Musculoskeletal Diagnosis · The Fascia Institute

Most patients told they have “sciatica” don’t have a compressed sciatic nerve at all. Their pain is referred — generated by the gluteal muscles and the fascia that surrounds them, then mislabeled as a nerve problem. Getting this distinction right changes everything about how the pain should be treated.

· Referred pain vs. radiculopathy   · Ultrasound diagnosis   · Fascia-directed treatment

By Jacques Courseault, MD, CAQSM, FAAPMR

Medical Director · The Fascia Institute and Treatment Center®

01 · The Mislabeling Problem

The word sciatica describes a symptom — pain that travels from the buttock down the leg — not a diagnosis. Over time it has become a label applied to almost any deep buttock or leg pain, and with it comes an assumption that the sciatic nerve is being pinched. That assumption is usually wrong.

In reality, buttock-and-leg pain has several possible sources, and they behave very differently. Some are true nerve problems. Far more are referred — pain produced by muscle and fascia that is felt somewhere other than where it originates. When referred gluteal pain is treated as if it were a pinched nerve, imaging gets ordered, injections get aimed at the spine, and the actual source is never touched.

02 · Why True Sciatic Neuropathy Is Rare

True sciatic neuropathy — direct injury or entrapment of the sciatic nerve as a single trunk — is uncommon. It typically follows a specific insult: a hip dislocation or fracture, deep gluteal trauma, a mass, prolonged pressure, or a surgical complication. These cases are real, but they are the exception, not the rule.

Even genuine nerve-related leg pain more often comes from the spinal nerve root — lumbar radiculopathy — rather than the sciatic nerve itself. Lumbar radiculopathy affects an estimated three to five percent of the population, and the majority of those cases settle with time and conservative care. When you subtract true radiculopathy and rare sciatic-trunk injury from the population of people labeled “sciatic,” a large group remains whose pain never came from a nerve at all.

That remaining group is the focus of this article. Their pain is muscular and fascial in origin — and it is highly treatable once it is correctly identified.

03 · The Real Culprits

The deep gluteal muscles and the fascia enveloping them are among the most common — and most overlooked — sources of pseudo-sciatica. When these tissues develop taut, irritable bands, they refer pain in patterns that look uncannily like nerve distributions:

These sources frequently cluster together — a gluteus minimus problem rarely travels alone. Because the gluteus minimus sits beneath the thick gluteus medius, it cannot be felt directly, which is one reason it is so often missed on a routine exam and why the pain gets attributed to the spine by default.

04 · How to Tell the Difference

A careful history and physical exam distinguish the two far more often than an MRI does. The distinction matters because the treatments point in opposite directions — one toward the spine, the other toward the muscle and fascia.

When the exam shows no true neurologic deficit and pressing the deep gluteal tissue reproduces the patient’s familiar pain, the odds strongly favor a referred, fascial source — even when an MRI happens to show incidental disc changes, which are common and often unrelated to the symptoms.

05 · Finding the True Source

At The Fascia Institute, we don’t guess. Fascial Mapping uses diagnostic ultrasound to examine the gluteal muscles and their fascial layers in real time — watching how tissues glide, where they are thickened or adhered, and which spot reproduces the patient’s exact pain when provoked.

This is what separates a fascial source from a nerve source with confidence. Rather than defaulting to the spine because “sciatica” was on the chart, we identify the actual tissue producing the pain, then direct treatment precisely to it.

06 · Treating the Source

Once the source is mapped, treatment is aimed at the tissue itself. Because the gluteus minimus and its fascia sit deep beneath the surface, surface-level techniques often cannot reach them. Hydrofascia Release™ — Dr. Courseault’s ultrasound-guided fascial hydrodissection — restores glide to these deep planes and relieves the adhesion-driven pain that mimics sciatica, all under direct imaging so the target is precise.

The through-line is simple: identify the tissue that is actually generating the pain, then treat that tissue directly. When the source is fascial and muscular — as it so often is in pain labeled “sciatica” — spine-directed care will keep missing, while fascia-directed care resolves it.

References

1. Simons DG, Travell JG, Simons LS. Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. Gluteus minimus and gluteus medius referral patterns.
2. Kim S, et al. Myofascial pain syndrome of the gluteus minimus mimicking lumbar radiculopathy. Anesth Pain Med.
3. Alrwaily M, et al. Referred pain elicited by manual examination of the gluteus minimus muscle. PMC.
4. Bogduk N. On the definitions and physiology of back pain, referred pain, and radicular pain. Pain.
5. Lumbar radicular pain — clinical overview and prevalence. RACGP.

This article is for educational purposes and is not a substitute for individualized medical evaluation. New or progressive weakness, numbness, or loss of bowel or bladder control requires urgent medical attention. © The Fascia Institute and Treatment Center®