Patient with Sciatica and Dorsiflexion Weakness: Treat or Refer Back?

I have recently been treating a patient with a few week history of sciatica with anterior tibialis weakness.   She reports her pain gradually came on for no apparent reason, and it worsened to the point where sitting, rising from sitting, and sleeping were difficult.

She reported to her doctor and was referred to an orthopedist.  The ortho doc referred her to PT.

Upon evaluation, it was noted she had a positive slump and SLR test and weakness through dorsiflexion, with her strength graded as 4/5.  My patient wasn't too concerned about it, and we proceeded with the eval, set up a treatment plan, and sent her on home with her home exercise program.

After the evaluation, I casually mentioned to a coworker about my patient with her sciatica and ankle weakness.  My coworker was astonished that I didn't refer my patient back to the doctor.  Sciatica with dorsiflexion weakness means that the sciatic nerve is pinched and the nerve needs to be decompressed right away, right?

I was confident that my patient would be ok.  Why?  Because her ankle weakness was mild during the initial eval, and over the course of 2 or 3 PT sessions, it wasn't getting worse.  It wasn't progressive weakness.

If my patient returned to me after the evaluation and her dorsiflexion strength was worsening, I would consider referring her back to her doctor.  But it wasn't getting worse.  The key is, progressive weakness needs swift attention.  Stable weakness needs monitoring, and I monitored my patient's condition at every PT session.

I recently saw this patient for her 5th PT session, and her symptoms are almost abolished.  And guess what?  Her dorsiflexion strength is almost back to normal.

So, what would you do?  When you encounter weakness from sciatica (or cervical radiculopathy), do you quickly refer back to the doctor?

If the weakness isn't progressive, it requires monitoring.  If it's progressively getting worse, it needs attention.