Most people with sciatica are told the same thing: rest, anti-inflammatories, wait and see. If that hasn’t worked after six weeks, consider a scan. If the scan shows something, consider an injection. If the injection doesn’t work, consider surgery.
The problem is that this pathway is mostly wrong — not because the steps don’t exist, but because the order is wrong and rest is actively unhelpful for most presentations. The evidence on sciatica treatment has shifted significantly in the last decade. Most GPs haven’t.
What sciatica actually is
Sciatica is nerve pain along the sciatic nerve — the largest nerve in the body, running from the lower back through the buttock and down the leg to the foot. When it’s irritated or compressed, you feel it as pain, burning, tingling, or numbness along that pathway — usually into the buttock, back of the thigh, calf, or foot.
The key distinguishing feature: leg pain is the primary symptom, often worse than the back pain. If you have back pain only, that’s a different problem. True sciatica goes down the leg.
What causes it
The most common cause is a disc herniation at L4/5 or L5/S1 — the bottom two segments of the lumbar spine — where the herniated disc material contacts the nerve root as it exits the spinal canal. This is responsible for the majority of acute sciatica presentations.
Less common causes include:
- Foraminal stenosis — narrowing of the bony canal the nerve exits through, usually from arthritis or disc degeneration. More common in older presentations.
- Piriformis syndrome — irritation of the sciatic nerve as it passes through or near the piriformis muscle in the buttock. Often misdiagnosed as disc-related sciatica.
- Spondylolisthesis — one vertebra slipping forward over another, compressing the nerve exit.
The cause matters because the treatment approach differs. A disc herniation in a 35-year-old responds very differently to treatment than stenosis in a 65-year-old. A proper assessment should clarify which you’re dealing with before assuming either direction.
Why rest makes most sciatica worse
Bed rest for back pain has been out of clinical guidelines for over twenty years. For sciatica, it’s actively counterproductive for two reasons.
First, the sciatic nerve needs movement to stay healthy. Nerves have their own blood supply — neural vascularity — that is maintained by movement. Sustained stillness increases neural tension and sensitisation, making the pain harder to shift. The nerve needs to be gently mobilised, not rested.
Second, the disc material responsible for most acute sciatica resorbs over time — but this process is accelerated by movement and loading. Studies using repeat MRI imaging have shown that disc herniations shrink significantly in most people over three to twelve months, often without any intervention. Movement supports this process. Rest doesn’t.
What the evidence actually says works
Targeted exercise — the right movements, not generic ones
Specific directional exercises — based on which movements centralise or reduce your pain — are the foundation of conservative sciatica management. This is not a generic back strengthening program. The goal in the early phase is to find the direction of movement that eases the leg pain and do more of it.
For most disc-related sciatica, extension-biased movement (prone press-ups, standing back bends) centralises pain — that is, reduces it in the leg and brings it back towards the spine where it’s more manageable. For some people the opposite applies. The assessment should establish which direction works for you before prescribing anything.
Nerve mobilisation
Neural mobilisation (or nerve flossing) involves gently moving the sciatic nerve through its full range by combining hip, knee, and ankle movements in a way that slides the nerve through its surrounding tissue. This reduces neural tension and improves the nerve’s own circulation.
Done correctly, this produces significant relief for many people within a few sessions. Done incorrectly — too aggressively when the nerve is highly sensitised — it can flare symptoms. This is worth doing with guidance rather than off a YouTube video.
Manual therapy to the lumbar spine and hip
Joint mobilisation and soft tissue work to the lower back and hip doesn’t fix the disc, but it reduces the mechanical load on the irritated nerve root by improving movement through adjacent segments. A stiff L3/4 segment above a herniation at L5/S1 forces more load through the already-compromised level. Freeing that stiffness reduces the compression on the disc. More on what manual therapy involves →
For piriformis-driven sciatica, direct soft tissue work and dry needling to the piriformis muscle is often the most effective treatment — and the one that gets missed when the diagnosis is assumed to be discogenic.
Staying active
Walking is one of the most effective things you can do. It loads the spine in an upright posture, moves the nerve, and prevents the deconditioning that makes everything harder to treat. Even if walking is uncomfortable initially — which it often is — the goal is to keep moving within a tolerable range.
What about scans, injections, and surgery?
Scans
An MRI will show you what’s at the level of the disc — but it won’t tell you whether that finding is causing your pain. Studies of asymptomatic adults consistently find disc bulges and herniations in people with no symptoms at all. The scan confirms anatomy, not pain. A positive MRI should inform management, not determine it.
Scanning is appropriate when there are red flags — progressive neurological weakness, bilateral symptoms, any change in bowel or bladder function — or when conservative management has genuinely failed after an adequate trial.
Injections
Epidural steroid injections are effective at reducing acute radicular pain — particularly in severe presentations where the pain is preventing any movement or sleep. The evidence supports their use for short-term relief. They don’t fix the underlying problem and their effects typically last weeks to months, not permanently. They’re most useful as a window that allows you to engage with exercise and physio that would otherwise be impossible.
Surgery
Discectomy is effective for disc-related sciatica when conservative treatment hasn’t worked. The evidence shows similar outcomes to conservative management at one to two years — surgery gets you there faster, conservative management gets you there eventually. The surgical route makes sense when the pain is severely disabling and not responding to six to twelve weeks of proper conservative management, or when there is progressive neurological weakness.
Surgery is not indicated because a scan shows a disc herniation. Most disc herniations causing sciatica will resolve without surgery.
When to worry
Most sciatica is uncomfortable but not dangerous. The red flags that need same-day medical assessment:
- Symptoms in both legs simultaneously
- Numbness or tingling in the inner thighs, groin, or perianal area
- Any change in bladder or bowel control
- Rapidly progressing leg weakness
These may indicate cauda equina syndrome — compression of the entire nerve bundle at the base of the spine — which is a surgical emergency. It’s rare, but the consequences of delayed presentation are severe.
How long does sciatica take to resolve
An acute disc herniation with radiculopathy: most people see significant improvement within six to twelve weeks of proper management. The leg pain is usually the last thing to resolve — the back pain tends to settle first.
Chronic sciatica — pain that has been present for more than three months — takes longer and often has a central sensitisation component (the nervous system itself has become sensitised to the pain signals) that requires a different approach alongside the mechanical treatment. More on why pain becomes chronic →
The people who take longest are the ones who were told to rest and waited three months before doing anything. The earlier proper management starts, the better the trajectory.