How do I know if my pain is from my hip or my back?

• Hip osteoarthritis classically hurts in the groin, sometimes down the front of the thigh to the knee. It is worse with bearing weight, pivoting and putting on shoes and socks.
• Lumbar spine pain classically hurts across the low back and buttock. When a nerve root is involved, it travels below the knee in a defined line.
• Both refer into the lateral hip and buttock (the outer side). That is the overlap zone, and it is the reason the confusion exists.

A third structure sits in the middle of the argument. Greater trochanteric pain syndrome — gluteal tendinopathy (damage in the buttock tendons), often miscalled bursitis — causes point tenderness over the bony bump on the side of the hip. It also causes pain when lying on that side at night. It is neither joint, and it responds to neither joint’s treatment.

What tests tell hip pain from back pain?

What does a numbing injection into the hip prove?

It settles the argument that the X-ray started. In one series, 83 patients had arthritis in both the hip and the lower spine on X-ray, and pain that did not fit either pattern cleanly. Each had numbing medicine placed into the hip joint under X-ray guidance. In 74 the pain dropped, from an average of 7.2 to 2.7 out of 10. The 11 who got no relief turned out to have their pain coming from the spine. The films showed two worn structures. The needle showed which one was talking.

A second series of 204 hip injections made the same point from the other side. Every patient whose pain was relieved by the injection was also helped by a hip replacement: a positive predictive value of 100%. Ten minutes of numbing medicine forecast the result of a major operation.

Growing up the only kid in a turban, in all-black and then all-white St. Louis neighborhoods, taught me how fast people file you under the first thing they notice. Hips get filed the same way. If the spine MRI was ordered first, whatever is on that film becomes the diagnosis. We test before we file.

What happens if hip pain is treated as back pain?

A lumbar fusion done for pain that was coming from a hip does not help, and it cannot be undone. A hip replacement done for pain that was coming from L4-5 does not help either. Both happen. Both are the predictable result of treating the region that was imaged instead of the structure that was tested.

There is a subtler version worth knowing. When both are degenerate (breaking down), fixing the hip can unmask the spine, or the reverse. Patients are then told their operation failed. It did not fail. It treated one of two problems.

Why do the hip and the back so often wear out together?

Mechanics is the first reason. A hip that has lost its ability to extend makes the lower back arch harder with every step, so the facet joints take a load meant for the hip. The second reason is metabolic. Cartilage and joint capsules sit in the same blood as everything else: high insulin keeps joint linings inflamed, and sugar bonds to collagen and stiffens it, so the hip and the spine age on the same clock. The third is how we live. Eight to ten hours a day in a chair shortens the hip flexors and quiets the gluteal muscles. The hip stops extending, and the back pays for it. The fix for that is as specific as an injection: hip extension and gluteal strength, done daily, plus the food and sleep changes that lower insulin.

How is each one treated once you know which it is?

A hip joint that tested positive gets a guided injection into the joint. Steroid calms an inflamed lining for weeks to months. PRP is the longer play, and its result depends on two things we control: the platelet dose actually delivered into the joint capsule under imaging, and the rehab for the glutes, the hip stabilizers and your gait that follows it. See hip arthritis and orthobiologics for back and hip pain. Sore gluteal tendons at the side of the hip are a different target, covered under hip bursitis.

A back that tested positive is treated by its source: a facet joint with radiofrequency ablation, a sacroiliac joint with a guided joint injection, a nerve root with an epidural. All of these are done awake with local numbing. You drive yourself home and are back to normal activity within two to four hours.

When is a hip replacement or spine surgery the right call?

When the hip joint is worn through and an injection has proven it is the source, a replacement is the operation that restores the structure, and we tell you so plainly. When a nerve root is compressed and the leg is getting weaker, a decompression such as a microdiscectomy is the right operation, and Dr. Padda performs it. What we push back on is surgery on the region that was imaged rather than the structure that was tested. A fusion for a hip, or a hip replacement for an L4-5 problem, cannot be undone.

When does hip or back pain need urgent care?

• You cannot put weight on the leg after a fall, or the leg looks shortened and turned out.
• A hot, painful hip with fever.
• Deep groin pain that started without injury in someone on long-term steroids or who drinks heavily.
• Weakness in the leg, a foot that drags, or any change in bladder or bowel control.

Frequently asked questions

Can hip arthritis cause low back pain?

Yes, indirectly and commonly. A stiff hip forces the lumbar spine to make up the missing motion. The segments above then take load they were not designed for.

If my X-ray shows hip arthritis, is that the cause?

Not necessarily. Hip arthritis on X-ray is common in people with no hip pain, exactly as lumbar degeneration is. It earns significance only by matching the exam.

Which do I treat first if I have both?

Usually whichever one testing shows is more clearly the main source, and often the one that limits function most. That is a conversation, and it should be an open one.

What is the figure 4 test for hip pain?

The figure 4 test is the FABER test. The hip is bent and turned out, with the ankle resting on the other knee. That loads the joint in flexion with rotation. We use it with FADIR and passive internal rotation. It is one part of an exam that also loads the lumbar facets, checks nerve root tension, presses on the bony point of the hip and watches how you walk.

What can be mistaken for hip pain?

The lumbar spine, most often. Both the spine and the hip send pain into the side of the hip and the buttock. That overlap is where the confusion starts. The other common impostor is greater trochanteric pain syndrome, often miscalled bursitis. It causes tenderness over the bony point of the hip and pain lying on that side at night. It is neither joint.

What if the exam cannot tell whether it is my hip or my back?

Sometimes it cannot, because you are allowed to have both. Then an image-guided diagnostic injection into one structure answers the question. If the pain goes away, that structure is the source. It is a test, not a treatment. It is worth doing before anyone operates on either your hip or your spine.

Can treating my hip help my back pain?

Often, when the hip was the reason the back was overworked. A hip that extends again lets the lumbar spine stop arching to make up the difference, and the facet joints that were carrying the extra load settle. It does not help when the back has its own separate source, which is why each one is tested on its own merits. One-sided low back pain near the hip is where the two most often overlap.

Do I need a referral to have my hip and back checked?

No. You can book directly; some insurance plans want a referral on file, so check yours. Bring hip and spine X-rays if you have them, and ask for both to be examined. What imaging can and cannot settle.

Related reading

• One-sided low back pain
• Sacroiliac joint pain
• What impersonates sciatica
• What happens at the first visit
• Hip bursitis
• Hip arthritis