disc herniation, and the self-help that suits one can aggravate the other.

The person told their scan explains it

A scan report listing a disc bulge, a protrusion or “degenerative changes”, and a leg pain that has been attributed to it. Sometimes that is right. Disc findings are also very common in people with no pain at all [11], and the question an assessment answers is whether the finding on the scan matches the pain in the leg.

The runner, cyclist or lifter with “sciatica” that won’t settle

Buttock pain into the back of the thigh in someone active, often treated for months as a back problem. In athletes the deep gluteal space and the hamstring origin are worth examining before the spine takes the blame.

The Fascial Lens: Why We See This Differently

Nerves live in fascia

A nerve is not a wire running freely through empty space. Along its whole course it is wrapped in connective tissue, and it passes through the deep fascia, between muscles and along fascial septa on its way down the leg. A review from the Stecco group describes how changes in that surrounding tissue can reduce the nerve’s ability to move independently of its neighbours, producing entrapment or an “internal stretch” injury, and notes that these presentations are easily confused with more common diagnoses [12].

Two of the most commonly missed causes of sciatica-like pain are exactly this kind of problem. The sciatic nerve can be irritated in the deep gluteal space, among the hip rotators, well below the spine [4]. And the cluneal nerves, which supply the skin over the buttock, pass through fascia at the back of the pelvic rim, where they can be trapped and refer pain into the buttock and thigh [5], [6]. Neither involves a disc. Both are routinely labelled sciatica.

Where you feel it and where it starts

Fascial Manipulation draws a clear line between the centre of perception — where you feel the pain — and the points of densification that may be changing how load is shared, which often sit in a neighbouring segment. For leg pain, those neighbours are the lower back, the pelvis, the hip and the thigh. A densified region in any of them can alter how the tissues around a nerve, or the joints of the back and pelvis, are loaded.

The back of the leg also sits on one of the body’s main longitudinal lines of fascial continuity: from the hamstrings, through the ligament joining the sitting bone to the sacrum, into the thoracolumbar fascia of the lower back [13], [14]. That is the deep longitudinal sling, and it is one reason we assess the back, pelvis and thigh together when the complaint is leg pain.

Being straight about the evidence

The anatomy above is well documented. What is not established is how often fascial change is the main driver of sciatica, and we are not aware of a controlled trial of Fascial Manipulation for sciatica specifically. The closest study compared two Fascial Manipulation sessions with two weeks of passive physiotherapy in 69 people with disc herniation confirmed on MRI and reported greater improvement in pain, movement and straight-leg-raise range; but its authors describe it as a single-centre series of observations, the method of allocation is only briefly described, and follow-up ended at two weeks [15]. We present the fascial lens as a reasoned part of a full assessment, not as a proven treatment for sciatica.

What Does the Research Say?

Four clinical features identify nerve root sciatica, without a scan

In 394 people consulting their family doctor with back-related leg pain, seven examination findings were tested against a clinician’s confident diagnosis. Four were retained whether or not MRI confirmation was required: pain below the knee, leg pain worse than back pain, a positive nerve tension test, and a neurological deficit [8]. The practical point is that a careful history and examination go a long way toward telling nerve root pain from referred pain.

Disc findings on scans are common without pain, and herniations often shrink

In people with no back pain at all, disc bulges are reported in about 30% of 20-year-olds and 60% of 50-year-olds, and disc protrusions in 29% of 20-year-olds rising to 43% of 80-year-olds [11]. Some findings are more common in people with pain than without it [16], and the type of finding matters [17], which is why a scan is interpreted against the examination rather than on its own. A scan also struggles to tell the two kinds of leg pain apart: in the same UK study, MRI showed possible nerve root compression in about six in ten people diagnosed with sciatica, and in about a third of those whose leg pain was referred [3]. When a disc herniation does cause leg pain, it frequently regresses: pooled cohort studies of people managed without surgery found spontaneous resorption in about two-thirds [18], with larger, extruded herniations the most likely to shrink [19].

Most people improve, and what you believe about it matters

In the UK study of 609 people seeing their GP with back-related leg pain, 55% had improved by 12 months, measured as at least a 30% fall in disability, and the figure was the same whether the leg pain was sciatica or referred. The strongest predictor of a poorer outlook was the person’s own belief that the problem would last a long time; a longer history of leg pain also predicted it. Whether the MRI showed a compressed nerve root did not [3]. We would rather say this plainly than promise a quick fix: recovery from sciatica is often measured in months, and how the problem is explained to you is part of the treatment.

Narrowing of the spinal canal behaves differently

Leg symptoms brought on by walking or standing and relieved by sitting or bending forward are among the most useful features pointing to lumbar spinal stenosis [9], and international criteria for it are built around that relationship with posture [10]. Without surgery, around a third of people improve over time, about half stay the same, and a minority worsen [20]. It is a common reason for leg pain in people over 60, and it needs a different plan from a disc.

Manual therapy and exercise

In a trial of 192 adults with back-related leg pain lasting at least four weeks, adding spinal manipulation to a home exercise and advice program reduced leg pain more than the program alone at 12 weeks. By 52 weeks the difference in leg pain was no longer significant, although global improvement, satisfaction and medication use remained better in the manipulation group. Neither the patients nor the practitioners could be blinded, which is a limit of any trial of a hands-on treatment [21].

A review of five trials found that structured exercise gave a small short-term advantage over advice to stay active for leg pain, and no difference in the longer term [22].

Current clinical guidance reflects that: stay active and avoid bed rest, use exercise, and offer manual therapy alongside exercise rather than on its own [1]. The effects of any single approach are modest, which is why the plan matters more than any one technique.

Surgery speeds relief for some, but a year on the outcomes are similar

A Dutch trial compared early surgery with continued conservative care, with surgery later if needed, in 283 people who had had severe sciatica from a confirmed disc herniation for six to twelve weeks. Early surgery relieved leg pain faster, but disability over the first year did not differ significantly between the groups, and by one year the outcomes were similar. About four in ten of the conservative group did go on to have surgery, after an average of around 18 weeks [23]. Surgery is a reasonable option when leg pain is severe and not settling; the decision usually turns on how much faster relief matters to you, weighed against the risks of an operation. That is a conversation to have with a surgeon, and we will refer you when it is time to have it.

Is spinal manipulation safe with a disc herniation?

In two matched groups of more than 34,000 people each with lumbar disc herniation, stenosis or nerve root pain, cauda equina syndrome was no more common after spinal manipulation than after physiotherapist-led exercise [24]. A separate cohort of 148 people with MRI-confirmed disc herniation treated with spinal manipulation reported no adverse events over a year, though without a comparison group it cannot tell us how much of their improvement was due to treatment [25]. Manipulation is one option among several, used only where the assessment supports it, and never when the warning signs below are present.

How We Approach Sciatica

Screening first. Every assessment starts by checking for the features that need urgent medical care rather than treatment — changes in bladder or bowel control, numbness in the saddle area, worsening weakness — and for the wider medical causes of leg pain. If anything points away from a musculoskeletal cause, we will tell you and refer you before any treatment.

Working out which “sciatica” it is. A history of how the pain behaves with sitting, standing, walking and bending, and a neurological examination of strength, sensation and reflexes, with nerve tension tests. This is how nerve root pain is told apart from referred pain, from the deep gluteal space and from the cluneal nerves.

The back, pelvis and hip together. Lumbar movement and the joints of the back, the sacroiliac joint and the hip, because each can produce pain felt in the leg.

The fascial assessment. A Fascial Manipulation assessment across the lumbar, pelvic, hip and thigh segments, looking for densifications that may be changing how load is shared. These may sit some distance from where you feel the pain.

Treatment. Typically Fascial Manipulation directed at the regions the assessment identifies, spinal manipulation where appropriate, and a graded plan to keep you moving and progressively loading — matched to the cause, because what eases a disc can aggravate stenosis and the reverse. Where imaging, a GP review or a specialist opinion is needed, we arrange it.

New to Fascial Manipulation? Read how it works →

Please note: The information on this page describes our general clinical approach and is intended for educational purposes only. Individual presentations vary, and your assessment and management will be tailored specifically to you. Nothing on this page constitutes clinical advice for your individual situation. Leg pain with changes in bladder or bowel control, numbness between the legs, or worsening weakness needs urgent medical assessment, not a booking. Please consult a registered health practitioner for advice about your specific condition.

What Can You Do Right Now?

1. Notice what moves the leg pain, not just what eases it. Does it change with sitting, standing, walking or bending forward? Does a movement send it further down the leg, or draw it back up toward the back? That pattern is the single most useful thing to bring to an assessment.

2. Keep moving within what the leg tolerates. Current guidance is to stay active and avoid bed rest [1]. Many people find short walks, frequent changes of position and getting up from the desk more often easier than long periods of rest. A mild increase that settles soon after you stop is common; pain that builds, spreads further down the leg or lingers is worth easing back from and mentioning at your assessment.

3. Make sitting shorter rather than perfect. If sitting provokes it, the number of minutes between breaks matters more than the chair. If a firm seat presses on a tender sitting bone, a cushion that takes the pressure off that point can help.

4. Find a sleeping position that unloads the leg. Many people find lying on the painless side with a pillow between the knees, or on the back with pillows under the knees, more comfortable. If one position is clearly worse, that is useful information too.

5. Know the warning signs. Read the urgent-care question below once, so you would recognise them.

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Frequently Asked Questions