Pain

“Sciatica” is one of the conditions people seek acupuncture treatment for most frequently. As you will say in the case below, most of the time it is not actually sciatica which people are experiencing.  I have prepared the following case study for you in order to give you an idea of how we evaluate and treat such pain with acupuncture. I hope the insight it gives you provides you with the confidence to seek treatment if you are suffering from this type of pain.

Case Study – Sciatica or PIrifomis Syndrome?

A 28 year old male came to the office on a Saturday with pain in the left posterior hip. The pain had begun several days earlier while working (physical labor). He had a strong ache in posterior hip with a radiating sensation down the leg. Additionally, the sensation made him feel anxious and uneasy, causing difficulty sleeping. Ibuprofen helped it only slightly. He had diagnosed himself with sciatica. 

What Is the Sciatic Nerve? 

The sciatic nerve is composed of nerve roots from the L4, L5, S1, S2, and S3 vertebrae. They merge to form a single, large nerve which exits under a bony arch called the sciatic notch. The sciatic nerve runs through the pelvis, travelling under the piriformis muscle before heading down the back of the leg.

It separates into two branches at the back of the knee to form the tibial and peroneal nerves, which supply the lower leg and foot. The sural nerves branch off from the tibial and peroneal nerves, terminating in the foot.

The sciatic nerve provides motor input for bending the knee, bringing the thighs together (adduction), and flexing and extending the ankles and toes. It conveys sensation from the back of the thigh, the entire lower leg, the ankle, and the sole of the foot.

Sciatica Vs. Pseudo-Sciatica

Many people experience the symptoms described above and identify it as sciatica. In reality, most of the time they are experiencing “psuedo-sciatica.”  What is the difference?

True sciatica is a set of symptoms caused by irritation or compression on one or more spinal nerve roots in your lower spine, not the sciatic nerve itself. This could be due to a herniated disc or spinal stenosis,. The nerve roots which merge together to form the sciatic nerve are under pressure. This is a form of radiculopathy. (Radix is a Latin term meaning root, and pathos is a Greek term for disease).

In reality, what most people are experiencing is a form of muscular tightness, called piriformis syndrome. In this case, the sciatic nerve is directly irritated or compressed by your piriformis muscle, deep in your hip. The symptoms of piriformis syndrome may affect the buttock and hip, as well as traveling down into the thigh and leg.

What is the Piriformis?

The piriformis muscle originates at the sacrum (the flat bone beneath your spine in the center of the pelvis) and attaches to a bony knob (the greater trochanter) on the femur (thigh bone) on the outermost part of the hip.

The function of the piriformis is to externally rotate and abduct the hip.  This means turning your hip outward and bringing your thigh outward to one side while your hip is bent. This happens when raising your knee and bringing your leg out when getting out of a car (which can be one of the painful movements when it is inflamed). It is also involved in walking, running and standing.

Causes of Piriformis Syndrome

Ordinarily, the sciatic nerve is directly underneath the piriformis. Occasionally, people have an atypical anatomical variation.  Sometimes, the sciatic nerve passes directly through the piriformis, which can lead to piriformis syndrome.  More commonly, there is inflammation of soft tissues, muscle spasm or both, causing nerve compression. 

This can happen with direct trauma such as a car accident or a fall. However, it is most likely the gradual tightening of the piriformis muscle is due to poor posture and overuse.  Activities, such as long distance running or prolonged standing without proper stretching and strengthening of piriformis muscle will contribute to piriformis syndrome. However, in my experience, people who sit for a long period of time with poor posture, especially drivers, seem to suffer from this the most.

Symptoms of PIriformis Syndrome

Symptoms of piriformis syndrome can be variable. Some of the common symptoms include:

• Pain in the opposite sacroiliac joint
• Pain with sitting standing or walking for more than 20 minutes
• Intense pain while sitting
• Sensation of pins and needles, numbness, burning, tingling, or itching down the back of the thigh, usually stopping above the knee
• Pain improves with movement
• Pain when moving from sitting to standing
• Foot numbness

Differentiation: Sciatica VS. Pseudo Sciatica

One way to tell is to consider WHERE the pain is felt:

• In piriformis syndrome, buttock and hip pain is typically more common than lower back pain.
• In sciatica, the leg pain is usually greater than lower back pain and the pain may extend below the knee. The affected leg may also feel heavy.

Another way to tell, is the effect of MOVEMENT

• In piriformis syndrome, the pain typically increases while sitting for long periods of time and/or during hip movements.
• In sciatica, raising the affected leg while lying down (while keeping the other leg straight) may induce pain.

Evaluation

The primary physical test for sciatic like symptoms is the Straight Leg Raising (SLR). The straight leg raise places stretch on the sciatic nerve as it passes through and around the structures of the pelvis and traverses down the posterior aspect of the thigh. The straight leg raise test is performed with the patient on their back. The examiner gently raises the patient’s straight leg, and the test is considered positive when the patient experiences pain along the lower limb.  In this case, the test was negative (which is good). 

The patient was walking with an antalgic gait.  Muscle testing revealed weakness at the gluteus medius (resisted hip abduction) and the tensor fascia latae.  Palpation revealed extremely tender points at the piriformis and gluteus medius.

Treatment

The purpose of the physical exam is to identify areas of muscle tension and weakness.  Acupuncture points are selected based on their neuroanatomical relevance. The majority of points chosen are motor points. Motor points when stimulated, especially with electrical acupuncture, can normalize the tension in a given muscle. This, in turn, reduces pressure on the underlying nerves and gives pain relief.

Acupuncture was given in the first session to the following points. The points are given with their acupuncture nomenclature, as well as the important anatomy they reference. 

GB-29 : Motor Point of Tensor Fascia Latae

GB-30: Motor Point of Piriformis.

UB-53: Superior Gluteal Nerve: innervates Gluteus Medius, Gluteus Minimus and Tensor Fascia Lata.  

UB-54: Inferior Gluteal Nerve: innervates Gluteus Maximus.

UB-37: Descending Branch of Posterior Femoral Cutaneous Nerve/Biceps Femoris Motor Point

UB 57: Lateral Head of Gastrocnemius Motor Point

The superior gluteal nerve was connected to the lateral gastrocnemius motor point for 10 minutes of electrical stimulation. Then gua sha was performed to the posterior hip and thigh. Upon standing, the patient felt better but still had some pain in the anterior aspect of the thigh. So treatment was performed to the following points:

ST-31 : Upper Rectus Femoris Motor Point

ST 32 : Lower Rectus Femoris Motor Point

These points were connected with .5 hz electrical stimulation for 10 minutes.

After the treatment, the patient had complete relief. The relief lasted for several hours, upon which the pain came back, but not as severe.  The patient required ibuprofen later that night, but by the next day the pain had abated substantially. Upon return to work on Monday, the patient was able to work with some restriction.  On Tuesday, we had a follow up visit. The pain was mostly resolved, we performed a treatment similar to the first, and the patient was released with a simple exercise to do at home for prevention.  

Discussion: 

It is important not to just treat the painful areas, but also muscles that contribute to movement of the leg and back as a whole. In addition to the piriformis itself, the Gluteus medius (the hip abductor) and tensor fascia latae are almost always a part of the treatment.  In this case, it was also necessary to treat the hip flexor. These areas of weakness can be uncovered by careful exam.

Also of note, the acupuncture points are selected based on what neuroanatomical structure they relate to, versus the traditional selection of points based on meridians. This, in the author’s opinion, creates an approach which is both more reasoned and more accurate.

Not every case resolves so quickly and easily. The chronicity of the condition, structural imbalances, age, and diet all play a role. In some cases, Chinese herbal medicine such as Du Huo Ji Sheng Tang is added. However, most cases can at least improve if not be totally resolved with acupuncture and Chinese medicine treatment.