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[Physio Explained] Is it really sciatica? A practical approach to differential diagnosis with Tom Jesson

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In this episode with Tom Jesson, we discuss everything about sciatica. We explore:

  • Definition of sciatica
  • What conditions might masquerade as sciatica
  • Diagnostic signs of sciatica

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Tom Jesson is a physiotherapist specialising in lumbar radicular pain, aka sciatica. He has written numerous books, articles and peer-reviewed publications on nerve root pain, and lectured internationally. In his writing, he takes confusing and complicated topics and makes them vivid and clear.

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Our host is @James_Armstrong_Physio from Physio Network

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UNKNOWN:

Thank you.

SPEAKER_01:

It's one of those things that people often don't realize that hip pain can look a lot like sciatica. Typically, we think of hip pain as groin or maybe anterior type pain. But in about 40% of cases, hip pain can pop up at the back of the hip, so in the buttock. And in about 20% of cases, it can actually radiate down below the knee. So you can see how that can easily be confused with sciatica, especially if you're just talking to someone on the phone or you're picking up someone else's diagnosis, another clinician's diagnosis. diagnosis.

SPEAKER_02:

Welcome back to the PhysioExplained podcast, the podcast that brings you clinical insights from the best in the business. In today's episode, we're joined by Tom Jessom, a physiotherapist, writer, and one of the leading voices on sciatica and nerve root pain. Tom has spent years researching, teaching, and simplifying complex topics in neuromuscular care. His work is widely respected for its clarity and clinical relevance, especially when it comes to understanding and managing sciatica. Together, we're tackling a critical cool question is it really sciatica in the episode we explore what sciatica actually is and the key differential diagnosis that every clinician should be considering and some tips on how you might go about that in your assessment and we finish with a simple evidence informed framework to inform your diagnostic accuracy plus and most importantly we have an exclusive offer for you the listeners where you can get your hands on a free copy of Tom's brilliant ebook Understanding Sciatica It's filled with practical tools and explanations that you can apply straight away in your clinical practice. To find out more on how you can get your copy of this e-book, stay tuned and listen to the episode. I'm James Armstrong and this is Physio Explained. Tom, welcome back to the podcast, the PhysioExplained podcast today. We're going to be talking about sciatica. It's great to have you. Great to see you again.

SPEAKER_01:

Thanks, James. It's really good to talk to you again. I enjoyed our last chat about chordal equine syndrome.

SPEAKER_02:

Brilliant. It's always good to have you on, Tom. Loads of content that you produce. For those listening who don't know, Tom's produced books on understanding sciatica, which we're going to talk about in a minute, chordal equine syndrome. We've got zines on everything from doing a neuro assessment to lower limb to chordal equine to sciatica. So yeah, really good content that Tom puts out. But importantly, today, we're offering you, the listeners, for a few days only, a free copy of Tom's e-book version of Understanding Sciatica when you sign up to masterclasses. So this is a great offer, Tom. Thank you for giving this to the listeners. I think it's going to be something that's been really useful.

SPEAKER_01:

It's a very good book, if I can say so myself. Yeah.

SPEAKER_02:

It is. And I can testify to that because I actually have a copy right here in my hand in my office. of which I've had since you first brought it out. And it's one of those books where you can just refer to it at different stages of clinical practice. It's not necessarily a book you're going to always read cover to cover, although I think I've read most of it quite quickly. But it's one that I certainly referred back to several times in the bits that I need to. So it's a really useful book to have in clinic to be able to refer back to as well. So listeners, you can get your hands on this. A few days only. Just sign up to the masterclass. There's been a lot of ink spilled on this issue, James, but when I talk about sciatica,

SPEAKER_01:

I just mean a shorthand for lumbar radicular pain. So an irritation to typically just one of the little wispy nerve, roots in the lumbar spine after they've left branched off from the spinal cord and before they form the sciatic nerve trunk if one gets irritated we can call it lumbar radicular pain if it's painful lumbar radiculopathy if there's a kind of a loss of nerve function and as a shorthand it's easy just to say sciatica so i guess the only thing to say about that is that it's quite a specific definition of actually a relatively rare problem so lots of things can happen in the lumbar spine that cause cause pain down the back of the leg. But when I say sciatica, typically most people are just referring to radicular pain, a specific kind of nerve injury to the lumbar nerve roots or lumbosacral nerve roots.

SPEAKER_02:

Definitely. As you said, yeah, a lot of ink spilled on this. And actually, it's a term that's useful because patients understand it. They're familiar with it as well, isn't it? So we could fight against it. But actually, it's not a bad term. Yeah, brilliant. So we're talking today, obviously, you've done a masterclass on a the listeners are going to be able to access if they sign up for the masterclasses, goes into lots of detail. But today we're going to talk about some of these differentials. What sort of things commonly present that might masquerade, if you like, look a little bit like a sciatica?

SPEAKER_01:

If we leave the kind of the serious pathologies or red flag stuff off the table, although there is a book on that, there's a book called Raquina Syndrome too, and vascular stuff. The stuff that's in our wheelhouse, I often split it up in my mind's eye and i think might be useful into stuff around the hip and stuff to do with the nerves so stuff around the hip might be that we talked about the hip joint the greater trochanter the dreaded piriformis syndrome sij and then there's nervy stuff like neuralgia parasitica ascetic neuropathy common perineal neuropathy and i think that helped me form a bit of a checklist in my head for that kind of very specific part of an appointment, which is I've spoken to my patient. I think they have radicular pain, sciatica. But I just want to run through a few things in my head to make sure I'm not missing something, that I'm putting them in the right bucket for now. And like I say, I'm happy to go through them if you want.

SPEAKER_02:

Yeah, let's go through some of the common ones and how they might present, what sort of things you might see that will differ them from a sciatica presentation.

SPEAKER_01:

So like I say, in my mind's eye, I always think of the stuff around the hip. And if you think of patients, typically when they have a hip pain, like arthritis, FAI, dysplasia, like the hip joint, they often put their, like the C signs, they put their hand on the kind of frontal side of their hip. So kind of in my mind's eye, I start there because that's one of those things that people often don't realize that hip pain can look a lot like sciatica. Typically with, we think of hip pain as groin or maybe anterior type pain but in about 40% of cases hip pain can pop up at the back of the hip so in the buttock and in about 20% of cases it can actually radiate down below the knee so you can see how that could easily be confused with sciatica especially if you're just talking to someone on the phone or you're picking up someone else's diagnosis another clinician's diagnosis and it seems surprisingly common actually that people do misdiagnose or confuse those two of course the difference once you know to kind of think of the hip as a differential is often quite clear you just have to think about it in your mind and we know the typical hip signs are things like difficulty putting on shoes and socks getting out of a car pain with weight bearing although that can be a sign of sciatica too clicking and popping that kind of thing whereas of course with sciatica you'd expect more complaints around the lumbar spine although of course that could coexist especially as people get older and more neuropathic type symptoms so more severity of pain below the knee tingling numbness that type of thing so the again with a lot of these the key is just to kind of know about it and put it on that checklist in your mind and then once you know it's not that difficult to disambiguate the two although sometimes it might come down to special tests and i think in that case you're trying to keep the lumbar spine still and move the hip so people know about the bad ear test flexion adduction internal rotation like the king of hip tests and then another nice one is people lie on get your patient to lie on the back and it's called the log roll test so move their foot in internally and externally rotate their hip by moving their foot and using their foot as a lever. And like most special tests and MSK, they're kind of good rule out tests. So if you're thinking, I think this patient has sciatica. I don't think it's the hip, but I just want to make sure if you do those tests and they're positive, patients like, oh, that hurts. It actually doesn't mean that much. But if they're negative, then you've learned something. Okay, this pain is probably indeed not coming from the hip. The only other thing to say about the hip is that with things like AVN, which actually I always think about because it's the first serious pathology I ever picked up, what feels like a long time ago now. Also, the severity of the pain can mimic radicular pain. So if someone comes in and they have unbelievable bad pain running down their leg you straight away think ridiculous but if a serious pathology in the hip can have that severity that makes it look ridiculous too. From there in my mind's eye I go kind of laterally round to the greater trochanter which is another one of those things where not to sound too smug but you kind of think well how can that be confused with sciatica but it's actually pretty well documented in the research that it often is so it's just a case of putting it on that checklist in your mind and remembering that greater trochanter it hurts to press on GTPS If it doesn't hurt to press there, it's probably not GTPS. You've got the single leg stance against the wall. And just kind of teasing them apart in your mind. Typically, radicular pain would be just as bad, if not worse, below the knee, whereas GTPS can radiate downwards, but there's probably going to be worse around the greater trochanter. And maybe the patient population is a little bit different with GTPS. It's more commonly, I believe, all the Fs, so with, forgive me, fat female and over 40. And those people certainly can get radicular pain too, but the patient population maybe moves the interaction of GTPS. But there's certainly being misdiagnosed as radicular pain. And again, I don't think you have to be Dr. House to work out the difference. It's just a case of knowing and then doing your kind of sensible assessment stuff. And I suppose I'm on a roll because I'm just, again, my mind's eye going back around the back of the hip to the dreaded piriformis syndrome or deep gluteal syndrome. And in the interest of keeping the podcast short, I'm not going to open that whole can of worms, but it seems to be very, very rare. I think most buttock pain is coming from the lumbar spine, whether it's referred or radicular. And there are kind of all the criteria for deep gluteal syndrome could equally even the special tests just be tests for sciatica too in my mind we don't have a lot of objective stuff to lean on there it's just a case of if you really want to diagnose deep gluteal syndrome you want a very unspiny presentation not much going on the lumbar spine at all and ideally like maybe some history of trauma or something implicating the buttock, and even something implicating the sciatic nerve as well, which is what deep gluteal syndrome is supposed to be after all. People often forget about that. But just continuing my tour, and then kind of I track even further around to the SIJ, which again is one of those things that I think is very rarely can look like sciatica, but pretty well documented that it can be pretty severe and go down below the knee, although obviously usually without the neuropathic aspect of sciatica. And also then again, there's some evidence that people with SIJ can reach down towards their toes pretty comfortably, whereas people with sciatica generally don't want to do that. And then again, of course, just the story will be different. You might be looking for something to implicate the SIJ in terms of a trauma or so on. Probably the most important thing to think about with the SIJ is, do you want to consider sacroiliitis? Like to open a door into another area of MSK briefly, that is inflammatory sacroiliac joints going to lead you to ask about what happens with that NSAIDs, uveitis, anthesitis and psoriasis and so on. But again, like with a lot of these things, it's all about kind of just knowing it and taking a step back and running through it in your head, especially if you've inherited the patient from a telephone assessment or a clinician who's been in a hurry. And then I guess for the last of the stuff around the hip, I always just think about the pelvic girdle generally and all the bad bony stuff that can happen there. Insufficiency, fractures, pathological fractures, osteosarcomas and so on. Does it hurt to palpate? Is there the pain very very severe has the patient got their hands on crutches because they can hardly wait there it's very easy to and i believe quite common to mistake that stuff for ridiculous pain because of the severity of the pain and the goodness me i don't want to move i don't want to do anything aspect of the presentation although of course those people may well have a history that makes you think of overtraining steroid use what else history of cancer osteoporosis that type of thing the key thing is just stepping back for me it helps to do that little talk eye around the hip and just weigh each one up and see where you are.

SPEAKER_00:

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SPEAKER_02:

But I think it's really good, isn't it? I think lots of clinicians will tell people about how their methods, their way of navigating these assessments. And I think that's quite nice for clinicians to have that in their mind, that tour around that area. But particularly, like you said there, if you're inheriting patients from other clinicians who may have been in a rush or telephone, but also being biased by your patient, because a lot of patients I know from experience will come in and tell you it's sciatica. And that's very easy, isn't it, then to then in your mind be drawn into that, but actually taking that step back like you said and having that tour even if it's just in your head and thinking okay what is this patient telling me and how does it sound but being having the confidence to be able to take a fresh look and a step back

SPEAKER_01:

yeah absolutely

SPEAKER_02:

yeah excellent wonderful so in terms of sciatica diagnosis of sciatica any key takeaways if you were to give our listeners anything to say this is something you think is really important that you've done from your reading your research and in clinical experience what would that takeaway be

SPEAKER_01:

I'm devastated because we don't have time to talk about the nervy differentials we're leaving that for another time

SPEAKER_02:

definitely let's leave that for that that's a cliffhanger for our listeners

SPEAKER_01:

I think in oh goodness me a key takeaway is probably considering base rates and being sensible so most pain that radiates down the leg comes from common stuff referred pain from the low back so back pain that's bad enough to go down the leg basically and referred pain from the hip so hip pain that's bad enough to go down the leg remember that sciatica I always forget get because I talk about it and write about it so much actually very pretty rare true sciatica like true neuropathic sciatica is pretty rare and so I guess my advice would be just not to complicate things don't doctor house stuff just have that checklist in your head and match the patient's pattern to the pattern of the kind of classic conditions that we know about and go from there because I always worry when I come on these things and I can often find myself getting carried away and rattling off a lot of information remember common things are common common just see enough patients and read read read to get an idea of what stuff generally looks like and all you have to do is match what the patient's talking about to your kind of platonic picture of the condition in your head.

SPEAKER_02:

Well I think it's a nice one isn't it in terms of keeping it simple and I think some of the thing from this for me is thinking like the title of this podcast episode is it really sciatica and look at thinking of those differentials running through your head and don't assume just because it's coming down the back of the leg that it is a automatically sciatica. So I think that's really good. And I think lots of listeners will probably take away your tour of the hip and lower back, Tom. So I think it's been really useful. Thank you very much for your time again.

SPEAKER_01:

We'll have to go on your like hour long version so I can talk about the rest of this stuff one day.

SPEAKER_02:

Absolutely. I think there's a lot more to dive into. I think we definitely get you onto the Physio Disgust podcast, which listeners will be aware of, where we've got a bit longer to dive into these details. And we'll definitely get you on for that, Tom. But as we said, listeners, you do have an opportunity for just a few to get all this information, a lot more information in the form of understanding Satka ebook from Tom himself. And all you need to do is sign up to masterclasses and say you've only got a few days to do this. So do click the link in the show notes below and get yourself a free copy of the ebook. I can say it is fantastic, really, really useful, as is all of the stuff that Tom's produced over the few years. So do check out Tom's other materials. They really are very accessible and very useful. in clinic Tom once again thank you very much and I look forward to seeing you or certainly speaking to you on the physio discussed at some point in the near future

SPEAKER_01:

that's great thanks James

SPEAKER_02:

cheers Tom take care