How to Tell the Difference Between Hip and Lower Back Pain

by Thomas Mazahery, MD

How to Tell the Difference  Between Hip and Lower Back Pain

Orthopedic treatment of hip and lower back pain is not black and white. As a practicing spine surgeon for the last fifteen years, I’ve found that determining the root issue of someone’s pain in these areas is often grey and filled with ambiguities. The anatomy of the hip and back is comprised of numerous parts that can be injured or wear out, and many problems that occur in this area can display the exact same symptoms or pathology.

To put it plainly, sometimes hip pain comes from the hip, but a lot of times hip pain comes from the back. Sometimes back pain comes from the back, but a lot of times back pain comes from the hip. Eighty to ninety percent of the population develops a debilitating back or hip pain at some point in their life, and this issue is the second most common reason for missed work behind the common cold.

Fortunately, our bodies typically take care of the issue on their own. When a flare up of symptoms occur in our hips or lower back, usually a combination of rest, activity modification, anti-inflammatories, and exercises calms the pain down.

Early and correct diagnosis is key

When seeing a physician for hip or lower back pain, imaging such as x-rays and MRIs are usually conducted at the sight of the symptoms. Yet, these studies can sometimes show abnormalities that are not actually the root cause of the pain. Let me share a quick example.

A fifty-year-old gentleman had severe pain in the outside of his hip. He saw a physician and had an x-ray of the hip area performed. It was determined that he had mild arthritis in the hip, but the arthritis should not have caused the extensive symptoms he was enduring.

So, he started physical therapy for a period of time and saw no improvement. He then received a cortisone shot in the hip, and that didn’t work either. His treatment plan moved on to a stem cell injection with platelet rich plasma in the hip, which also offered no improvement to his symptoms.

This man’s symptoms started in April and proceeded to get worse and worse to the point that he was in a wheelchair when he came to the OrthoVirginia office in August. I looked over his symptoms and decided to have a MRI performed on his lower back, even though he had absolutely zero pain coming from his lumbar spine.

It turned out that the L3 and L4 nerves in his back were being compressed, and the symptoms were appearing in his hip. A minimally invasive surgery was performed, and his pain was gone immediately.   

Again, hip and lower back orthopedics is not always straight forward. There is often more than one diagnosis, but an early and an exhaustive physical exam of all potential areas that could be the root cause of the problem is key in determining the correct diagnosis.

What are the symptoms of hip conditions?

In general, people suffering from hip pain from hip pathology have symptoms that appear in the front of the hip and the groin area. Sometimes the pain will radiate into the front of the thigh but very rarely goes past the knee.

After sitting for a period of time, patients suffering from hip pathology find it difficult to walk when they first get up. The pain is worse initially, but after a couple of limping steps, the hip lubrication kicks in, and the pain subsides.

What are the symptoms of lower back conditions?

Patients with debilitating back issues develop symptoms in the back of the hip near the buttocks. The pain goes down the back of the hamstring, past the knee, and to the outside or back of the calf.

What can we do if the diagnosis isn’t clear?

If you are still in pain after trying more conservative treatment options such as anti-inflammatories and physical therapy, and the x-ray or MRI imaging studies aren’t showing us what exactly is wrong, we can do a series of numbing injections to clear the fog. Essentially, we will numb up an area of the hip or lower back and see what happens.

If there is no response to the numbing injection in the hip area for example, then that is obviously not where the root cause of the pain is located. However, if your pain has dispersed after a numbing injection, then we have located the area of the root cause. These injections act as both a therapeutic and diagnostic tool we can use as physicians.

Another route we can take is an EMG or nerve conduction test. Needles can be put into your leg to see the conduction or activity of nerves. If some nerves are slow or are not signaling correctly, then we know that an angry nerve is the culprit of the symptoms.

Treatment options

Hip

  • If you are a younger patient with symptoms in the front of the hip and in the groin area, a hip arthroscopy is usually the best surgical option.
  • If you are an older patient with hip arthritis, a hip replacement is the best surgical option.

Spine

From a spine standpoint, it is an exciting time in our world. The surgeries we were doing fifteen years ago are completely antiquated. The surgical treatment options of today are much more minimally invasive, and the advancement in robotic technology has become a mainstay for spine surgeries.

However, not all surgeries are perfectly suited for every patient. When consulting with a physician about undergoing spine surgery, you want to make sure that the physician has all types of surgery from open procedures to minimally invasive procedures to robotic procedures in their toolbox.

  • If you have a pinched nerve, a small, minimally invasive outpatient procedure is performed to remove the pressure from the nerve.
  • If you have instability due to arthritis, or instability is created after the fixing of a pinched nerve, a fusion of the spine will be needed.

So, what are the highlights?

  1. If pain is in the front of the hip/groin region and radiates down the thigh to the knee, it is most likely a hip issue.
    If pain is in the back of the hip/buttocks region and radiates down the hamstring to the calf, it is most likely a spine issue.
  2. Early physical examination and consultation with an orthopedist is going to get you the right treatment.
  3. X-rays and MRI’s can often find asymptomatic, normal degenerative issues, and relying on imaging along can be misleading.

Frequently asked questions

When lying down, what causes pain that shoots from the knee to the ankle?

It all depends on where the pain is shooting from. If the pain starts in the buttocks and shoots down the back of the leg past the knee to the ankle, that is most likely a pinched nerve in the back. Patients with a pinched nerve in the back often can’t lie down flat, and they will have use a recliner or wedged pillow to relieve some pain when laying down.

However, if the pain is just from the knee down, the issue could be from a knee pathology.

After a long-distance run, why is my lower back in pain?

As a long distance runner myself, I have experienced this issue firsthand. Running is an extremely beneficial exercise both mentally and physically, but long-distance running takes a toll on the body.

Long-distance running can actually be great for your back. The discs located in your spine have poor oxygen supply. By running, you get your heart rate up, and this increases circulation to those discs. However, after running a certain distance, your muscles become fatigued, and you begin to compensate by shifting your weight from your hip abductors to your back.

You will notice that a runner’s gait at the beginning of their run looks a little different compared to the end of their run. As their hip abductors become fatigued and weaken, their running gait becomes more labored, and the muscles in their spine start to carry more weight than they are used to.

Before running, you should always stretch your muscles so they are prepared for the workout. You can also do activation exercises before a long distance run such as short jogs and sprints. Lastly, hip abductor exercises with or without a resistance band can help strengthen your core and get you over that fatigue in those later miles of your run.

What are some reasons that back pain is significantly worse at night or in the morning?

Back pain is often perceived as one general term, but in my world back pain can mean a thousand different things. So your specific pathology will play a significant role in what time of day your pain is at its peak. I think the hormonal shifts that wakes us up in the morning and then makes us more tired by the end of the day contributes to inflammation.

If the pain is waking you up in the middle of the night, that is more of a red flag and should be assessed earlier.

What is your opinion on acupuncture if surgery is not an option?

Back pain often has low success rates when it comes to surgery compared to buttocks pain that has high success rates. So if surgery is not an option for you, I think the answer is yes try everything else.

Everything else can range from physical therapy to acupuncture to chiropractic care to stem cell therapy. I have had patients respond to every version of therapy, and I have had patients respond to none of these options.

I would absolutely recommend trying acupuncture to see how much relief that provides you.