Why Your Sciatica Isn't Getting Better (It Might Not Actually Be Sciatica)
If you've been dealing with pain shooting down your leg and someone told you it's sciatica — that's a start, but it's not a diagnosis. It's a description of a symptom. And that distinction matters more than most people realize, because sciatica can come from several completely different places in your body, each requiring a completely different treatment approach.
Treating one like another is one of the most common reasons people with sciatic symptoms spend months in pain without getting better.
Sciatica Is a Symptom, Not a Condition
The sciatic nerve is the largest nerve in the body, running from the lumbar spine through the glutes and down the back of each leg. When it gets compressed or irritated anywhere along that path, you feel it as pain, numbness, or tingling that travels down the leg. That's sciatica — a description of where you feel symptoms, not an explanation of why.
The why is what changes everything about how it should be treated.
Source One: Disc Herniation
The most commonly recognized cause of sciatic symptoms is a disc herniation at L4/L5 or L5/S1 — the two lowest segments of the lumbar spine. When a disc bulges or herniates, the displaced disc material can press directly on the nerve root as it exits the spinal cord, sending pain, numbness, or tingling down the path of that specific nerve.
The pattern is usually recognizable. Pain typically starts in the low back and radiates down the leg, often tracking below the knee. Bending forward, prolonged sitting or standing, sneezing, and coughing tend to make it worse because they increase pressure inside the disc. A straight leg raise test — lifting the leg while lying flat — is often positive, reproducing the radiating pain. There are frequently true neurological findings: changes in reflexes, muscle weakness, or altered sensation in a dermatomal pattern that maps to the affected nerve root.
This presentation needs to be treated at the spine. Decompression, joint mobilization, and reducing the mechanical load on the affected segment are the primary targets.
Source Two: Nerve Root Compression from Stenosis
A related but distinct presentation involves nerve root compression from spinal stenosis — a narrowing of the spinal canal or foraminal openings caused by degenerative changes like bone spurs, thickened ligaments, or arthritic joint changes rather than a disc.
The symptoms can look nearly identical to disc herniation, but the history is usually different. Onset is more gradual, the population tends to be older, and the pattern of aggravating factors can shift — extension-based activities like walking or standing often become the primary aggravator rather than flexion. Imaging helps differentiate this from disc herniation, and treatment needs to account for the degenerative nature of the compression rather than assuming the source is discal.
Source Three: Piriformis Syndrome
This is where a significant number of misdiagnosed cases land. The sciatic nerve runs directly underneath the piriformis muscle — a small but deep hip rotator sitting in the posterior glute — and in some people it runs directly through it. When the piriformis gets tight, hypertonic, or develops adhesions, it can compress the sciatic nerve and produce symptoms that feel exactly like sciatica.
The key difference is in the pattern. Piriformis syndrome typically produces pain in the buttock and upper thigh that stays above the knee in most cases. It's aggravated by prolonged sitting, hip rotation movements, and direct pressure on the posterior glute. Unlike disc herniation, it typically doesn't produce the classic neurological deficits — no reflex changes, no myotomal weakness — though numbness and tingling along the nerve path can still occur. The straight leg raise is often negative even when symptoms are severe.
The problem lives in the soft tissue of the hip, not in the spine. Treating it with spinal decompression or lumbar joint mobilization alone will produce little to no improvement, because the compression point is downstream of the spine entirely. The piriformis needs to be released directly — through soft tissue work, dry needling, or a combination — and the hip mechanics driving the muscle's overactivation need to be addressed.
Why the Diagnosis Has to Come First
The overlap in symptoms between these three sources is exactly why so many people cycle through treatment after treatment without resolution. If you treat a piriformis syndrome patient with lumbar-focused care and miss the hip entirely, the nerve stays compressed and the symptoms stay present. If you treat a disc herniation patient with only soft tissue work targeting the glute, you're managing where it hurts rather than what's causing it.
A proper assessment — including neurological testing, orthopedic provocation tests, dermatomal mapping, and a thorough history — can differentiate these sources with a high degree of accuracy before any treatment begins. That's the step that most people with unresolved sciatica never got.
If your sciatic symptoms haven't responded to treatment, the most important question isn't what treatment you need. It's whether anyone has accurately identified where the problem is actually coming from.
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Dr. Brian Trautman is a chiropractor, certified athletic trainer, and strength and conditioning specialist at Optimal Health & Performance in Cincinnati, OH. He specializes in movement-based care for athletes, runners, and active adults.
