You Probably Don’t Have Sciatica. Here’s What You Actually Have.

If you have pain shooting down your leg, you have probably been told you have sciatica. It is one of the most commonly used terms in medicine — and one of the most misused.

True sciatica is compression of the sciatic nerve itself, usually in the buttock or posterior hip region. A tight piriformis muscle compressing the nerve is a classic example. It happens, but it is relatively uncommon.

What most people are actually dealing with is lumbar radiculopathy — irritation or compression of a nerve root at the spine, usually from a disc herniation, disc bulge, or spinal stenosis. The pain radiates down the leg because the nerve root that exits your lumbar spine travels into your leg. The source is in your back, not your buttock.

This distinction matters because the treatment is different.

Why the Diagnosis Matters

A patient with true sciatic nerve compression in the hip needs treatment directed at the hip — soft tissue work, stretching, and addressing whatever is compressing the nerve locally. A patient with lumbar radiculopathy needs treatment directed at the spine — nerve mobilization, directional preference exercises, spinal manipulation, and progressive loading.

If you treat lumbar radiculopathy like it is a hip problem, you miss the source. If you treat sciatic nerve compression like it is a disc problem, you miss the source. The evaluation determines which one you have.

What Our Evaluation Looks At

When a patient comes in with leg pain, we do not assume sciatica and start treating. It starts with listening. How did the pain begin? What makes it worse? What makes it better? What time of day is it worst? What positions provoke it? What is your activity level? What have you already tried? Your story tells us where to look before we ever put our hands on you. From there, we assess:

• Where exactly does the pain go? — Above the knee, below the knee, into the foot? The distribution tells us which nerve root is involved.
• Is it the spine? — Lumbar range of motion testing, directional preference assessment, and neural tension testing help us determine whether the source is a disc, stenosis, or facet joint.
• Is it the hip? — We screen the hip for mobility, strength, and provocation of the sciatic nerve in the posterior hip.
• Is there a neurological deficit? — Strength, reflexes, and sensation testing tell us the severity and guide urgency.
• What type of nerve irritation is it? — Compression, inflammation, sensitization, or mechanical tension each respond to different interventions.

This takes time. It cannot be done in a 5-minute consult. And it cannot be replaced by an MRI — because the MRI does not tell you how the nerve responds to movement, load, and position. Our evaluation does.

How We Treat It

Once we know what you actually have, the treatment is targeted:

• Directional preference exercises — specific movements that reduce nerve irritation based on your presentation. Some patients respond to extension, some to flexion, some to lateral movements. The evaluation tells us which.
• Nerve mobilization — gentle techniques to restore normal nerve gliding and reduce tension on the irritated nerve root.
• Spinal manipulation — when the clinical evaluation supports it, manipulation produces immediate neurophysiological pain relief.
• Dry needling — targeted release of the muscles guarding around the irritated segment.
• Progressive strengthening — building the capacity of the spine and hips to handle load so the nerve is no longer compressed or irritated.
• Structured aerobic training — at your ventilatory threshold (VT1), aerobic exercise activates your body’s pain relief systems and reduces the central sensitization that develops with persistent nerve pain (Sluka et al., Pain, 2018).

The Aerobic Piece

Patients with radiating nerve pain frequently develop central sensitization — their nervous system becomes amplified and signals that should not hurt start to hurt. Research shows that 25–35% of patients with radiculopathy demonstrate features of central sensitization (Smart et al., Manual Therapy, 2012).

Structured aerobic training at VT1 — your first ventilatory threshold — activates endogenous pain relief systems and progressively restores normal pain processing. For patients with significant symptoms, we start at VT1 using a rower, ski erg, bike, or inclined treadmill. As symptoms reduce, we add intermittent sessions at VT2 to push the nervous system further. This is threshold-based training, not a suggestion to go for a walk.

Do You Need an MRI?

For most patients with radiating leg pain, no. Our evaluation identifies the source and severity without imaging. If the presentation raises red flags — progressive neurological deficit, loss of bowel or bladder function, or pain patterns that do not match a mechanical source — we refer for imaging immediately. Knowing when imaging is necessary is just as important as knowing when it is not.

Do You Need Surgery?

Surgery for lumbar radiculopathy is rare. The vast majority of cases — even those with disc herniations confirmed on MRI — resolve with conservative care. Physical therapy is the recommended first-line treatment, and most patients never need anything beyond it. In the rare cases where surgery is appropriate, we refer to the surgeon we believe will give you the best outcome. We are independently owned, with no financial relationship influencing that decision.

And if you do need surgery, we manage the full post-operative recovery. Learn more about post-surgical rehab.