At Washington University School of Medicine, Departments of Orthopaedic Surgery and Neurology and Physical Therapy, surgeons and therapists wanted to examine patients who had hip osteoarthritis and back pain. The hip-spine complex can be a tricky and complex area to diagnose. Finding the true source or sources generating a patient’s pain can be equally complex. 

Marc Darrow MD, JD. Thank you for reading my article. You can ask me your questions about  this article using the contact form below. 

In this study, the hip was the true disguised pain generator in back pain patients

In their study presented in the journal PMR, the Washington University team found links between the hip and the spine affecting pain and function. The key finding was that hip disease, before it was even evident on an MRI as osteoarthritis, could cause problems in the lower back.1 The hip was the true disguised pain generator in back pain patients.

  • What is this research telling us? If you had an MRI of your hip, and nothing presented itself as obvious, then the doctor may chase something in the spine that is not causing the pain.

Research: A patient presenting with low back pain should be examined for hip osteoarthritis

The same team of researchers, publishing earlier  in February 2017 were also able to conclude that physical examination findings indicating hip osteoarthritis (loss of range of motion and acute pain) are common in patients who also have low back pain. A patient presenting with low back pain should be examined for hip osteoarthritis.2

Similar findings were reported in a study from doctors at Vanderbilt Orthopaedic Institute the incidence of symptomatic osteoarthritis of the hip and degenerative lumbar spinal stenosis were examined because the subjective complaints can be similar, and it is often difficult to differentiate intra- and extra-articular hip pathology from degenerative lumbar spinal stenosis. These conditions can present concurrently, which makes it challenging to determine the predominant underlying pain generator. A thorough history and physical examination, coupled with selective diagnostic testing, can be performed to differentiate between these clinical entities and help prioritize management. 3

It should be noted that a physical examination was called for. In the above study “selective diagnostic testing.”

Back surgery for hip pain? Hip replacement for back pain? Is surgery addressing a problems on MRI that is not a problem for the patient? Research: Physicians should not replace clinical observation with the use of magnetic resonance images (MRI).

Are doctors breaking away from MRI for the complexity of this problem? I have discussed over-reliance on MRIs before. In February 2012, research was presented at the American Orthopaedic Society for Sports Medicine’s (AOSSM) Specialty Day meeting suggesting that when doctors treat people with hip pain,

Physicians should not replace clinical observation with the use of magnetic resonance images (MRI).”

The research stated that when MRIs were performed on volunteers without hip pain, 73% showed abnormal findings and that  Abnormal findings on MRI typically lead to surgical procedures. Medical journals are filled with studies suggesting that while MRI is frequently used to diagnose conditions affecting the hip, its effectiveness in determining hip pain is not as valuable as a physical examination. And MRIs are not cost effective. 4

In the medical journal Pain Physician, doctors agreed, and they offered a commentary that warned physicians that the true causes of hip pain can be easily overlooked and misdiagnosed because of the MRI. 5

Dr Allan A van Zyl, a researcher in South Africa  noted in his heavily cited 2010 paper that in as many as 50% of elderly patients, MRI gave a false positive diagnosis of spinal stenosis. Those MRI results might prompt a surgeon to perform spinal surgery. When the hip symptoms persist and remain undetected, it is even possible that a second unnecessary back surgery could be performed.6

Not only might you get a hip replacement you may not need, you may, in addition, get a back surgery you don’t need.

Not only might you get a hip replacement you may not need, you may in addition suffer a back surgery you don’t need. Doctors have noted that the symptoms of hip pain and spinal stenosis leg pain can be very similar, with only subtle differences in both history and clinical examinations. Spinal stenosis is classically diagnosed in patients with leg pain that occurs during standing or walking and is relieved when the individual sits down. This is a clinical diagnosis that doctors say can only be confirmed by MRI.

This is why some patients continue to experience hip pain after elective hip replacement surgery. One research study advised doctors to look for pain originating from different sources not directly linked to the replacement hardware, as something else must have been the problem.7 This revelation comes a little late.

I see patients who were misdiagnosed and their pain generators overlooked. They have hip pain and an MRI in their chart showing a herniated disc in the lower back. After they had back surgery, the hip pain remained.

Ask Dr. Darrow about your spine and hip pain

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1 Prather H, Cheng A, May KS, Maheshwari V, VanDillen L. Association of Hip Radiograph Findings with Pain and Function in Patients Presenting with Low Back Pain. PM&R. 2017 Jun 16.

2. Prather H, Cheng A, May KS, Maheshwari V, VanDillen L. Hip and Lumbar Spine Physical Examination Findings in People Presenting With Low Back Pain With or Without Lower Extremity Pain. J Orthop Sports Phys Ther. 2017 Feb 3:1-36. doi: 10.2519/jospt.2017.6567.

3 BJ, Yates AJ, Kang JD. Hip-spine syndrome. J Am Acad Orthop Surg. 2012 Jul;20(7):434-42. doi: 10.5435/JAAOS-20-07-434.

4. Keeney JA, Nunley RM, Adelani M, Mall N. Magnetic resonance imaging of the hip: poor cost utility for treatment of adult patients with hip pain. Clin Orthop Relat Res. 2014 Mar;472(3):787-92. doi: 10.1007/s11999-013-3431-7. Epub 2013 Dec 21.

5. Tasoglu O, Sirzai H, Onat SS, Ozgirgin N. Is hip originated pain misdiagnosed? Pain Physician. 2015 Mar-Apr;18(2):E259-60.

6.  van Zyl AA. Misdiagnosis of hip pain could lead to unnecessary spinal surgery. SA Orthop J (Pretoria). 2010; 9(4). 6. Ferrata P, Carta S, Fortina M, Scipio D, Riva A, Di Giacinto S. Painful hip arthroplasty: definition. Clin Cases Miner Bone Metab. 2011 May;8(2):19-22.

7 Ferrata P, Carta S, Fortina M, Scipio D, Riva A, Di Giacinto S. Painful hip arthroplasty: definition. Clin Cases Miner Bone Metab. 2011 May;8(2):19-22.