Sciatica may be in the form of neuralgia (nerve pain) or neuritis (nerve inflammation).  True Sciatica is inflammation of the sheaths or connective tissue surrounding the axons of the sciatic nerve.  The pain in this instance is often a constant dull ache.  Sciatic neuralgia is often caused by nerve root compression, a herniated intervertebral disc at L4, trauma, or lumbar spondylosis (degeneration of the intervertebral discs), or spondylolisthesis (one segment of the spine is moved).  Pain is often paroxysmal, shooting, throbbing and intermittent.  Pseudo Sciatica is a term used for sciatic-like symptoms created by a contracted iliotibial band, sacroiliac lesions, Piriformis Syndrome, Fibromyalgia or a number of other conditions which aggravate the sciatic nerve.

Causes of Sciatic Complaints (of varying types)
True Sciatica is caused by nerve root compression, often due to a lumbar injury and or a lumbar disc herniation.  Pseudo Sciatic is most often caused by a contracted iliotibial band, but it can also be caused by sacroiliac lesions, Fibromyalgia, Piriformis Syndrome (when the piriformis muscle is contacted and squishing the sciatic nerve), osteoarthritis of the hip, trocanteric bursitis, lumbar lordosis or scoliosis. In addition, sciatic symptoms can be caused by pregnancy, constipation, tumors, diabetes or peripheral nerve injury.

Signs & Symptoms
With a complete lesion of the sciatic nerve, the patient will present with foot drop and steppage gait (as the toes hang down, the patient will lift the affected leg higher than normally needed in order to avoid dragging the toes on the ground).  Muscle wasting of the hamstrings, tibialis anterior, the extensors of the toes, gastrocnemius, soleus and the intrinsic muscles of the foot may present.  Causalgia (intense, burning pain) may occur affecting the tibial division off the sciatic nerve. Sensory impairment may be present in the posterior thigh, leg and lower leg in addition to the anterior lower leg and foot.  Pain will be aggravated by straining, sneezing and coughing if the cause is a herniated disc. Sitting may increase nerve root compression.  The patient may be a hyper-pronator which will cause the piriformis muscle to overwork in order to control excessive internal rotation of the hip.

Orthopedic Assessment
Some of the typical orthopedic assessment techniques a massage therapist may use are:

• Active and passive range of motion testing of lumbar spine and hip.
• Straight Leg Raise is a test in which the patient is asked to lay face up on the table. The therapist will raise the unaffected leg expecting to reproduce the symptoms. There are a number of variations and add-ons to this test all of which help identify causative factors.
• Obers Test is a test in which the patient is side lying. The therapist will lower the patient’s leg from behind to determine the whether or not there is an iliotibial band contraction.
• The PACE Abduction test is performed with the patient seated with their knees together. The therapist will place a hand on both sides of the knees, while the patient attempts to move the knees apart.
• The Piriformis Length test can be performed in a number of ways to determine the length of the piriformis muscle.
• Valsalvas is a test in which the patient is seated and asked to hold their breath and bear down, as if evacuating the bowels. This increases abdominal pressure which will elicit symptoms if there is a ruptured disc.

Massage Treatment Goals
Therapeutic massage aims to remove the cause of the irritation if possible, while decreasing pain and sympathetic nervous system firing.  Massage therapy can be used to reduce fascial restrictions, prevent and decrease contractures and adhesions and deactivate trigger points, commonly found with sciatic symptoms in the gluteus medius, quadratus lumborum, piriformis and iliopsoas muscles.  Massage therapy can be useful in preventing muscle atrophy, reducing edema (if present), and preventing pressure ulcers.  The massage treatment aims should include maintaining or improving joint range of motion and increasing circulation as well as lymph drainage.  Finally, massage therapy should be aimed at reducing muscle tension, spasm and hypertonicity, involved in associated muscles as well as the compensatory muscles of the pelvis, back and neck.

Typical Massage Treatment
The muscles of the lumbar spine, gluteal region and legs should be treated in cases of sciatica. The therapist may determine that the hip flexors should also be addressed.  A typical massage treatment may include the therapists taking the hip and leg through passive ranges of motion.  Swedish massage techniques may be used to increase circulation and maintain tissue health.  Myofascial release and skin rolling may be used to help decrease fascial restrictions.  Petrissage may be used to reduce muscle spasm and to decrease hypertonicity of muscles and frictions and attachment release may be used to reduce adhesions.  The therapist should be careful not to release any stabilizing muscle splinting.  Neural stroking may also be used to reduce spasm, pain and neural activity. Heat and passive stretching may be used to help reduce contractures. Trigger points may be assessed and addressed.

Massage Contraindications & Precautions
Massage is contraindicated in the acute stages where pain prevents the patient from being treated.  If the patient has had a cortisone injection the massage therapist should not perform local massage for at least 10 days after the injection. The therapist should be aware that Pseudo Sciatica may be caused by tumors, nerve injury, diabetes or gout – in any case massage may have to be modified.  In addition, the therapist should be aware that chronic leg cramps may be due to pressure on the nerve by a thombus.  If a thrombus is suspected, massage is contraindicated.  The patient may have impaired or lost motor control, leading to atrophy, as well as paresthesia or sensory loss.  Severe and chronic cases will lead to trophic skin changes.

Typical Suggested Homecare
Deep moist heat may be recommended over the lumbosacral area in order to reduce hypertonicity, while a cool towel wrap may be suggested to help reduce any edema.  Breathing exercises, in addition to static contractions of the quadriceps muscles and active stretching of the piriformis and gluteal muscles may also be recommended. The therapist may also help educate the patient on postural awareness in addition to effective daily habits, like sleep position.  And if hyper-pronation is present the therapist may recommend the patient get orthotics.