There is no doubt that back and hip pain are often linked and sometimes confusing to diagnose. But sometimes it’s hard to differentiate the two, and what may be the underlying cause versus the symptoms.
We discuss in this week’s podcast episode.
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#AskMikeReinold Episode 373: How to Differentiate Between Hip and Low Back Pain
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Show Notes
• Evaluation and Treatment of Athletic Low Back Pain
Transcript
Francesco Casale:
All right, so we got Tim from Montreal. “I’m a recent grad, a little over a year out. In some of my younger athletes, I have had a hard time with lumbopelvic injuries. How do you differentiate between mechanical low back pain and hip-related pathology in athletes?”
Mike Reinold:
Good question, Tim from Montreal. Wow. You think this is like Tim Horton Tim, like the Tim Horton?
Dan Pope:
Could be.
Mike Reinold:
It didn’t even click until I said Tim from Montreal. Yeah, good question. I feel like, Cesco, we talked about this last week in the clinic a little bit with Emmett, a little bit about hip and low back pain, especially when you have younger athletes. I think that’s what I really liked about this question here, was that it’s about younger athletes.
So, having a hard time with lumbopelvic. How do you differentiate between mechanical low back pain and hip-related pathology? Who wants to start? I’m going to pick Dan Pope, but I know I want to hear from Kevin Coughlin. I know he’s jumping in on this one. But Dan, what do you got?
Dan Pope:
Yeah, I think the two can be very much related. They’re so close to one another, and I think a lot of times, do present together. I think the subjective is going to drive things for the most part.
And generally speaking, when folks have low back pain, it’s closer to their low back. And if they are having symptoms that extend to the hip, it’s usually the backside of the hip, and then sometimes the leg if you’re dealing with more radicular symptoms. I think for the hip, you’re most often seeing anterior hip pain, and you’re seeing kind of a C sign. So I think those are the big ones.
I think you can also just think about that mechanism of injury. So essentially, how did that person hurt themselves? If it seems like they just put more strain on the low back, then you might be thinking a little more low back. If it’s more strain on the hip, it could be more of a hip injury. I think the mechanisms are often similar, and it really depends on the athlete that you’re dealing with.
I think the other one that’s a pretty good dead giveaway is just when you’re doing your special tests, and I think it’s a little tough. You have to keep in mind, when you’re doing your hip special testing, when you take the hip joint to its end range, you’re oftentimes moving the spine. So if I’m just taking that person to end range flexion, I’m flexing the spine. So you have to be a little bit cautious with that.
But if I’m doing a FABER and a FADIR and I’m noticing that I’m getting more anterior pain, reproducing the patient with familiar symptoms, I’m automatically thinking it’s a little bit more hip-related. And if I am getting more pain in the spine, in the backside, the back of the hip, I’m starting to think it’s a little bit more spine-related. But the two could be presenting pretty similarly, or they have injuries in two different areas, excuse me, two areas, going on at the same time.
Mike Reinold:
Which probably isn’t unrealistic. He said young athlete again, too, so it’s probably a sport-related injury. It’s chicken or the egg, maybe sometimes. Was he starting to get tight or hurt his hip, and then he put some extra stress on his back, or vice versa, that type of thing?
Man, you made a lot of really good points there, Dan. I think one that I really liked, I thought was cool, is while you were saying it, I was thinking of it myself, but you’re right. A lot of times, groin pain, hip pain, back pain, they can be kind of fumbled together into one big cluster. But I really like what you said right there. I can’t recall the last time I’ve seen somebody with just hip pathology have isolated back pain. Have you guys? Am I off on that? I haven’t felt like that.
Dan Pope:
It’s rare.
Mike Reinold:
Yeah. So that’s probably the first big thing to look for, and I like how you said C sign and then go lateral for the hip because I think that’s pretty common too. But yeah, I thought that was really helpful stuff, Dan. It was awesome. Kevin, what do you think? I know you’ve got some good thoughts on this, too. I wanted to hear your thoughts.
Kevin Coughlin:
Yeah, I definitely agree with a lot of what Dan said, and I think, just specific to the question, if he’s talking about younger athletes, that’s where it would start with the subjective for me in getting a good history. Because we know there are certain injuries that are common in certain sports.
So, if you have a young athlete who does an extension-rotation sport like baseball or golf, or something along those lines, and they’re complaining of that back pain, maybe some hip tightness is something you’ll see with that, but you immediately want to shift towards starting to look at a spondy or pain primarily coming from the back. Versus, if this is a catcher or someone who does a different type of sport, maybe a soccer player, you might be thinking a little bit different. Maybe this is more of a hip pathology. So, I think always using the subjective to guide your testing and figuring out what pathology we might be suspecting.
I definitely agree with what you guys said in terms of we don’t really see pain work its way proximal, so we won’t really see isolated back pain with someone with a primary complaint of hip pain. But I guess if we’re going through the subjective and figuring out what sport they play, when did their pain start, what’s aggravating for them, we start to piece together, “Does this seem a little more related to motions of the back or motions of the hip?”
And I would say also keeping in mind a few big buckets of pain. So maybe spine-related pain, which would be something like a spondy, versus radicular type pain, which we might be worried about a little bit of nerve involvement or a disc pathology that we could also see in that population. And then for the hip, I think we’re thinking of either intraarticular, so is this someone with symptoms of known FAI or hip dysplasia or something along those lines, or does this seem extraarticular, maybe more of a groin-related adductor pain or even a high hamstring type pain?
So, I know that’s a lot of buckets, but you kind of get a little lens into what’s going on through the subjective. And then when you’re taking them through your assessment, when we’re moving the spine around, if it’s reproducing their pain, it’s giving us a pretty good indication this might be coming from their spine. Whereas with the hip, it’s doing tests like Dan said, the FADIR, the FABER, not the most specific test, but maybe they’re giving us an idea, “Is the hip joint irritated?” And I think with those, important to keep in mind is just that we probably get a lot of false positives on that, so people get some pain, but we don’t know exactly, “Hey, is this your primary complaint?” So always coming back to that primary complaint, too, that you’re picking up in the subjective.
Mike Reinold:
Awesome, yeah. Dan, did you…
Lenny Macrina:
Which gives me… That was me. I don’t know if you saw a hand.
Mike Reinold:
Oh, I thought Dan wanted to jump in too. No worries, yeah.
Lenny Macrina:
Jump in, Dan, continue.
Mike Reinold:
Len’s about to drop a bomb on us, so I figured if you’ve got a comment on Kevin’s stuff, Dan, jump in.
Lenny Macrina:
Yeah, go ahead, Dan. I’ve got to wrap it up with my case from yesterday, so it all ties it in.
Dan Pope:
Yeah, I was just going to say, I’m thinking one in my head where I had a patient, pretty interesting, but came in and he had terrible anterior hip pain. And he went to a hip specialist, and they did find a hip labral tear, and he was thinking about undergoing surgery. And it was very clear that he had radicular low back pain. And I think if that’s the case, you’re probably going to see dermatomal, myotomal issues, positive straight leg raise, positive slump. Those generally aren’t going to be positive in folks that have hip pathology. So I think if you do have radiating pain from the back, like radicular low back pain, I think it’s usually pretty obvious if you just do your other tests and try to provoke the spine without provoking the hip, and vice versa.
Mike Reinold:
That’s perfect. Len, this is going to sound like a Chasing Scratch episode.
Lenny Macrina:
Trust me, yeah, I was thinking that myself.
Mike Reinold:
Kudos to Eli. Go ahead.
Lenny Macrina:
Yeah. That’s hilarious. But no, I had a case yesterday of a woman, actually, Dan, you’re seeing her next week, not to reveal too much, but interior hip pain. In her subjective, it was kind of all over the place. Her gait started to change. She was really affected by this, a very active, 40-something-year-old woman.
And I’m like, “Well, I can’t rule out your back. I can’t rule out other stuff.” Is it a gluteal tendinopathy? Because she’s getting a little stuff down lateral side, but nothing really… I looked at her back. I had her flex, extend. I had her do slump. I had her do all these tests, and it all came back to hip, that interior hip pain.
She had a positive FADIR and a positive FABER, and that was her pain, which is what Kevin said. So I want to tie it into… Is that your pain is going to be the key question, and then look on the other side too. Because you could provoke somebody with all these moves, and they think that’s their issue, but if you go on the other side, that’s also painful. So provoke it on the other side. And I wasn’t able to provoke it on her other side.
So I think it was pretty clear that she had some interior hip pain that was probably a result of an FAI, and she had an MRI that showed that she had a pincer lesion and superior labral tear. So she was getting multiple opinions from PTs and is coming to see us now, and hopefully we can guide her in a good direction and give her some closure to the issue. So yeah, I just want to tie it all together, that it can be differentiated.
Mike Reinold:
I remember too, lots of people have labral tears, especially some athletes, a hockey player or something like that, an ice hockey player.
Lenny Macrina:
Yeah. They’re going to find something.
Mike Reinold:
Of course. Yeah, that’s kind of part of it. Then you start chasing the wrong path a little bit here.
I think I’ll summarize it as this, Tim. Clearly, you can see even just from our dialogue here that it’s not always straightforward. There’s a bit of overlap. So that’s probably why you feel like you’re having some difficulty with this sometimes. It actually makes sense. We do too sometimes.
But to kind of tie it up, we talked with the students, Cesco and Emmett, last week a little bit here, is the concept of structural and functional diagnoses and your exam process, and going through that. Just keep in mind that oftentimes they’re confusing because you’ll have one area that has structural pathology, and the other area has several functional pathologies that are probably leading into that somehow, and vice versa with the hip and the back.
So keep that in mind. You almost treat them together quite often. So keep that in mind. That might be why sometimes you’re getting… I don’t know, I guess you’re a little unsure of yourself sometimes because they might be having mechanical low back pain, but they’re having some functional limitations of their hip, and who knows if it goes together.
So great question, Tim, appreciate that. If you have any questions, just head to MikeReinold.com, click on that podcast link, and you can ask away. And please, Apple Podcast, Spotify, some new AI-generated podcasting that’s not invented yet, if you follow us there, like us, subscribe, review. We appreciate it. We’ll see you on the next episode.
