All too often we think of pain in the buttock and thigh simply as sciatic pain. But this may not always be accurate. True sciatic pain is pain caused by some type of insult to the sciatic nerve, or the nerve roots that give rise to the sciatic nerve. This can be due to herniated disc, stenosis, impingement by the piriformis or other external hip rotator muscles.

Something that can easily be overlooked or mistaken is an irritation to a small nerve called the posterior femoral cutaneous nerve (PFC). This nerve supplies the skin on the back of the thigh, from the lower buttock to the knee, with sensation. If the pain is only in the back of the thigh and does not travel below the knee, there is a good chance this is the main nerve structure involved, and not the sciatic nerve. There should also be no evidence of neurological signs such as muscle weakness and reflex changes upon physical examination if the PFC nerve is the main culprit. This nerve does not have a motor, or muscle component, and therefore this function should be intact. True sciatic nerve pain will often present down the lateral side of the thigh and below the knee and can consist of sensory changes such as pain/tingling, and/or motor, or muscle weakness. Of course there are always exceptions, but this is the classic pattern. There are also other causes of thigh pain that can be purely muscular or fascial, such as hamstring or glute injury, and trigger point referral patterns.

Insult to the posterior femoral cutaneous nerve can be due to compression injury, impingement due to adhesion, and/or connective tissue and muscle tension that restricts sliding of the nerve causing stretch irritation. Direct trauma, or falling on the buttocks, repetitive cycling, and injections have been known causative factors. It is often successfully treatable with conservative care, responding very well to acupuncture needling, aggressive, manual soft tissue work such as Active Release Techniques and Fascial Manipulation and active rehabilitation. This can also be a very stubborn area, so it is important to address is as soon as possible. Usually the more chronic the condition becomes, the longer it can take to correct. A thorough exam is essential, not only to rule out other causes of nerve irritation, but also to determine any mechanical imbalances, repetitive strain and joint dysfunction that may be underlying contributors. As with all treatments, it is important not only to address and relieve symptoms, but to correct causes and restore/establish healthy balance so that the body can function optimally.

Dr. Robert Inesta