For three years I have had severe gnaw­ing pain in my but­tock with sci­atic nerve pain. It is worst sit­ting or lying down and I can’t sleep for long because the pain wakes me. I have tried an osteo­path, altern­at­ive ther­apies and had a scan, but noth­ing has worked. I’m 53 and oth­er­wise very healthy. Any sug­ges­tions?

It is likely that exer­cise will be able to help clear up the pain and pre­vent a recur­rence, but not at this stage. As you have real­ised, you need treat­ment first. I hear many stor­ies of long-​term pain that doesn’t seem to respond to treat­ment, so here’s a few point­ers that I hope will improve your chances of suc­cess.

If there is no sug­ges­tion of a more ser­i­ous under­ly­ing cause, I firmly believe you should be able to sort out the pain with the help of a physio­ther­ap­ist, osteo­path or chiro­practor. Each of these pro­fes­sions has a slightly dif­fer­ent approach, and it is a per­sonal decision which to go for. However, as with fit­ness train­ers, no two osteo­paths or physios are going to be the same – and some are simply bet­ter and more skilled than oth­ers.

Rather than do the rounds of altern­at­ive ther­apies – many of which have a poor evid­ence base for what they do – I sug­gest you seek out another osteo­path or a sports physio­ther­ap­ist, prefer­ably one who spe­cial­ises in the back and pel­vis, and try again. This is expens­ive and frus­trat­ing, but if it can ban­ish your pain it will be worth it.

Your ther­ap­ist should be able to give you some kind of dia­gnosis by the end of your first visit, but with chronic pain the ther­ap­ist often has to be a detect­ive, try­ing out one the­ory and mov­ing on to the next one if that doesn’t work. Stick with it for about four ses­sions before judging whether the ther­ap­ist is right for you. You should cer­tainly expect to feel some relief from your pain within that time, but it may take rather longer to ban­ish the pain alto­gether.

One reason for this is that pain is a very tricky and indi­vidual thing. Two people with identical injur­ies can exper­i­ence extremely dif­fer­ent levels of pain. Once pain is really “wound up”, it may stay that way, even though the dam­age is small, or heal­ing, or even com­pletely bet­ter. Your ther­ap­ist can help you start to “unwind” it. They should also try to work out what caused the ori­ginal prob­lem, so that you can pre­vent a recur­rence.

Once things start to improve, look for a “clin­ical Pilates” instructor and get some highly spe­cial­ised indi­vidual exer­cise tuition to help cor­rect the way your pel­vis and low back are work­ing. Over time (it may take a few months), your pain should gradu­ally fade away.

Meanwhile, you might get some pain relief by lying on your back, knees bent and lower legs and feet rest­ing up on a chair in front of you. Also try a sim­ilar pos­i­tion in bed, prop­ping your lower legs up on lots of pil­lows and sleep­ing on your back.