My hip hurts but Dr. Akinbo says it’s not my hip

“Hip pain” is one of the most common complaints seen by a general orthopedic surgeon or a joint replacement surgeon. There are many causes of hip pain but three diagnoses represent the most common causes of non-acute/non-traumatic presentations for evaluation of hip pain. The three most common causes of hip pain in my practice are greater trochanteric pain syndrome, hip joint arthritis, and lumbar radiculopathy. People can be dissatisfied when referred for evaluation of “hip pain” and are told their pain is not from their hip, but from their back. Instead of the hip replacement they have been referred for, they are being advised to go through weeks of physical therapy or have cortisone injections to their spine! This blog post will examine the three most common causes of non-acute/non-traumatic “hip pain” and help create an understanding of when your hip pain is not coming from your hip or hip joint. 

Greater trochanteric pain syndrome

                Lateral hip pain (“pain on the outside of my hip”) is most commonly from greater trochanteric pain syndrome as opposed to pain from impingement in the back or from hip joint arthritis. Greater trochanteric pain syndrome includes the generic hip bursitis but also includes tears in the abductor tendons. Pain in the lateral hip from this diagnosis can be present at rest, walking, or even getting up from sitting down. This can be debilitating. 

                Management measures are mainly non-surgical. People with painful greater trochanteric pain syndrome will usually undergo an evaluation by their physician and sometimes have an x-ray of the hip taken to rule out hip arthritis. Physical therapy can be prescribed. Home exercises can also be very useful. Anti-inflammatory medications can also provide relief. Other non-surgical options can include a cortisone injection to the trochanteric region. If no significant relief with all non-surgical measures, or no lasting relief, an MRI can be considered. An MRI of the hip can sometimes show tears in the abductor tendons or evidence of inflammation of the trochanteric bursa. In these cases, if with significant debilitative symptoms and after exhaustive non-surgical care, surgical intervention can be considered. Surgical intervention can be open or arthroscopic. Abductor tendon tears are best surgically treated with repair of the tendon tears.

 Hip joint arthritis

                Hip joint arthritis mainly manifests as groin pain about 75% of the time or more. To a much lesser extent, it can cause lateral hip pain or buttock pain. Pain from hip joint (ball and socket joint of the hip) arthritis can be present at rest, but is more commonly present with ambulation or activities. Hip arthritis can develop from regular wear and tear of daily living and the incidence is higher with advancing age. It can also develop as a consequence of trauma, or inflammatory conditions of the hip joint. This pain can be debilitating as it can limit the ability to get around or be involved in usual daily activities. A history and physical examination can help with making a diagnosis. Hip x-rays can help with confirming a diagnosis. Sometimes when the symptoms and history are consistent with hip arthritis, the x-rays may only show mild arthritic changes. In these cases, a local anesthetic/cortisone injection to the hip joint could serve as an additional confirmatory test/procedure. 

                Initial treatment of hip joint arthritis is non-surgical. Non-surgical measures include anti-inflammatory medications, Tylenol, weight loss, physical therapy, home exercises, and cortisone injections. If no significant relief with non-surgical measures or if with persistent pain issues, surgical measures can be indicated. Surgical management for end-stage hip arthritis is mainly hip replacement surgery. Hip replacement surgery involves replacing the ball and socket joint with metal, and plastic/ceramic components. There are multiple approaches/techniques to perform hip replacement surgery with good long-term results. See Hip for more information on hip arthritis and hip replacement. 

 Lumbar radiculopathy

                Out of the three causes of hip pain examined here, lumbar radiculopathy is the most common cause of pain in the gluteal/buttock region. Greater trochanteric pain syndrome does not cause focal pain in the gluteal/buttock region, and hip joint arthritis does not commonly cause pain in this region. Lumbar radiculopathy generally refers to impingement of nerve roots (pinched nerve) in the lumbar spine (lower back). Pain in the gluteal/buttock region from a pinched nerve can also shoot down the leg. Nerve impingement/pinched nerve can also cause other symptoms like numbness or tingling. 

                Lumbar radiculopathy can occur for a number of reasons to include lumbar disc herniations and lumbar spine arthritic changes. Depending on the cause of the radiculopathy, some people can have pain with standing or walking, others can have pain with just laying down or sitting down. Pain from lumbar radiculopathy can be very disabling. A history and physical examination can usually help make a diagnosis. Some patients might require x-rays to evaluate the spine, and/or hip joint. A patient with gluteal/buttock pain is unlikely to have hip arthritis, and more likely to have lumbar spine nerve impingement/pinched nerve issues if the hip x-rays do not reveal hip arthritis. This is so even if the spine x-rays do not reveal severe degenerative disease of the spine. 

                Initial treatment of lumbar radiculopathy is non-surgical. Non-surgical management can include anti-inflammatory medications, a home exercise regimen or supervised physical therapy and activity modification. Majority of patients would respond to the above management measures. If the above is not successful, an MRI of the lumbar spine might be needed and a therapeutic injection to the lumbar spine might be ordered. If no satisfactory relief with non-surgical measures, a consultation with a spine surgeon would be necessary. Spine surgery for lumbar radicular pain would depend on the source of the impingement and can involve decompression surgeries (taking pressure off the nerve) as well as decompression with spine fusion surgeries.