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Pain in the Butt?? It Could be "Pseudo-Sciatica!"

A patient comes into my office complaining of pain starting in the low back radiating into the buttocks and down the back of her leg into the calf, and her toes are tingling. Sounds like a classic disc herniation patient where we’re going to decompress the disc with traction to relieve pressure from the nerve it’s compressing, right? Well the patient says that the first chiropractor at a decompression clinic she went to did that and it didn’t help…

Ok, ok I got it now! Piriformis syndrome causing sciatica! The sciatic nerve is being compressed underneath the piriformis muscle and it’s producing her symptoms. We need to relax the piriformis with some muscle work, stretching, and dry needling; problem solved! Turns out the PT she went to after the first failed chiropractic attempt did that same thing and it only temporarily helped her problem. Well, shoot, what else could it be?

Ahhh of course! How could I not realize it sooner? Lumbar spine subluxation! See, this x-ray she brought with her proves it. She has a mild spinal curve in the lumbar spine and that’s interfering with the ability of the nervous system to flow freely. Some good ole chiropractic manipulation of the low back and pelvis will fix it right up… Oooh the last chiropractor she saw did that too and it didn’t help either? Hmmm, what are we missing!?

What is “Pseudo-Sciatica?”

In general, sciatica refers to any symptom associated with the compression of the sciatic nerve, either from the spine or in the soft tissues. The prefix “Pseudo-“ means “false” but in the medical field also relates to conditions that “deceptively resemble” other conditions. “Pseudo-sciatica” is a complex multi-layered condition most times, but simply put, my most fitting definition is pain that “deceptively resembles sciatica.” These patients present with familiar disc-like referral pain or sciatica-like complaints: low back pain starting around the sacroiliac joint, a burning or deep aching pain in the buttocks, radiating into the back of the thigh, and sometimes into the calf and foot. Many times, these patients complain the pain is worse in the leg than in the back. They may feel like the leg is “weak” and they cannot lift their leg while walking.

What causes “Pseudo-Sciatica?”

Type the term “sciatica” into Google or PubMed and you’ll get thousands of reliable results from reputable sources describing all different types and kinds of sciatic nerve compression. But type in “pseudo-sciatica” or “false sciatica” and the results are limited or automatically redirect you back to conventional sciatica search results. As I said, “Pseudo-sciatica” (PS) is a complex multi-layered condition that can have multiple sources of nerve entrapment, joint restriction, and soft tissue problems overlapping to produce sciatica-like symptoms. One spot, in particular, I like to address with my PS patients is an entrapment of the medial branches of the superior cluneal nerve within an “osteofibrous tunnel.” This entrapment has been described by several research studies including 2017 study in the Journal of Pain Research titled Anatomical etiology of “pseudo-sciatica” from superior cluneal nerve entrapment: a laboratory investigation (Link provided below!) This branch has a connection to the same lumbar spinal nerve roots that the sciatic nerve does. It is theorized that irritation and entrapment of these superior cluneal nerve branches can cause some irritation of the connected lumbar nerve roots and produce the sciatic like referral pattern of pain. The pictures below show the connection between these different nerves!

Any time there is excessive and chronic tension on the low back region (slumped posture at a desk or while driving, poor spine stabilization while exercising/lifting objects, pregnancy, etc) adhesions or “Velcro” can form between the tissues. If a nerve like the medial branch of the superior cluneal is already in a tight narrow area like the “osteofibrous” tunnel, even small amounts of velcro and tension can narrow the tunnel further and compromise the nerve.

How do we treat “Pseudo-Sciatica?”

Treating PS can be tricky as it could be a combination of multiple problems that each need to be addressed separately. Soft tissue techniques like Active Release Technique or Graston therapy can improve superior cluneal nerve movement through the osteofibrous tunnel and remove the compression of the sciatic nerve along its path. Chiropractic manipulation of the pelvis and thoracolumbar spine can improve joint mobility, as well as provide a slight tug on the soft tissues associated with the superior cluneal nerves! Neurodynamic exercises like a sciatic nerve slider promote nerve movement through tissues that can keep those adhesions from building up again. Exercises like DNS Bear or Birddog exercises can improve diaphragm activation, lumbar spine, and pelvic stability to reduce the amount of chronic strain being placed on the low back tissues that compress these nerves. A combination of these mobility and stability techniques applied properly can be a game-changer when treating stubborn sciatic pain that hasn’t responded to any other single conservative method, and keep patients out of the operating room for unnecessary surgery.


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