Leg Pain: Sciatica or Pseudo-Sciatica?
PERSPECTIVE
William H. Koch
DC
Have you noticed that almost every patient who comes to you with leg pain has been told by another doctor or therapist that they have sciatica?
Sciatica has become a catch-all, generic diagnosis for all leg pain, but true sciatica is a very specific diagnosis. Stedman’s Medical Dictionary defines sciatica as “pain along the sciatic nerve that radiates from the lower back to the buttocks and back of the thigh and is usually caused by a herniated lumbar disc.” Stedman’s also says, “The sciatic nerve arises from the lumbar plexus and passes through the sciatic foramen to the mid-thigh where it divides into the common peroneal and tibial nerves.”
In my experience, true sciatica of discogenic origin makes up less than 50% of cases with leg pain. Much of the leg pain we see is lateral leg pain originating in the hip joint or anterior leg pain from the iliac crest and inguinal area radiating into the quadricep muscle to the knee.
There is a significant incidence of disc bulges and herniations in our population beginning with people in their 20s and increasing with age. However, in every age group, a percentage of people clearly show disc lesions on MRI but are otherwise asymptomatic. A significant percentage of people also present with moderate to severe low back and leg pain who do not show discogenic disease.
These discrepancies create a diagnostic and treatment conundrum for physicians who depend exclusively on imaging for their diagnoses. While the diagnostic gold standard for establishing the presence or absence of disc lesions is the MRI, imaging alone does not tell the whole story, and cannot be depended upon for accurate diagnosis of the cause of back and leg pain. The fact is that imaging cannot prove or disprove the existence of pain.
Every chiropractor who treats patients with failed back surgeries has seen many cases in which preand post-surgical imaging showed excellent technical outcome of the surgery but resulted in little or no reduction of the patient’s symptoms. In fact, we often see a worsening of symptoms after apparently “successful” surgery.
In cases involving leg pain, lumbar discogenic sciatica should not be assumed to be the inevitable and only diagnostic choice. Numerous mechanisms in the spine, pelvis, and lower extremities produce a variety of leg pain patterns. The reason so many back surgeries fail is the fact that the leg-pain-producing mechanism was something other than the disc on which surgery was performed.
Treatment failure, in most cases, lies in the diagnostic process. The exclusive dependence on imaging without correlating the physical findings of a properly targeted examination is the major cause of failed treatment, whether chiropractic or surgical.
It is interesting that an anonymous source at the Harvard Medical School stated, “We are graduating a record number of doctors—most of whom do not know how to perform a good physical examination.”
Chiropractors are, by virtue of orientation and training, experts in physical diagnosis of neuromusculoskeletal conditions. Physical examination provides us with the ability to establish a differential diagnosis that allows us to accurately identify the source of orthopedic and neurogenic problems. In the case of true discogenic sciatica, the chiropractic exam can give an accurate differential diagnosis, even to the point of distinguishing between lateral, central, and sequestered herniations.
I specialize in difficult cases that have had disappointing results with previous chiropractic, physical therapy, and medical and surgical care. Many of my patients have had failed back surgeries, and even some with multiple failed surgeries. Often the reason for previous unsuccessful treatment has been the failure to recognize and treat the actual mechanism producing the patient’s pain.
Much low back and leg pain is caused by pelvic imbalance that disrupts the body’s normal weight-bearing distribution, placing uneven forces on all seven joints of the pelvis. Foot, ankle, and knee joints are also frequent contributors to leg pain, often unrecognized if they are asymptomatic.
It is important that we differentiate between true sciatica and the leg pain I refer to as pseudo-sciatica. Pseudo-sciatic leg pain has its origins in the pelvis, knee, ankle, and foot joints. Pelvic imbalance is exacerbated by torsional stress on the acetabulum exerted by the powerful leverage of the length of the femur. Likewise, the femur, tibia, and fibula exert leverage on the knee joint from above and below. The stress caused by tension, pressure, and torsion on these joints causes inflammation that disrupts the extensive proprioceptive function of the hip joint.
In his soft tissue orthopedic research, one of my mentors, M.L. Rees, DC, DACBO, DIGS, identified 156 individual mechanoreceptors in each hip joint. In Soft Tissue Orthopedics 1989, Booklet #21, Acetabular Technic CAT II Extremities, Dr. Rees wrote, “If an acetabular subluxation is found, the doctor can expect leg, hip, and back pain.” He includes a “list of some of the lower extremities and body parts that lose their maintenance when an acetabular subluxation disrupts the proprioceptive information to the brain.” He lists the knee, sartorius muscle, femur head, ilium, sacrum, femur bone, acetabular joint elements, and perineum, as well as other internal pelvic structures. He concludes, “The majority of your patients do have knee pains, so this is a vast and fertile field for those who will work to develop their skills in knee and acetabular analysis and therapy.”
My protocol for examination begins with traditional orthopedic testing, followed by general and specific muscle tests to identify imbalances in the seven joints of the pelvis. I also check SOT indicators to determine the correct category. I always look for knee misalignments whether or not the patient complains of knee pain. Most importantly, in this regard but often neglected, is palpating for tenderness and swelling in the popliteal fossa. I also check for indications of subtalar joint misalignment, foot displacement, and fixations in the joints of the feet.
If during the examination a true discogenic sciatica is suspected, it is important to differentiate the type and severity of herniation. This can be done by observing the side of sciatica relative to incline. For example, right sciatica with left spinal incline suggests a right lateral disc herniation. On the other hand, right sciatica with right spinal incline suggests a central herniation. Mild to moderate cases of discogenic sciatica may be treated by chiropractic effectively.
In my treatment protocols for low back and leg pain, I always begin by releasing the psoas, which is predictably contracted from too much sitting. As indicated by my exam findings, I then move on to correct imbalances in any of the seven joints of the pelvis. I utilize both the ArhroStim and VibraCussor instruments to do these corrections. At this point, I often do corrective procedures on the knees using the ArthroStim. I then proceed to block the patient in accordance with their SOT category indicators. If needed, I then do ankle and foot corrections. This constitutes my basic procedure for balancing the pelvis and lower extremities. At this point, I always revisit the muscle-testing procedures to ascertain, for myself and the patient, that the corrections were effective. This lets us both know if my treatment is on the right track. The interactive aspect of preand post-muscle testing always makes a positive impression on the patients.
I start with my basic pelvic balancing technique even when I suspect a disc herniation or have seen one on imaging. If possible, first balance the pelvis. I then proceed to use the SOT category 3 blocking procedure. In many cases, even where there is disc bulging or herniation, symptoms may be relieved by chiropractic corrective procedures and surgery may be averted.
However, severe sciatica with a negative Valsalva sign, suggesting the possibility of a sequestered or fractured disc, should be immediately referred for surgical consultation, as should be any case where there is loss of bladder and bowel control.
Once a diagnosis has been established and treatment begins, physical findings should be monitored on a visit-by-visit basis. This can be easily and quickly done and allows both doctor and patient to objectively assess the progress of treatment.
Leg and associated back pain treated using instrument-assisted adjusting techniques that reset the joint mechanoreceptors provide us with easy, efficient, and comfortable corrections of the pelvis and extremities that cannot be duplicated using manual techniques alone.
Dr. William H. Koch, a 1967 Palmer graduate, just began his 52nd year as a chiropractic physician, writer and technique instructor. He has practiced successfully in the Hamptons of New York, The Bahamas and Florida. He currently splits his time between Abaco,Bahamas and Mount Dora, Florida. Dr. Koch is author of the books "Chiropractic the Superior Alternative" and "Conversations with Chiropractic Technique Masters" available through Amazon. He writes a blog: "ChiroPractice Made Perfect" DrWilliamHKoch.com and teaches classes on "The Koch Protocols — Integrated, Advanced, Chiropractic Techniques." Simple, Effective, No Nonsense Chiropractic Seminars. Learn more by visiting KochSeminars.com. Or contact him via email at [email protected].
