Over the past ten months, I’ve repeatedly mentioned my sciatic symptoms, particularly how they have limited my exercise program.
In this blog post, I’ll describe my sciatic symptoms, postulate their etiology, and share how I intend to manage them.
Why “Sciatic Symptoms,” and Not “Sciatica”?
Eagle-eyed readers of this blog would have noticed that I had previously referred to the symptoms in my left butt and leg as “sciatica” but now call them “sciatic symptoms.”
Here’s why I changed terminology.
As I was preparing to write this post, I found it relatively easy to relate the chronology of my symptoms – I merely had to refer to the notes in my diary and expand on them.
However, for a presumed or tentative diagnosis, there are a few medical conditions that could/can explain my symptoms, e.g.:
- Deep gluteal syndrome
- Sciatica (i.e., “true sciatica” or “discogenic sciatica”)
- Spinal stenosis
Without the benefit of an expert opinion and special investigations, such as a recent MRI scan of my lumbosacral spine and electromyography, I can’t make a definitive diagnosis.
Some people describe symptoms arising from any disturbance of the sciatic nerve or one of its nerve roots as “sciatica.” I’ve chosen not to do this.
“Sciatica” implies nerve root impingement, i.e., compression or irritation of one of the nerve roots (L4, L5, S1, S2, and S3) that make up the sciatic nerve.
Because I cannot be sure my symptoms have been due to nerve root impingement, I prefer not to call them “sciatica.” I’ll use the term “sciatic symptoms” instead.
Left Buttock Pain in August 2021
I might have experienced it earlier, but my first record of left buttock pain was on August 11.
Initially, the pain was localized to the left buttock and occurred only at bedtime while I lay supine. The pain was severe (8/10 on the numeric pain rating scale) and came in bursts that lasted two or three minutes. After ten to fifteen minutes, the entire episode would pass, and I could sleep.
The pain in my buttock was not associated with back pain or discomfort. I also had no lower limb symptoms, such as numbness, paresthesia, or weakness.
I experienced these episodes of buttock pain on at least ten consecutive nights.
Symptoms Associated With the Left Buttock Pain
After about a week, I started developing twitches in my left hamstring muscles associated with the buttock pain while lying in bed. While the hamstrings were twitching, I not only could feel pain in the back of my thigh but also felt repeated, involuntary contractions of the muscles with the fingers of my left hand. These twitching episodes were harrowing. They resolved spontaneously after about ten to fifteen minutes. I tried stretching my hamstrings while experiencing the twitches, but this didn’t stop the muscle twitching or relieve the pain.
I had an isolated episode of rectal spasms on attempted defecation on August 26. The pain was severe (10/10 on the numeric pain rating scale), sharp, and lasted about 3 minutes before it gradually subsided. I had previously experienced something similar in 2017 and early 2018. Then, I linked the rectal pain on defecation to ulcerative colitis. But I suspect this most recent episode was unrelated to ulcerative colitis and probably had something to do with the left buttock pain.
Both hamstring twitches and rectal pain can occur in sciatica and piriformis syndrome, so neither symptom helped differentiate between the two conditions. However, twitching of the hamstrings while I had the buttock pain and when I was lying supine suggested the problem was more likely in the piriformis muscle. It felt like a muscle deep in my butt was spasming (causing a sharp pain in the butt) and irritating the sciatic nerve (causing the twitching in the hamstrings).
Evolution of the Buttock Pain in August 2021
By August 28, 2021, about three weeks following the onset of my buttock pain, it had become more constant throughout the day instead of occurring only at bedtime. Still, its intensity had diminished, being only mild to moderate, with occasional (once every few days) and brief episodes (lasting 10-15 minutes) of sharp, excruciating pain. These episodes usually happened while I was lying supine in bed at bedtime but could also come on, seemingly spontaneously, while I worked at my desk.
Why I Believed I Had Deep Gluteal Syndrome
As with all other aches and pains in my muscles and joints, I thought little of the left butt pain when it first appeared in mid-August. I brushed it off, thinking it resulted from doing a relatively large running volume in the previous weeks.
In July and August 2021, I ran between 8 and 13 km or rowed for 60 minutes every day except on rest days. I took only four rest days in July 2021 and seven in August 2021.
One motivation for running as much as I did was the prospect of joining a team in a virtual running challenge next year. I had narrowly missed the opportunity to sign up for the challenge in June 2021.
When the pain became more persistent in late August, I began considering plausible reasons other than the typical musculoskeletal pain from exercise.
My initial impression was that I had deep gluteal syndrome. (But several weeks later, I wondered if discogenic sciatica was more likely.)
I suspected the relatively large amount of running and rowing either fatigued or caused microtrauma to my left piriformis muscle or another adjacent muscle (superior gemelli, obturator internus, obturator externus, inferior gemelli, or quadratus femoris), leading to tightening or spasming of the muscle, thus irritating the adjacent sciatic nerve.
I had been sitting at my desk for many hours while working on a project. Sitting for long periods is a risk factor for deep gluteal syndrome.
In short, I believed the exercise I had been doing, coupled with prolonged sitting, resulted in secondary deep gluteal syndrome.
There was some tenderness on deep self-palpation of my left piriformis muscle (and none on the right side), but I could not reproduce the severity of the sharp pains I was getting in my left butt at night.
Both the seated piriformis test and active piriformis test were negative. The straight leg raising test was likewise negative.
I did not walk with a limp.
From late August (August 28, 2021, to be precise), I presumed I had deep gluteal syndrome and acted accordingly.
Worsening of Left Buttock Pain, Radiation of Pain Down the Leg, and Paresthesia and Numbness of the Left Leg and Foot
On August 28, I had an incredibly severe episode of left buttock pain at around midday while sitting at my desk. Because the pain persisted for more than an hour, I tried 10 mg of oral prednisolone (to reduce possible inflammation of the left piriformis muscle) and did not exercise that day. I don’t know if the medication helped, but the pain subsided to a tolerable level later in the day.
Because I believed cycling and running could worsen piriformis syndrome, I avoided those two forms of exercise for more than a month. I was unaware that rowing could also worsen deep gluteal syndrome, particularly piriformis syndrome, and continued rowing, albeit for shorter periods (between 30 and 60 minutes per session), as my only form of exercise from August 30 through September 11.
In the meantime, I developed more symptoms. From September 7, I had intermittent sharp shooting pains and a tingling sensation (paresthesia) radiating down the back of my leg to my ankle, occurring while I was sitting or lying in bed, but never while standing or walking.
I felt left leg and foot numbness in mid-September. The numbness was not always present; there would be times throughout the day I did not experience any numbness in my left leg and foot. Prolonged sitting and sometimes rowing precipitated the numbness.
I started supine stretching of my piriformis muscles daily in mid-September, which seemed to help somewhat.
At no time did I notice any weakness in my left lower limb.
Three-Week Exercise Holiday and Resolution of Symptoms
On September 19, I realized I might have made a mistake in continuing to row after reading that rowing could also contribute to my sciatic symptoms. The pain in my left butt was not improving, and the left foot numbness worried me. So, I stopped rowing then.
Between September 19 and October 5, I did not row, run, or cycle.
For exercise, I walked long distances, between 15.5 and 18.8 km, on reasonably even terrain on alternate days.
Despite the reduction in exercise in September and the first week of October, I still lost about 6.3 kg over three months, i.e., between July 6 and October 5.
Abstinence from running, rowing, and cycling seemed to do the trick because my symptoms resolved entirely.
I was symptom-free when I attended my gastroenterology clinic appointment on October 5.
I continued walking regularly, resumed running on October 8, and occasionally rowed for the rest of the month until my first COVID-19 vaccination on October 27. I exercised for a little over 19 hours in October 2021.
COVID-19 Vaccination in October and November 2021
After my first COVID-19 vaccine dose on October 27, 2021, I took a week off exercise because of the small increased risk of myocarditis and pericarditis, especially in young adults and adolescents, following administration of the Pfizer-BioNTech (BNT162b2, Comirnaty®, or Tozinameran) vaccine.
As an added precaution, I took it easy when I resumed exercise, e.g., a light 8.1 km run on November 3, a 20-minute row on November 4, and a 7.8-km walk in about one and a half hours on November 5.
I continued to do similar exercises until my second COVID-19 vaccination on November 17, 2021.
I experienced some side effects after the second dose of the COVID-19 vaccine, but they did not prevent me from exercising from November 25 onwards.
Because the risk of myocarditis and pericarditis was reported to be higher after the second vaccination (compared to after the first), I was cautious not to overexert myself. My run on November 25 covered only 7.93 km in 48 minutes. I took the next four days off because of nausea and brain fog but could exercise again on November 30. From then until Christmas Eve, I restricted my workouts to runs between 45 and 49 minutes (7.9–8.5 km), walking (up to 18.3 km), and rowing (only twice – for 15 minutes on December 12 and 30 minutes on December 9).
In November 2021, I spent only about 495 minutes or 8.25 hours exercising. In December 2021, the figure had increased to 20.4 hours, but this volume was considerably less than I had been doing before my sciatic symptoms.
Recurrence of Symptoms in December 2021
In the second week of December, I felt my left buttock pain and left leg and foot numbness again.
Occasionally, the left buttock pain radiated down the back of my thigh and leg and into my foot.
The numbness became so intense in the last week of December that I took a 10-day break from all forms of exercise.
I ran 8.2 km in 51 minutes on January 4, 2022, but this session aggravated my left leg symptoms – the sensation of numbness in my left leg and foot now felt more like pain. Because the pain in my left lower limb was quite severe, I did not exercise for five days. I tried to go out for a light stroll in the neighborhood on January 7 but had to abort this plan after walking only about 0.7 km because of excruciating pain at the top of my left foot.
I had hoped the sensory symptoms (numbness and pain) in my left leg and foot would subside and eventually disappear as they did in the second half of September 2021. Unfortunately, the left leg and foot numbness has persisted, to varying degrees, until today.
To satisfy my need for exercise, I rucked for over 23 km on January 10 without worsening my symptoms. I did more rucking in subsequent weeks and months instead of running, rowing, and cycling.
Episode of Severe Back Pain and Left Leg and Foot Numbness in January 2022
In mid-January 2022, I experimented with a standing desk setup to help with my sciatic symptoms. I hypothesized that standing instead of sitting while working at my desk would reduce stress on my lower back, preventing left leg and foot numbness if I had true sciatica.
It didn’t take long to learn that a standing desk was not workable in my case. I suffered an enormous amount of lower back pain, accompanied by left leg and foot numbness and paresthesia.
So, the standing desk experiment aggravated my symptoms despite many tweaks instead of improving the situation. Sitting, rather than standing, at my desk on January 28 relieved my back pain and leg and foot numbness.
Since the episode of back pain and left lower limb symptoms in January 2022, my sciatic symptoms have been stable, neither better nor worse, for any prolonged period.
There may be periods lasting up to 10 days in which the symptoms are more noticeable than usual. A moderate volume of rowing or running invariably precipitated these episodes. My symptoms improved when I ceased these physical activities.
Below, I summarize the individual symptoms I experience almost every day.
Sensory Symptoms in my Left Lower Limb
I experience numbness in the lateral aspect of the left lower leg and the top of my left foot (L5 dermatome). The numbness is present most of the time, fluctuates in intensity throughout the day, and is least intense (or even absent) when I first get out of bed in the morning.
In the past few weeks, sitting on my Varier Variable Balans kneeling chair either brings on the leg and foot numbness or worsens it. Since I sit on this kneeling chair for many hours throughout the day, I often experience numbness. A sensation of tingling or burning (paresthesia) often accompanies an intensification of the numbness, especially at the ball of my left foot. When it is severe, the sensation feels more like pain rather than numbness or paresthesia; the pain is mainly in the area under the foot between the first and second toes and between the second and third toes.
The sensory symptoms are relieved by getting off the chair (standing), walking, and (strangely) stair climbing. These symptoms become imperceptible after about 10 minutes of walking or stair climbing.
Lying supine in bed with a thin pillow under my calves eases the numbness in my left leg and foot or often takes it away completely. I may feel numbness and paresthesia in the leg and foot if I (unconsciously) move from this position during my sleep.
Intermittent Low Back Pain
I have suffered lower back pain for over 25 years, making it difficult to tell whether my back pain is sciatic.
The pain in the small of my back is mild and may be associated with my left lower limb symptoms. My lower limb symptoms may occur without me feeling any back pain. But, these days, I usually have sensory symptoms in my foot simultaneously when I have back pain.
Symptoms I Do Not Have
Besides describing my symptoms, I think it is essential to mention some negatives.
The left buttock pain I had around 13 months ago went away after about two months; I’ve not felt any pain in my butt in the past 11 months.
I have noticed no weakness in my legs or feet.
I have had no sciatic symptoms in my right lower limb.
My bowels and bladder are functioning normally.
Potential Causes of My Sciatic Symptoms
The two most likely causes of my sciatic symptoms are:
- Deep gluteal syndrome, and
- Discogenic sciatica.
In both conditions, irritation, pressure, or some other sciatic nerve disturbance leads to similar symptoms. Telling them apart has proven challenging for me.
None of the following symptoms I’ve been experiencing helps to differentiate the two conditions:
- Onset or worsening of the left leg and foot sensory symptoms in the L5 distribution on sitting for more than a few minutes, especially on my kneeling chair (which is surprising because some patients with sciatica report improvement with the use of a kneeling chair)
- When lying supine, improvement of my left lower limb symptoms when resting my calves on a thin pillow
- Low back pain (though I have had similar pain off and on for at least the past quarter of a century)
In either condition, we expect walking and stair climbing to exacerbate my symptoms. However, in my case, walking or stair climbing improves or eliminates the symptoms!
When I developed buttock pain and hamstring twitching a year ago, I was pretty confident it was deep gluteal syndrome. I had logged many miles of running in the preceding two months, which could have injured a muscle in my left buttock, e.g., the piriformis, leading to the muscle tightening or spasming, resulting in entrapment of the sciatic nerve in the deep gluteal space.
However, after the symptoms in my left buttock and hamstring disappeared, I thought lumbar radiculopathy (i.e., true sciatica) was more probable. I failed to consider the possibility of chronic deep gluteal syndrome as a sequela of injury and inflammation, which may cause the formation of fibrous bands in the sub-gluteal space or contracture of the piriformis muscle pinning the sciatic nerve against the pelvis.
Do I Need to Know the Cause of My Sciatic Symptoms?
In case you haven’t figured it out already, I have given little attention to finding the cause of my sciatic symptoms.
Why? You may ask.
In their current form, I believe I can manage my symptoms with conservative treatment, regardless of their etiology. Knowing what is causing my symptoms will not change my approach, which includes temporary cessation of activities that aggravate the symptoms (such as rowing, running, and cycling) and stretching exercises.
Having a definitive diagnosis might be nice, but it is unnecessary.
Pursuing a diagnosis will entail special investigations, which I don’t fancy because they have risks.
I will see a back and hip specialist if:
- The numbness in my left leg and foot becomes persistent, i.e., it doesn’t improve with the maneuvers that have been successful for me, or becomes more intense
- The pain in my back becomes intolerable
- I develop pain in my left leg or foot
- I have leg weakness
- My bowels and bladder don’t work normally
How I Manage My Sciatic Symptoms
My sciatic symptoms and exercise program are inextricably linked. My symptoms worsen with increased physical activity and subside when I reduce or stop my exercise. Also, the sciatic symptoms limit how much physical activity I can do – if I am troubled by symptoms, I avoid aggravating them by reducing the volume or intensity of exercise or avoiding exercise altogether until my symptoms improve.
Temporary Abstinence from Running, Rowing, and Cycling
About two weeks ago (mid-August 2022), I wanted to see if I could return to a state where I did not experience the numbness in my left leg and foot daily. So, I refrained from rowing, running, or cycling from August 14 onwards. For exercise, I have been walking or stair climbing only:
- Walking. In the last fortnight, my walking sessions have been between 2 hours and 2 hours 40 minutes only (9.8–13.1 km), always with some weight (between 4 and 6 kg) in my backpack. I am reluctant to push any further for fear of injury.
- Stair climbing. I have gradually escalated the duration of my stair climbing sessions – they go on for around 1 hour and 30 minutes these days. I had been stair climbing with no added weight on my back, but I stair climbed with about 3.5 kg in my backpack today with no immediate adverse effect.
Exercises to stretch the piriformis and other deep buttock muscles, hamstrings, and lower back may help my symptoms. I haven’t been consistent in stretching exercises, so this is an area for improvement.
Optimize My Sleeping and Sitting Posture
While lying supine in bed, I’ve been using a thin pillow under my calves. This position offers the most relief from numbness and paresthesia in my leg and foot.
Sitting on my kneeling chair has been problematic. Although some people swear by kneeling chairs for the amelioration of their sciatic symptoms, I’ve had the opposite experience; using my Varier Variable Balans kneeling chair either precipitates my sciatic symptoms or makes them worse. One probable reason is that I have been slouching in the chair instead of sitting upright. I need to pay more attention to my sitting posture. In addition, keeping my knees on the chair’s knee pads (instead of placing my feet on the floor) and occasionally rocking the chair – it’s designed for gentle rocking motions – may help.
I have been wearing Finn Comfort’s “Soft Prevention” line of shoes for work – I have not found shoes more comfortable than these. However, as is the custom in Southeast Asia, I walk around barefoot at home.
Today, as I was finishing this post, I tried wearing an old pair of Finn Comfort shoes at home. After a couple of hours of wearing them, I believe they help to provide some relief.
I subsequently tried a pair of Finn Comfort leather sandals. These seemed to provide the same beneficial effect in that they helped to reduce the numbness in my left leg and foot. They were more breathable than the shoes and therefore more comfortable in warm and humid local weather.
There is a noticeable difference in my left leg and foot numbness when I put on the Finn Comfort shoes and sandals compared with other footwear I own. I can only surmise that the insoles of the Finn Comfort products have something to do with it. Finn Comfort claims their “footbeds” (insoles) are “anatomically contoured and ergonomically designed to support and align the body naturally,” and the design “encourages good posture and proper foot function while cradling and guiding your feet from heel to toe.” Based on my experience with Finn Comfort footwear in the past nine years, I have no reason to doubt their claims.
I’ll continue to put on the Finn Comfort footwear as much as possible at home and see if we can sustain the improvement.
In summary, I first experienced intermittent left buttock pain and hamstring twitching in August 2021, but these symptoms resolved after a couple of months. However, the sensory symptoms that developed in the left L5 distribution in September 2021 have continued to trouble me. These symptoms correlate positively with the volume of running and rowing I do, worsened during a brief trial of a standing desk setup in January 2022, and improve with a reduction in or avoidance of exercise.