How now, which of your hips has the most profound sciatica?
Measure for Measure
Question: I drive a fair amount as I commute to work and live in a rural area. After just a few miles, I get serious pain from under my wallet that goes down my thigh into my leg. It is more than just aggravating. Sometimes I have to pull over and walk it off. What is causing this? Is there a treatment?
To answer the last question first, there is very likely a conservative non-surgical treatment for this condition that is easy and inexpensive. The treatment, as always, depends on the cause.
Now let's discuss the first part of the question. We need to do a physical exam with neurological and orthopedic testing to really see the source of your pain. Sometimes x-ray or other imaging is necessary. Together, the history, exam, and imaging gives us a fairly complete picture with a high degree of accuracy.
The sciatic nerve is composed of several nerve roots that arise from the lower part of the spine. It is about the size of your thumb, and it is the longest and widest nerve in the body. This nerve exits the pelvis next to a notch carved into the pelvic bones, appropriately called the sciatic notch, before going through or under a muscle called the piriformis. Pain from this nerve is called "sciatica," or "sciatic pain," a term dating back to 1586, when it appeared in a Shakespearean play.
The piriformis muscle connects from the sacrum, that triangular bond on which you are likely sitting, to the top of the femur. When you contract it, the femur, or thigh bone, is turned outward. You need this muscle to walk as well as to drive. When it goes into a spasm, it causes deep burning pain under your wallet. Since the sciatic nerve goes under or through this muscle, when the piriformis is in a spasm, you might have sciatic pain without anything going wrong from the spine itself. We would look here first to see if your problem is coming from this area.
By the way, look at the thickness of your wallet. Many of us clean out those receipts, coupons, ticket stubs, etc., every five years, so the wallet gets fat. If you are driving with that in your pocket, it is pressurizing this nerve as you sit. That alone can give you sciatic pain. Consider a thin wallet as a replacement. Ask me to see mine. It holds all my stuff, but stays flat.
Sometimes the source of the sciatic pain is in the spine. A good history and physical exam can pinpoint the cause in the majority of cases. You might be feeling the result of a simple misalignment in the pelvis or vertebrae of the lower part of the spine, or both. In that case, an adjustment of the spine might do the trick.
In other cases, there is a spinal disc that has a bulge in it that hits an adjacent nerve. When that happens, you may feel pain, numbness, and tingling wherever that nerve goes. That's why you might feel pain in the leg when the problem is in the spine. In some cases, muscles served by that nerve may become weak compared to the other side. That is a more serious problem and warrants more timely attention.
When a disc is involved, we can reduce the bulge either with a decompression table or a decompression manipulation technique. Using the table, we can decompress multiple discs at once with a gentle, comfortable stretch. The manipulation technique is used to treat specific discs in the spine. With both of these, you will feel a gentle stretching motion, sometimes with electrotherapy, ultrasound, or laser therapy to increase your comfort. The goal here is to literally pull the bulge back into the proper position so that it is away form the nerve.
Not everyone responds positively to conservative care, although most do. If you do not respond to treatment with at least 50% improvement (subjective and objective) in the first one to four weeks of care, we typically get more aggressive. Further imaging, change of technique, referral, or co-management may be considered, depending on your case specifics.
There is a subset of sciatica sufferers with more ominous causes of sciatic pain that require discussion. I have seen fractures, spinal tumors, pelvic tumors, and even pregnancies that cause sciatic pain. Obviously, some of these require referral to appropriate providers. Many times I find myself in the role of case manager here when some patients lack insurance or relationships with medical/surgical providers, so we need to help them navigate a system that may not be user-friendly.
Sciatica, then, can have a cause that is simple or complex. If it persists, move your wallet and see if that fixes the problem. If it does not, see someone who specializes in musculoskeletal diagnosis (a chiropractor) and get it checked out. Don't ignore it, because you might be one of those for whom the cause is more serious. Either way, it is still a pain in the...well, seat. Ask Shakespeare.