Why they are so easily confused
The hip and the lumbar spine sit centimetres apart and share innervation. A diseased hip can hurt in the buttock and the thigh, exactly where you would expect a nerve problem; and an irritated lumbar root can hurt in the groin, exactly where you would expect a hip.
On top of that, past the age of 60, both structures usually show wear at the same time. The patient arrives with a spinal MRI full of findings and a hip radiograph that is abnormal too. The problem stops being about finding lesions and becomes another, much harder one: deciding which of the two is hurting now. That situation is called hip-spine syndrome.
It matters because it determines what is treated first. Operating on the spine of a patient whose pain came from the hip — or the reverse — is one of the commonest reasons for being no better after technically impeccable surgery.
The signs that point one way or the other
None of these decides anything on its own, but together they draw a pattern:
| Clinical finding | Points to the hip | Points to the spine |
|---|---|---|
| Where it hurts | Groin, sometimes the front of the thigh to the knee | Low back, buttock and the back of the leg, often past the knee |
| What triggers it | Turning in bed, putting on socks and shoes, rising from a low chair | Walking a certain distance; eases on sitting or bending forward |
| Tingling or weakness | Uncommon | Common, in a defined territory |
| Coughing or straining | Does not usually change the pain | Can clearly increase it |
| Hip mobility | Limited, painful internal rotation | Preserved |
What a questionnaire cannot do
The findings that genuinely discriminate are not the ones a patient can report alone. They are manoeuvres: measuring hip rotation in degrees, provoking the sacroiliac joint with specific tests, examining strength and reflexes, watching the person walk.
And when the picture remains ambiguous — as it does — there is an arbiter: the diagnostic injection. Anaesthetic is placed inside the hip joint; if the pain disappears for the hours it lasts, the hip was responsible. If nothing changes, the spine has to be looked at.
That is why this page does not give you a diagnosis. It gives you your symptoms in order and an honest orientation, so that the consultation starts much further along than it usually does.
Dr. Kushner’s approach: my subspecialty is hip and pelvis, and that is exactly why I examine both. I treat what falls within my remit — hip, sacroiliac joint, fractures — and take you to the right specialist when the source turns out to be surgical spine. What I do not do is treat a doubt.
When not to wait for an appointment
There are situations that are not resolved with a questionnaire or a scheduled appointment. If you have any of these, seek care immediately:
- Difficulty passing urine or controlling the bowels, or numbness in the saddle area — go to an emergency department today.
- Weakness getting worse in one leg, or the foot dropping when you walk.
- A significant blow or a fall, or a minor fall if you have osteoporosis.
- Fever, unexplained weight loss or a history of cancer.
- Pain that does not settle lying down or at night and worsens week by week.
Frequently asked questions
Can a questionnaire tell me whether it is the hip or the spine?
No. What distinguishes them with certainty are physical examination manoeuvres and, in doubtful cases, a diagnostic injection. A questionnaire orients and helps organise your symptoms before the consultation.
I had a spinal MRI and it showed findings — isn’t that enough?
Not necessarily. Degenerative changes in the spine are very common in people with no pain at all, so finding them does not prove they are the cause of yours. Imaging is interpreted alongside the physical examination.
What exactly is hip-spine syndrome?
It is the coexistence of wear in the hip and in the lumbar spine in the same patient. The challenge is not finding abnormalities but determining which of the two generates the current pain, because that determines what is treated first.
Do you operate on the spine?
No. My subspecialty is hip, pelvis and trauma. I carry out the full assessment, the initial treatment and the differential diagnosis; if the problem turns out to be surgical spine, I refer you to the specialist with the work-up already under way.
What do I bring to the consultation?
All the imaging you have already had, even if it is of the spine and even if you were told it was normal; the treatments you tried and how long each lasted; and comfortable clothing, because hip and spine have to be examined with movement.
References
- Devin CJ, et al. Hip-spine syndrome. J Am Acad Orthop Surg. 2012;20(7):434-442. DOI
- Sakellariou E, et al. Differentiating sciatica from hip osteoarthritis: diagnostic challenges. Diagnostics. 2026;16(16):2515. DOI
- Foster NE, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368-2383. DOI
- Laslett M, et al. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther. 2005;10(3):207-218. DOI
Educational information reviewed by Dr. Michael Kushner Shrem. It does not replace an in-person medical assessment.