You’ve done the stretching. You’ve taken the ibuprofen. You’ve maybe done a round of physical therapy, or gotten a cortisone injection, or spent weeks on YouTube looking for the right piriformis stretch. It got better for a while. Then it came back. If you’re reading this, that cycle probably isn’t new to you. The pain down your leg eases up, you think you’re past it, and a few weeks or months later it returns — sometimes worse than before.
After twenty years and thousands of clients with this exact pattern, here’s what I can tell you: the reason your sciatica keeps coming back is almost always the same. The treatments you’ve tried have been addressing the pain without addressing what’s creating it. That’s not a knock on those treatments — they often do bring relief. But relief and resolution are different things.
The pain is real. It’s also the messenger.
Sciatica isn’t a diagnosis. It’s a description — pain along the sciatic nerve, usually running from the low back or buttock down the back of the leg. The question that matters is: what’s compressing or irritating that nerve?
In most of the clients I see, the answer falls into one of two categories. The first is the piriformis muscle — a deep hip rotator that sits directly on top of the sciatic nerve. When this muscle gets chronically tight or hypertonic, it squeezes the nerve and produces that familiar burning, shooting pain down the leg. The second is lumbar compression — the muscles along the low back tightening around the nerve root where it exits the spine.
Here’s the part most people miss: both of these are downstream consequences of something else.
The glute connection no one talks about
The piriformis is a small muscle. It’s not built to be a primary stabilizer of your hip and pelvis — that’s the job of the gluteus maximus and the gluteus medius. But in most people who sit for a living, the glutes are functionally quiet. They’ve been shut off by hours of sitting, day after day, year after year. The body still needs hip stability, so the piriformis steps in. It takes on a load it wasn’t designed for. It tightens. And because it sits right on top of the sciatic nerve, that tightness becomes pain.
This is why stretching the piriformis gives temporary relief but doesn’t solve the problem. You’re loosening a muscle that’s tight for a reason. As long as the glutes aren’t carrying their share of the work, the piriformis will tighten back up. The compression returns. The sciatica comes back.
The same logic applies to lumbar-origin sciatica. When the glutes are weak, the low back muscles compensate by doing extra stabilization work. They tighten, fatigue, and eventually start compressing the nerve roots in the lumbar spine. Stretching the low back helps temporarily. But the tightness returns because the underlying imbalance hasn’t changed. I write about this broader pattern — the posterior chain problem — in more detail here →
Why the common treatments don’t stick
Stretching can calm a tight piriformis temporarily, but it can’t strengthen weak glutes. And during an active flare, hamstring stretches often make things worse — they pull directly on an already-irritated sciatic nerve.
Anti-inflammatories reduce the inflammation around the nerve, which brings real relief. But they don’t change the mechanical compression that caused the inflammation in the first place. The pain returns when the medication wears off because nothing structural has shifted.
Cortisone injections do the same thing more aggressively — knock down inflammation at the site. They can be genuinely useful in a severe flare to break the pain cycle. But if the piriformis is still hypertonic or the lumbar muscles are still guarding, the compression rebuilds over weeks or months.
General physical therapy is the closest to addressing root cause, and good PT often does. But generic protocols — the same exercises for every client — sometimes miss the specific muscular pattern creating the compression in a particular body. Not every sciatica case is a piriformis problem. Not every one is lumbar. The work has to match the pattern.
What actually changes the pattern
In my practice, the approach has two parts. First, I identify exactly where the nerve is being compressed and release the specific muscles creating the problem. That means hands-on neuromuscular and myofascial work — targeted pressure on the piriformis, the deep hip rotators, the QL, the lumbar paraspinals, whatever is creating the compression in your body specifically. This isn’t a relaxation massage. It’s diagnostic bodywork aimed at the structures that matter.
Second — and this is the part that determines whether the relief lasts — we address why those muscles were tight in the first place. That usually means waking up the glutes and gluteus medius through specific strengthening work you do between sessions. Glute bridges, clamshells, single-leg work, banded walks. None of it is exotic. What matters is that you do it consistently, because the posterior chain doesn’t rebuild from a two-week program. It responds to a permanent change in how you use your body.
Most clients with sciatica notice a meaningful shift within the first two or three sessions. The pain changes — it moves, or it eases, or the worst of the shooting stops. That’s the compression releasing. The longer-term work is keeping it released, and that’s where the glute strengthening and regular maintenance sessions do the heavy lifting.
When to come in — and when to see your doctor first
You don’t have to wait for the pain to be at its worst to start this work. But if you’re in an acute flare, that’s fine too — the approach shifts to gentler, more neurological work that calms the guarding muscles without provoking the nerve. Either way, we can usually start making progress from the first session.
There are a few situations where you should see your doctor before booking with me: new numbness or tingling that’s spreading, any loss of bladder or bowel control, or leg weakness that’s getting rapidly worse. Those are signs of something that needs medical evaluation first. Short of that, soft tissue work is safe and usually the fastest path to relief.
Related: Sciatica treatment — how I work with it · Piriformis syndrome · The posterior chain problem