We see a lot of what is identified as "sciatica" in our clinic and school. The most common presentation of this so-called "diagnosis" is one-sided pain, consisting of elements in the low back, the glutes, the groin, and the lateral hip and leg. Occasionally knee pain may also be a component.
I know this pattern well. Before I was a bodyworker, even as a very young man, I would experience regular periods of intense, crippling pain in my back, hips and legs. Fortunately, I had friends who guided me toward less invasive alternative therapies, and I never ended up under the scalpel. However, I also didn't really get any lasting help.
The seemingly unrelated collection of complaints called "sciatica" confuses most practitioners. Because sciatic pain patterns often roughly resemble dermatomal nerve patterns, most people assume that an impinged nerve is responsible, and the sciatic nerve is most commonly blamed.
Dr. Travell was careful to point out that the term sciatica is not a diagnosis (Travell & Simons, 1992, 173), but simply a common pain pattern. In actuality, nothing about it implies or reveals the true source of the pain – it's just a symptom.
I didn't get any lasting relief from my pain until I discovered trigger point therapy and began studying the true origins of pain. I used my own body to self-experiment, and was able to decrease the frequency of my pain episodes. Eventually, as my knowledge grew, my pain disappeared.
A basic tenet of trigger point therapy and Coaching The Body™ is that most pain originates in areas of stagnation in muscles (trigger points). Without this extremely important key, it's easy to be fooled by serious pain conditions and assume that some type of injury and/or neurological involvement is responsible. I call this injury-centric thinking, and unfortunately it pervades our culture.
Evaluating Leg Length
In the 20 years I've spent developing CTB, I've observed an extremely high correlation between unilateral pain in the lower body and leg length discrepancy (starting with myself). This makes a lot of sense when you understand how trigger points develop and behave – and none if you don't. More on that in a moment.
Actual bony lower limb length inequality of > 5mm has been observed in approximately 50% of various populations (Travell & Simons, 1992, 56-58). Bony limb length differences are not rare, and in individuals with unilateral pain they are actually quite common.
Unfortunately, evaluation of lower limb length is seriously misunderstood. I find that most clients who have been evaluated for leg length have been evaluated while lying on a table. Here’s why this approach doesn’t make sense...
When the client isn't bearing weight on their feet, what you’re actually observing is the effect of the muscles that control pelvic lateral tilt (primarily the quadratus lumborum), unfettered by joint stacking and gravity. If one QL has trigger points and taut fibers, it will pull the hip up closer to the ribs and make that leg appear shorter on the table.
The problem is that it's the QL on the long side that is most likely to develop trigger points and become adaptively shortened. On the table, without the client weight bearing, this could actually cause the long leg to appear shorter.
Here’s how we assess for leg length discrepancies (we call this an effective leg length assessment since we aren't doing any imaging of the bones):
Step 1: Ask the client to stand up straight with feet close together. This accentuates any asymmetry between left and right.
Step 2: Measure the height of the iliac crests as well as other bony landmarks against a visual level. While this process is far less perfect than detailed radiography, it usually works quite well in practice.
Step 3: Verify your theory by placing a correction under each side in turn, and getting subjective reports from the client. Having the lift on the short leg may feel "different" but not bad, while having the lift on the long leg will exacerbate the issues and may produce more pain.
While this technique isn't able to provide perfect results and there will sometimes be complicating issues, overall it has a high rate of success due to the fact that we're subjectively verifying with the client that a correction on a specific side feels better. So we don't let perfection get in the way of being able to help.
When Manual Therapy Is Not Enough
Some practitioners tell their clients that their problems can be corrected via non-invasive techniques such as chiropractic or manual therapy. This is the lesser evil. The unfortunate ones are told that they need back surgery (of course, this could be indicated, but statistically this is relatively unusual).
As someone who spent many years having bouts of severe, crippling back pain at times, I could have easily believed that I needed back surgery.
Functional scoliosis predictably develops if the base of the spine is tilted at the sacrum due to a lower limb length discrepancy. This structural change will then cause the muscles that stabilize the pelvis and spine to adapt and have different resting lengths on the left and right.
The quadratus lumborum (QL) is affected profoundly by this scenario, as its function is to posturally unite the pelvis and the ribs.
No amount of spinal adjustment or manual therapy on the QL will resolve pain in a lasting way under these conditions. I spent 12 years trying to get relief from chiropractic. I had an undiagnosed bony leg length discrepancy, but when I would faithfully visit the chiropractor twice a week, he would use an activator to adjust my L3-4 segments out of their rotational subluxations every single time, measuring my leg length on the table instead of in a weight-bearing position.
I was happy at the time if I could string together a week or two of reduced symptoms. In retrospect, I can see why this approach was so misguided. Trigger point therapy, correcting hyperpronation, corrective exercise and a heel lift has allowed me to be pain free for many years now.
The Analysis Is The Key, Not Fancy Techniques
The reason I never got lasting help was in the analysis, not the techniques. Bony adjustments can be life savers under the right circumstances. In my case, the practitioner failed to understand the chain of events that I now know had unfolded.. He apparently thought that my issues started and ended with my spine, because that was the only thing he ever treated.
But it makes little sense if someone goes through life with tilted hips and sacrum to expect that the solution would reside in the spine. After many years of research and study, this is what I have come to understand as the genesis of my own and many others' issues:
- Anatomical lower limb discrepancy causes the sacrum and pelvis to tilt laterally.
- The structural asymmetry causes stabilizing muscles to operate at abnormal and asymmetrical resting length.
- The CNS attempts to stabilize this abnormal and potentially dangerous situation by employing trigger points and taut fibers in the deep spinal muscles, QL, iliopsoas and others. This can be worse in people with excess mobility, as this is naturally a condition of less stability.
- Trigger points cause pain referral and establish chains of satellite referral into the glutes and down the leg.
- Compensating deep spinal muscles move spinal segments out of normal and occasionally cause neurological impingements – which further compound the issue and can lead to critical levels of pain and dysfunction. Tapping segments back into place doesn't address the reason that they became distorted - it's a symptomatic fix that overlooks the origins of the asymmetry from below.
Having bony adjustments occasionally would correct the final step in this sequence and get me out of urgent trouble, but failed to address the real issues that preceded it.
As a yogi and martial artist, I was extremely active, but no amount of movement or stretching could keep my problems from returning. This goes to show that highly conditioned athletes are still vulnerable to pain and dysfunction caused by leg length discrepancies.
Many of my clients and students feel that they should be able to overcome anatomical variations like LLLI and hyperpronation by developing strength. My experience has shown me that being strong and flexible is a good thing, but it isn't enough. Wearing corrective insoles and a heel lift allows someone who is looking for peak performance to achieve higher peaks, and to train without regular interruptions from pain.
Bodywork In Its Proper Place
Bodywork is still necessary. I don't mean to minimize the importance of treating the correct muscles in the right order. That is usually our first step, because we know that we can reliably reduce the client's pain. We also do the assessments in the first session, because the goal is to change the pattern, not to have a dependent weekly client.
I never wanted for clients or work – even with this seemingly cavalier attitude about keeping clients. Referrals tend to go through the roof when you are the one who helps someone after 30 failed practitioners. I tend to get bored if I do the same thing every time, so it wasn't really an option for me to do a lot of maintenance work.
As I developed certification programs to teach others what I do, I created a concept called a protocol which superficially seems like a sequence, but is actually a living process. You cannot blindly follow sequences and expect to help people reliably, because you end up doing a lot of work that is unnecessary – and missing the really important things that reveal themselves if you pay attention.
In our certification program, we focus on protocols for the most common pain patterns in the upper and lower body. The protocols guide you through visiting the relevant muscles for each pain pattern, based on years of compiling what we've learned, over thousands of cases.
The 80/20 rule, or Pareto Principle, popularized by Malcom Gladwell in his book The Tipping Point, is very much applicable here (Gladwell, 1905). Clinical bodywork and the analysis of pain patterns are complex activities, yet most of the problems people report originate in the same patterns and similar groups of muscles.
We have made this process highly accessible to our students by focusing our base level certification program on the protocols that generate the vast majority of reported issues. We've actually discovered that a relatively small group of muscles along with attention to common perpetuating factors, such as leg length, can resolve a huge portion of client complaints.
In the case of sciatic pain, a common satellite chain begins with the response of the QL to leg length differences, and then cascades through the glutes and leg muscles, resulting in a widespread but highly predictable and related pain pattern. Most of these cases are easily addressed by following the protocols in our basic certification program.
The good news is that anyone can learn this approach, but it makes me sad when I meet yet another client whose life has been compromised for decades and could have been helped a long time ago. I was fortunate. This is why I do what I do, and why I want to get this work more widely recognized.
Thanks for reading! If you would like more information about our online and in-person programs, please visit our website and/or attend one of our webinars.
My next live web class will be on November 19, 2020, covering self care for sciatic pain - click below to register.