3 Proven Methods Physical Therapists Use to Diagnose Sciatica Pain

Show Notes

In this episode of the Dr. JJ Thomas Podcast, I share three proven methods that physical therapists use to diagnose sciatica pain effectively. From understanding the specific symptoms to utilizing state-of-the-art diagnostic tools, I break down each method to help you recognize the best approach for managing your condition. I'm here to guide you through the complexities of sciatica, ensuring you're well-informed and ready to discuss your treatment options with your healthcare provider. Join me as we delve into practical, evidence-based strategies for a pain-free life. Don’t miss out on expert insights that could change your approach to sciatica pain.

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What is The Dr. JJ Thomas Podcast?

Welcome to The Dr. JJ Thomas Podcast! Here I'll be talking all things physical therapy, raw and unplugged, giving you the unfiltered insights you've been searching for in your cash-based physical therapy business. If you're caught in the grind of the traditional model, swamped with paperwork, or feeling like you're not reaching your full potential as a physical therapist, this podcast was created just for you.

Dr. JJ Thomas: 00:00

If them looking up and not changing anything else changes their nerve pain, changes their tension, I shouldn't even call it nerve pain, because they may not feel pain in the exact spot in this test that they normally feel pain. But what we wanna know from this test is when they lift their head, does it change the tension on the back of their leg anywhere? Welcome to the doctor JJ Thomas podcast. Hey, everybody. Welcome to doctor JJ Thomas podcast.

Dr. JJ Thomas: 00:29

I'm JJ Thomas. Today, our episode is going to help clinicians. I'm going to give you guys 3 different scenarios of how to assess and address your patient that comes in complaining of sciatic nerve pain. So the first thing we have to do when we're deciding, how and what to give our patients for their sciatic nerve pain is we have to first decide is it the sciatic nerve that's causing their pain? If we look at the sciatic nerve on the app and we remember from our anatomy, we know that the sciatic nerve, as I've demonstrated here, as I've clicked it here, you can see it highlighted in blue, the sciatic nerve comes off from the lumbar segments L4 through s 3.

Dr. JJ Thomas: 01:09

So the the nerve roots of L4 through s 3 will all conjoin, will join together to form the sciatic nerve. I'm gonna remove the sacrum here for a second, so you can remember and envision all of those nerve roots coming off and joining to form the sciatic nerve. I'm not gonna click them all individually, but you can see how they're coming off of the spine. Here's l 5 up there. I also highlighted the ilium.

Dr. JJ Thomas: 01:35

This thing's a little, sometimes finicky, but L5 is under there as well, coming down to join the sciatic nerve. So it could be that what they're really feeling is potentially an L5 nerve root issue, or it could be in fact an entrapment under the piriformis or somewhere else in the ilium area where the sciatic nerve actually comes out or could be entrapped further down in between the ischial tuberosity and the lesser trochanter where the quadratus femoris muscle comes around. So all really important considerations when we're evaluating our patients and figuring out how we're going to best get their sciatic nerve pain down. As I said, the first thing we have to do is figure out is it in fact the sciatic nerve or another nerve that's causing their pain, or there's another potential that we're gonna go through at the end of the episode, which is maybe it's not nerve pain at all. Maybe it's actually a somatic muscle pain.

Dr. JJ Thomas: 02:32

So I'm gonna go through how to determine that. Right now, we're gonna go through the evaluation of, let's first determine is it or is it not in fact a nerve irritation or inflamed nerve, pattern. So the first thing, my favorite nerve test, I'm sure you guys remember this from PT school, and hopefully you all still use it in some way, shape, or form, I like the loaded slump test. So for me, the loaded slump test is my go to. Anytime I really wanna decide, is there is there not nerve root involvement?

Dr. JJ Thomas: 03:03

Or nerve involvement. I shouldn't say nerve root because a nerve test, a positive slump test, is going to tell us that there's a, a tension on the nerve in some way, shape, or form anywhere from that nerve root all the way down to the down to the foot. So it's not discriminative in terms of where that nerve is being compressed. Could be multiple places, could be one place, but it will tell us, accurately, pretty accurately, is it or is it not a nerve problem? So the slump test, if you remember, I have my patients sit usually on the tape on a high treatment table, and I have them all the way back so their full femur is on the table.

Dr. JJ Thomas: 03:40

So I have them with their hands behind their backs, and slumped down with their heads in a fully flexed flexed position. I like that full flexed position like this, because then I know I'm standardizing my test at the top, and then I can delicately bring on the tensioner or the the slump, the tension portion of the slump test, on my own. So normally, I will do this manually, but I'm since I'm by myself today, I'm just gonna show you. The components after you have them stay in this position, is you're going to have them stay head down, and then I will manually, dorsiflex their foot, internally rotate their femur and their tibia even, and then keep them dorsiflexed as I tension them across the body to put tension along the nerve, essentially the sciatic nerve path, but also all the way leading up to the l 4 through s, three nerve roots. Now, the real part of the test, that's just the position.

Dr. JJ Thomas: 04:41

Right? Once I feel that tension, I have them in this position, and then, once I feel the tension and they feel the tension, I'm going to ask the patient to lift their head. So in this position, say I get them to here, we feel the tension, I feel the tension, they feel the tension. Now I say to them, all I want you to do is lift your head, like that. So from a side view, we have them in that position.

Dr. JJ Thomas: 05:08

All I want you to do is lift your head, so that's it. Right? I'm not changing the flex of the thoracic spine, I'm not changing the flex of the lumbar spine, all I'm changing is head position. If the if them looking up and not changing anything else changes their nerve pain, changes their tension, I shouldn't even call it nerve pain, because they may not feel pain in the exact spot in this test that they normally feel pain. But what we wanna know from this test is when they lift their head, does it change the tension on the back of their leg anywhere?

Dr. JJ Thomas: 05:38

And if it does, that's a positive nerve test. That's a positive slump test. All that tells me is that somewhere along the chain, that nerve root is involved. Now, if that test is negative, then we're looking at muscle pain, we're looking at somatic pain. And I'll give you some examples of why someone might feel they have sciatic pain when it's actually somatic pain a little later.

Dr. JJ Thomas: 06:00

So let's go back. Our patient, you just did the test, they have nerve pain. They have a positive slump test, you know there's a nerve root involved, there's a nerve involvement. Now, it could be entrapped it could be entrapped, as I said, at the gluteals in 2 spots. It could either be entrapped, commonly it's entrapped at the piriformis, which people commonly refer to as the piriformis syndrome, and so that's a possibility.

Dr. JJ Thomas: 06:23

It can also be entrapped, this is a very common area that I think is miss, you know, missed a lot, is at that, I've marked it here, at this spot here under the between the ischial tuberosity and the lesser trochanter of the femur. I'm gonna try to show you. If I remove the gluteus maximus, then right here, you can see where the sciatic nerve comes between the hamstring attachments. I'm gonna draw oh, no. I'm not.

Dr. JJ Thomas: 06:56

The hamstring attachments and quadratus femoris. This is quadratus femoris right here highlighted. Here are the common hamstring tendons going up in the ischial tuberosity. So between the hamstring tendons attachments at the ischial tuberosity and the quadratus femoris muscle, which essentially sneaks right between the ischial tuberosity and the lissotrocanter, that's another really common site of entrapment of the sciatic nerve. So if they have nerve pain and the description is not necessarily giving you the feel that it's very disky or or nerve root pathology, don't miss this entrapment area.

Dr. JJ Thomas: 07:33

It's it's a high quality area. If you do believe, let's talk about scenarios. So we have a positive slump test, which we need to now treat the nerve. Let's talk about clinical scenarios under that. If it's a hot, inflamed nerve root, this patient comes in, they're shifted, they're they're like, Oh my God.

Dr. JJ Thomas: 07:52

I couldn't get my socks on. I couldn't sit at work today. I can't sit. I can't lie. They're uncomfortable.

Dr. JJ Thomas: 07:58

Highly inflamed, irritable, unrelenting, burning, searing pain down their leg. That's likely a nerve that's likely a nerve root, impingement in some way, shape, or form. It's also a chemically it's in a chemically irritated state. Right? So our goals for treating this patient are going to be calm down the inflammation in any way, shape, or form we can.

Dr. JJ Thomas: 08:21

Things we have to consider are number 1, position. So, oftentimes, patients, I find, that have that real irritable nerve root will do pretty well with prone posturing or very, very, very gentle, prone triceps. Now if you're gonna do that with these patients, you must do a lot of test retest. So because they're highly inflamed, highly irritable, you can tip that you can tip that, waiter's table really easily. So you'll have to do maybe a couple reps.

Dr. JJ Thomas: 08:56

Really easy. Make sure they're not using their back muscles to do it. Make sure they're using their hands to do it and then let them come down. And then up a little bit, let them come down. And then up a little bit.

Dr. JJ Thomas: 09:07

Breath is really important with it. So really simple press ups for them. The other exercise that's really great for these, people, these patients, is get them moving, not not just exercise, but intervention all around, is treat other areas. So treat the thoracic spine. Do scapulothoracic mobilizations in a position, maybe side lying, that doesn't irritate them.

Dr. JJ Thomas: 09:33

Get their thoracic spine moving to take pressure off the area in the lumbar spine that's potentially entrapping that nerve that inflamed nerve root. You can calm down the inflamed nerve root as best you can with modalities and massage, etcetera, but you can also indirectly calm that nerve root down by getting the other joints up above and below to move better in a way that doesn't inflame the nerve root. So in this position, elbows sort of under shoulders and just doing scapular presses in this position to get scapular activation and stability, get a little bit of pseudo lumbar extension. Right? But mostly getting scapulothoracic mobility, again, to take stress off the lumbar spine.

Dr. JJ Thomas: 10:21

If they're shifted, obviously you're gonna try to correct that shift. So you're gonna have them I like to do standing side glides, for that correction. All of those things that you learn in a PT school are fair game. In terms of intervention for a highly inflamed irritable nerve root, I also like, I prefer dry needling to the multifidi. I do more than one segment, so I'll do multiple segments.

Dr. JJ Thomas: 10:45

If I think it's l 5, I'm going to treat honestly, I'm probably gonna treat, if you're trained, make sure you're trained in these, but I'm gonna treat at least up to l one, and down through the sacrum, and I'm gonna put needles in the gluteals as well, and I'm gonna hook all that to stim. Because, those that treat with me and know with me and have taken our dry needling master classes, you know that I don't always prioritize e stim first, but for these patients I do. You do have to consider position of comfort, and make sure that they're going to be able to not be inflamed in whatever position you're in, so when you get them off the table, your good work of the needling and stim doesn't go to waste. But needling and stim for these patients is excellent. That's about it for the nerve root.

Dr. JJ Thomas: 11:30

I mean, early on, as I said, you're calming down the inflammation, getting the theres the scapulothoracic joint moving better. Oh, nerve root wise, you're gonna give them I'm gonna give them sliders if they can tolerate it. So so these are the ones where you're in this position, instead of being full tension like we tested them, you're gonna do the reverse. So you're gonna bring the leg up and have them look up, and then bring the leg down and have them look down. So you're gonna alternate.

Dr. JJ Thomas: 12:00

You're gonna glide the nerve rather than tension the nerve, if that makes sense. So that's your highly, highly inflamed nerve root scenario. For the, for the patient that has what you believe is an entrapment, either under piriformis or under that little nook that I was talking about between the hamstring attachments and the quadratus femoris, Those patients I find, their hip mobility is huge, their lack of hip mobility is huge in the predisposing factors to creating this irritation of truly the sciatic nerve. This is actually the sciatica that people think they're talking about. And some have it and some don't.

Dr. JJ Thomas: 12:43

But if you think they're this patient, after checking their hip range of motion you're obviously gonna target what their main limitations are, but what I tend to find with these patients are a pattern. Oftentimes they have a limited favor, flexion, abduction, external rotation, but they're also gonna have limited hip extension passively. So they're the patient that, you know, they're kinda stuck here in standing, so they're kind of like here, and they're super tight in their hip flexors as well, hip flexors and adductors. So there's a couple really great stretches for this, and I'm gonna go through some great activation exercises as well. But first let's talk treatment.

Dr. JJ Thomas: 13:23

For these patients, I do tend to, in terms of dry needling, I do tend to like to dry needle gluteus maximus, and I'll go through a technique with that, in a future episode. We do have our master classes, you can always join us. But I lift off glute maximus, and I thread it across that way, perpendicular to the fibers. You're also going to clean out any of those, gluteal muscles that are limited and try to regain that range of motion as much as possible. So this is a nerve pain scenario that's not the highly inflamed nerve root scenario.

Dr. JJ Thomas: 13:57

This one is more of a, this patient, the pain comes on when they're driving all driving their kids around all day. It's kind of slow and grows, it disappears, maybe they get up in the morning, they feel a little bit better, but it's aggravated over time, but it's not highly inflamed. Okay? This patient, you can you can go a little bit more aggressively with exercises, and you can put them in a little bit more, you know, stressful or loaded positions. So one of the exercises I love for these patients is that frogger stretch.

Dr. JJ Thomas: 14:27

It's one of my favorites. So you start them in like quadruped here, and then you walk their legs out, but I want you to get 90 degrees at the hip, knee, and ankle. So most people end up like this, but I actually really want their tibia, their tibia femoral angle, and their ankle, their dorsal flexion angle to be 90 degrees. And then from there, they're gonna drop down to their elbows if they can, and then push back. And that's really gonna do such a nice job of stretching the adductors, and also, which will affect that, adductor magnus attachment onto ish tube, which will help open up that other side of where the sciatic nerve lives.

Dr. JJ Thomas: 15:13

So, Frogger stretch is a must for most of these patients. The other ones I really like are essentially, if they can do, like, a loaded squat position. So stand, load, squat, and then they can work on internal and external rotation there. So they can do one leg, 2 leg, you know, 1 leg, 2 legs, and I usually have them hold on to something like this so they can get a little lower, and then they're going in and out. So getting hip range of motion in a loaded position, and you can see how that just kinda uses those muscles right around where that sciatic nerve, comes through, between ischial tube and lesser trochanter, and really helps open up that that area.

Dr. JJ Thomas: 16:03

The third one I really like, which combines muscle activation with, so a stretch with a strengthening, is in this supine position, you're gonna have them lock one knee, like that, to lock their pelvis, and then from there they're gonna bridge up as high as they can. And for most people it'll be pretty tight, it may not be that high, and that's okay. But they're gonna strengthen those gluteals in a way that also stretches the anterior hip at the same time. Don't let them cheat and do that, you've got to really have them lock this down. And then lift, and lift, and lift, like that.

Dr. JJ Thomas: 16:50

So don't forget to strengthen these patients, especially the ones that have lower irritability. Remember, nerves need they need blood flow, they need space, and they need mobility. So all of these three exercises that I gave so far will give you those things. The strengthening piece, that bridge one with the single leg locked, that one's really great because that strengthening piece is also gonna bring the blood flow, and it's also gonna strengthen the muscles in the pattern that they need to help support the pelvis, which will allow the muscles to relax, which will give the nerve root, blood space, and mobility. In that on that same line of thought, don't forget that you can do Another great strengthening exercise would be to do, having these patients go from Can you see me?

Dr. JJ Thomas: 17:38

Having these patients go from just internal and external sorry, external and internal rotation actively, and then progressing them to using a band for resistance. Right? They can squeeze a ball and do internal, kinda rocking around, getting those gluteals to activate right around where that sciatic nerve lives. So flushing that blood flow through movement and activation is really great for these patients. And the last one would be, get them doing hamstring curls.

Dr. JJ Thomas: 18:09

Like, a lot of times those hamstrings are tight because they're trying to do too much work, and more work than their capacity allows. And so, it sounds counterintuitive when they have nerve pain that's going in the back of the leg, but if you think that nerve pain is coming at that entrapment site of the near the ischial tuberosity, then 100%, I challenge you to strengthen those hamstrings with leg curls. Either use a band or do standing, weighted curls with or without BFR, or just use a regular old curl machine. But if you're gonna use a curl machine, I encourage you to do single leg as much as possible. So that's your, that's how to treat your sciatic nerve pain patient, who's actually a true sciatic nerve pain patient patient with entrapment at the glutes.

Dr. JJ Thomas: 18:58

The last scenario is the patient that has symptoms that seem like sciatic pain because they're complaining of this symptom, like, right behind the leg here, and a lot of times they'll have these these patients will also say, it goes down outside the hip, and down the outside of the leg. And because that is the exact referral pattern of L5, even clinicians will sometimes be fooled by this. Right? But if you've taken that patient, and you've taken their history, and you've heard them say, Okay, I have this pain down the leg, and you're thinking, Oh, it might be L 5, oh, it might be sciatic nerve. Remember that if that slump test is negative, it may just be somatic pain.

Dr. JJ Thomas: 19:42

And if it's somatic pain, there's one main muscle group that you need to clear, really 2, but it it's likely either going to be gluteus medius, which we'll share on the on the on the video screen, we'll share with you the referral pattern for that, so you can see it. Gluteus medius, because it's controlled by L 45, We've talked about referral patterns before, and what they really mean, what they really tell us. Because gluteus medias is controlled by L 45, the referral pattern for gluteus medius is exactly that. It comes down. It's kinda comes here, down here, and then down to the outside, the l five side of the leg, and it also is in the posterior thigh, which is what people feel is sciatic.

Dr. JJ Thomas: 20:27

But if that slump test is negative, it's likely a gluteus medius issue versus a true sciatic nerve pain. So if it's a gluteus medius restriction, how are we gonna treat that? Essentially, remember, gluteus medius is your single leg stabilizer, so if they're having an overuse issue with gluteus medius, again, you have to go back to your range of motion measures, like I said with the last one, and you're gonna have to clean up some range of motion things. That squat one's a good one, because they'll still get progressive transfer of weight, right? The working on these guys, really holding on is better to do that.

Dr. JJ Thomas: 21:06

Also getting just lateral lunges. Get them out of straight plane. Get them into a lateral lunge, up, like that, on both sides, and progress them towards pushing. So some of the less obvious ones I'd like to highlight for you are to put these patients in, positions that will encourage stability around the pelvis to give glute medius the support it needs so it can stop screaming at you. So what I mean by that is essentially put them in half kneel.

Dr. JJ Thomas: 21:36

Right? Half kneel is a regression of single leg stance stability. So if you put them in a nice, sturdy half kneel position, and then you begin to load them around this position, you'll train that glute medius, to have the support it needs. So one of my favorite exercises for this, it's a progression, you can literally, from this position, have them almost like they're gonna do, an RDL. Right?

Dr. JJ Thomas: 22:04

So like a like an RDL, only now they're gonna be here, in half kneel, and this leg will be doing its fair share of the work as well. So from here, boom. Just like that. Right? If we wanna progress them, and I'll show you a side view there so you see the hip extension.

Dr. JJ Thomas: 22:23

So, boom. Boom. Just a simple hip hinge, getting the glute activated, but in a regression of single leg stance so that their body can meet the capacity that their body's demanding them. The progression of that would be from here to a clean. Right?

Dr. JJ Thomas: 22:46

So here to a clean. We're still getting that hip hinge, only now we're just having to power up a little bit stronger to ask more of that muscle. So here, clean. Right? A progression of that would be some people I will just continue to do this, clean, and then have them press it overhead.

Dr. JJ Thomas: 23:12

This is a heavy weight if you have somebody with perceived sciatic pain. This one's £20, so you may wanna lower it a little bit if you're gonna have them overhead, especially that first time, or you could start at the top of the range. You could have them just get it there once, right, and then have them go like this. Right? So now we're asking glute mead and min to adapt to the changes in rotation and the changes in single leg stance, and we're getting help from our friend on the opposite side, and we're progressing towards single leg stance without being a full single leg stance.

Dr. JJ Thomas: 23:55

So those are some really great options for addressing a perceived sciatic pain that's actually somatic pain from glute med men. I'm gonna give you one more that people don't often think of, and that's a side plank. Right? So side plank progressions I'm just gonna move these out of our way. For think about this.

Dr. JJ Thomas: 24:17

For glute med, what does it do? Right? In closed chain, it's gonna stabilize the pelvis and support a reduction. So elbow under shoulder, get in this side plank position with the knee down to start. Make sure their hip isn't flexed.

Dr. JJ Thomas: 24:36

Get them out of that hip flex posture. Get them knee, hip, shoulder, all in line. And then from there, if that's easy, if they can maintain that height and not drop down, if that's easy, then you can lift the leg, you can start going adding rotation like this. Right? You can add rotation like this.

Dr. JJ Thomas: 24:58

So now we're working around glute med and asking it to functionally support, but in a way that's more manageable, more directive, more specific than if we just go tell them to walk or stand on one leg. Like, it drives me crazy when I see patients getting an exercise that's outside of their capacity. The glute med is inflamed and irritated, and that's why it's producing pain that feels like sciatica. So the only way to treat that well is to come down to its capacity. These are great exercise options for that.

Dr. JJ Thomas: 25:35

The last scenario that falls under the third scenario, really, the last somatic pain referral pattern that we that we would that we would think about is a straight hamstring dysfunction. Right? And if somebody has a straight hamstring dysfunction causing their perceived sciatic pain, you would wanna obviously test their active, their resistive their strength with it. Right? Make sure that they didn't actually have a hamstring injury where they potentially had a underlying tear or something that would need to be addressed further.

Dr. JJ Thomas: 26:04

But if it's just a strain and their pain is associated with a muscle strain, so they would be painful, arm resisted flexion of the hamstring, right, but painful and strong. And if you get that type of response, you're gonna load it. You're gonna do the same thing I said earlier when I was encouraging you to feed that, that peripheral nerve entrapment with blood flow, strengthen that hamstring. Do all kinds of hamstring exercises you can think of, everywhere from isometric, for instance, if they're if they're, you know, pretty weak and you need to get them somewhere, you can just do heels digging in. Right?

Dr. JJ Thomas: 26:40

So heels isometric digging in. You can do heels digging in with a bridge. You can do single leg heel digging in with a bridge, but I'm actively activating my hamstring the whole time. And then progress that to, to loading. Progress that to, actually, you can do them all at once, if they can tolerate it.

Dr. JJ Thomas: 26:58

Load that baby. It really the muscles need it, and sometimes when they ache it's because they're not getting what they need in terms of input. So those are the main scenarios. Just to recap, when you have a patient that's complaining of sciatic pain, remember it could be pain actually driven from the L five nerve root, Pain driven from an entrapped nerve, either at the piriformis or between that ischial tuberosity and less trochanter, where the hamstring and the quadratus femoris come meet each other. If it's the if it's any of those scenarios, they're gonna have a positive slump test.

Dr. JJ Thomas: 27:35

So if that nerve is irritated in any of those three places, it's gonna have a positive slump test. Go through and recap how chemically irritated it is, if you think it's an L5. How chemically irritated it is, if you think it's L5. And then from there, you're gonna progress them as their body allows. The last scenario is that somatic scenario, the one that sounds like sciatic nerve pain to them, but it's actually really muscle referred pain.

Dr. JJ Thomas: 28:08

And those are the ones that you're gonna address, you know, fairly aggressively with movement and exercise, and really loading them. So, hope this was great for you. I I think it's something we see common, and and it's really helpful for patients to understand also what their pain actually is and where it's coming from. And then when we give them exercises and interventions to address these things, it makes more sense to them. So thanks for joining me today.

Dr. JJ Thomas: 28:32

I hope this helps. Looking forward to next time. If you need or want any more information like this, you're always welcome to check us out on our our primal, primalhq.com is our primal university website, and there you'll find our courses with more and more knowledge, just like this. Take care.