Sciatica describes pain or other neural symptoms that travel along the sciatic distribution; it does not identify where the nerve is being irritated. The source may be a lumbar nerve root, the sciatic nerve in the deep gluteal space, the proximal hamstring region, or another structure entirely. Deep gluteal syndrome is a recognized extra-spinal sciatic nerve entrapment disorder, and surgical literature has documented fibrovascular bands and scar adhesions restricting the nerve in selected patients. At Novo Soft Tissue in the Denver Tech Center, we start by determining whether the symptoms are neural, then localize the likely site of irritation before choosing manual treatment, rehabilitation, shockwave, imaging, medical referral or another pathway.
Background
What Does “Sciatica” Actually Mean?
Sciatica is a description of where symptoms travel: through the buttock and down the back or side of the leg, sometimes with numbness, tingling or weakness. It does not automatically mean a disc herniation, piriformis syndrome, deep gluteal syndrome or adhesion. The useful question is where along its course the nerve is being irritated.
- Lumbar radiculopathy: a lumbar nerve root is irritated or compressed inside the spine, most often by a disc herniation or stenosis. Symptoms may follow a nerve-root pattern and can include sensory change, weakness or reflex change.
- Deep gluteal syndrome: the sciatic nerve itself is entrapped after it leaves the pelvis, in the space beneath the gluteus maximus.
- Other peripheral sciatic entrapment: the nerve can also be irritated near the proximal hamstring origin or by other less common structures. Pain at the sitting bone that rises with hamstring loading may instead be proximal hamstring tendinopathy.
These are not mutually exclusive. Lumbar and deep gluteal problems can coexist, and some buttock and thigh pain is referred from muscle, tendon or the hip joint rather than a nerve. The examination is covered in more detail in deep gluteal syndrome vs. lumbar radiculopathy.
What Is Deep Gluteal Syndrome?
Deep gluteal syndrome is best understood as a non-discogenic sciatic nerve entrapment disorder occurring beneath the gluteus maximus. A 2020 systematic review of 14 studies and 853 patients found the condition was defined by three features: it is non-discogenic, it is a sciatic nerve disorder, and the entrapment is in the deep gluteal space. Posterior hip or buttock pain, radicular symptoms and difficulty sitting were common, and diagnosis typically combined history, physical examination, imaging, response to injection and, in some studies, nerve-specific testing such as electromyography.
Can Fibrous Bands or Scar Adhesion Entrap the Sciatic Nerve?
Yes, in selected patients. Endoscopic surgery has directly visualized fibrovascular bundles and scar adhesions restricting the sciatic nerve in patients with deep gluteal syndrome. In another endoscopic series, fibrovascular bands were the most common identified cause of sciatic compression. A 2025 systematic review confirms that fibrous bands are a recognized operative cause of deep gluteal sciatic entrapment, although most evidence remains retrospective.
Adhesion is a possible finding, not an explanation for every case of sciatica. The full evidence, including what it does and does not show, is in can fibrous adhesion entrap the sciatic nerve?
Examination
What We Examine
- Where the symptoms travel, what provokes them, and how sitting, bending, walking and lumbar loading affect them
- Neurologic screening: strength, reflexes and sensation
- Lumbar movement and loading tests
- Neurodynamic testing, including the straight-leg raise with ankle dorsiflexion as a sensitizer
- Deep-gluteal provocation and tenderness, hip rotation and seated piriformis-type tests where appropriate
- Hip joint, proximal hamstring and gluteal tendon screening
- Previous imaging, treatment and response
A restricted straight-leg raise that changes with ankle dorsiflexion can support a neural component, but it does not by itself localize the problem to the lumbar spine or deep gluteal space. Novo may assess tissue and nerve mobility in the deep gluteal region, but palpation alone should not be presented as a validated test that proves a fibrous adhesion.
Differential diagnosis
Piriformis Syndrome Is Only One Subset
“Piriformis syndrome” is too narrow to describe every deep gluteal sciatic entrapment. The piriformis is one possible cause. Others described in the imaging and surgical literature include:
- Fibrous or fibrovascular bands
- Obturator internus and gemelli
- Quadratus femoris and ischiofemoral pathology
- Proximal hamstring pathology
- Postoperative scar and trauma
- Vascular structures and anatomic variants
- Masses and other less common lesions
Treatment selection
How Treatment Is Selected
Lumbar pathway. If nerve-root signs dominate, care follows the lumbar presentation. See low back pain.
Manual treatment is used for selected deep-gluteal tissue and nerve-mobility restrictions found on examination. Palpation guides treatment, but it does not prove microscopic adhesion.
Radial shockwave has direct randomized evidence in piriformis syndrome, with outcomes similar to corticosteroid injection in one trial.
Focused shockwave may be used for a deeper, localized target. Current evidence does not establish it as superior to radial treatment for piriformis syndrome.
Rehabilitation and neurodynamic management are selected by presentation, including loading, hip and trunk strengthening, and graded nerve-mobility work.
You do not need to decide which treatment you need before your visit. All four tools are compared on the services page.
Imaging & referral
Symptoms That Need Urgent Medical Care
Go to an emergency department rather than booking a clinic visit if you have new bowel or bladder dysfunction, numbness in the saddle area, progressive leg weakness, or severe, rapidly worsening neurologic symptoms. Prompt medical assessment is also needed after major trauma, or with fever, systemic illness, or a history that raises concern for cancer or infection. Ordinary radiating leg pain on its own is not a red flag.
When Does Sciatica Need Imaging?
Lumbar MRI is considered when lumbar radiculopathy or another nerve-root problem is suspected and the result would change management, and sooner when there is significant or progressive neurologic deficit.
Pelvic MRI or MR neurography may help when deep gluteal entrapment is suspected or the source remains uncertain, because it can show the sciatic nerve and surrounding structures. It is not required for every case.
Many people with sciatica do not need imaging at the first visit, and a disc change on a scan does not by itself prove the source of leg symptoms.
Imaging, medical or surgical referral comes first when red flags, progressive deficit or an unclear source call for it. For carefully selected patients who do not improve with conservative care, endoscopic sciatic nerve release is a recognized option.
Evidence
What Research Says
- Definition: a 2020 systematic review of 14 studies and 853 patients defined deep gluteal syndrome as a non-discogenic sciatic nerve entrapment in the deep gluteal space (Kizaki, 2020).
- Direct visualization: endoscopic series have documented fibrovascular bands and scar adhesions restricting the sciatic nerve (Park, 2016; Aguilera-Bohorquez, 2018).
- A proposed clinical phenotype: in a 2020 retrospective case series, 13 of 132 low-back-pain patients (9.8%) met proposed criteria for sciatic nerve entrapment attributed to fibrous adhesion. After targeted Manual Adhesion Release®, straight-leg raise improved by an average of 20.8° and pain fell by 3.7 points (Brady, 2020). The study was uncontrolled, its criteria have not been independently validated, and the author disclosed a financial interest in the technique.
- Radial shockwave: in a 35-patient randomized trial, radial ESWT and ultrasound-guided corticosteroid injection both improved piriformis-syndrome pain, with no clear difference at three months (Ahadi, 2023).
- Shockwave vs. injection: in a 70-patient randomized trial, ESWT and ultrasound-guided corticosteroid injection both improved, without a clear difference in improvement rate (Fu, 2026).
Evidence supports multiple distinct pathways, which is why “sciatica” should not be treated as a single diagnosis.
Read the shockwave evidence review → · Fibrous adhesion and the sciatic nerve →
Sources: Kizaki et al., Knee Surg Sports Traumatol Arthrosc 2020 · Hernando et al., Skeletal Radiol 2015 · Park et al., BMC Musculoskelet Disord 2016 · Aguilera-Bohorquez et al., Rev Esp Cir Ortop Traumatol 2018 · Elzeiny et al., Eur J Orthop Surg Traumatol 2025 · Brady, J Musculoskelet Disord Treat 2020 · Ahadi et al., J Bodyw Mov Ther 2023 · Fu et al., J Formos Med Assoc 2026