Low back pain is the commonest musculoskeletal reason for consultation in the world and the leading cause of years lived with disability. Almost all of us will experience it at some point. The good news is that the great majority of episodes improve, and that very few need surgery.
What is needed is a serious assessment. And here is the point I see most often in clinic: not all low back pain comes from the spine. A significant proportion comes from the hip or the sacroiliac joint, and is treated differently.
First, what the evidence says
In most cases no specific lesion is found in the spine to explain the pain: this is what is called non-specific or mechanical low back pain. International guidelines converge on the same initial approach: explaining clearly what is happening, staying active (prolonged rest makes things worse), directed exercise, and prudent use of medication, imaging and surgery.
On radiographs and MRI scans we should be clear: ordering them up front, in the absence of red flags, does not improve outcomes and often confuses matters. Degenerative changes — dehydrated discs, facet arthritis, disc protrusions — are very common findings in people with no pain at all. Finding them does not mean they are the cause. That is why imaging is always interpreted alongside the physical examination, never on its own.
The commonest causes
Non-specific mechanical low back pain
The commonest. Pain that appears with certain movements or postures, eases on changing position and does not travel below the knee. There is no single guilty structure: muscles, discs, facet joints and postural habit all contribute. It responds well to exercise and to resuming normal activity.
Lumbar disc herniation and sciatica
The disc protrudes and compresses or irritates a nerve root. The pain travels down the leg along a defined path, sometimes with tingling or weakness. Frightening as it is, most improve within weeks or a few months with conservative management. Surgery is considered mainly when leg pain is disabling and persistent, or if there is a neurological deficit.
Sacroiliac joint pain
Pain low down and to one side, over the buttock, worse on rising from a chair, climbing stairs or loading one side. It is very easily mistaken for a disc herniation. It is identified with specific examination manoeuvres and, when needed, with a guided diagnostic injection.
Deep gluteal syndrome
Compression or irritation of the sciatic nerve as it passes through the gluteal region (what used to be called piriformis syndrome). Prolonged sitting hurts and there is deep discomfort in the buttock. It is a diagnosis of exclusion and requires lumbar and hip causes to be ruled out first.
When back pain actually comes from the hip
This is the part that generates the most misdirected consultations, and where my training in hip and pelvis changes the outcome.
Hip osteoarthritis and degenerative problems of the lumbar spine are both common from the age of 60, they frequently coexist in the same patient, and they produce complaints that look very much alike: pain on walking, stiffness, difficulty putting on shoes. When both are present, the challenge is not making a diagnosis but deciding which of the two is generating the pain now, because that 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 causes of dissatisfaction after technically well-performed surgery.
| 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 distances; eases on sitting or bending forward |
| Examination | Limited, painful internal rotation of the hip | Signs of nerve root irritation; normal hip examination |
| Tingling or weakness | Uncommon | Common, in a defined territory |
When the picture remains ambiguous — and it does — a diagnostic injection into the hip joint settles the question: if the pain disappears for the hours the anaesthetic lasts, the hip is responsible.
Red flags: seek care promptly
- Significant trauma, or a minor fall in an older person or someone with osteoporosis.
- Progressive weakness in one leg, or the foot dropping when you walk.
- Difficulty passing urine or controlling the bowels, or numbness in the saddle area: this is an emergency, seek care immediately.
- Fever, unexplained weight loss, or a history of cancer.
- Pain that does not settle at rest or at night, or that worsens week after week.
How I assess it in clinic
- Focused history: exactly where it hurts, what eases and what worsens it, how far you walk before having to stop.
- Full examination of both spine and hip in the same consultation — not one or the other. Gait, ranges of movement, provocation manoeuvres and neurological examination.
- Imaging only if it changes management: standing radiographs where appropriate, MRI if there is specific suspicion or red flags.
- Guided diagnostic injection when hip has to be separated from spine or the sacroiliac joint confirmed.
- Initial plan: education, reactivation, directed physiotherapy and pain control. And if the source turns out to be spinal and requires surgery, I refer you to the spine specialist with the diagnosis already worked up.
Dr. Kushner’s approach: my job here is to order the problem and tell you honestly where your pain is coming from. I treat the cause when it is within my remit — hip, sacroiliac joint, fractures — and take you to the right specialist when it is not. What I do not do is operate on a doubt.
What if the pain is coming from somewhere else?
Hip and spine are often confused. Answer six questions and bring the summary to your appointment. (In Spanish.)
Frequently asked questions
Do I need an MRI straight away?
Almost never at the start. Without red flags, an early MRI does not improve outcomes and usually shows age-related changes that also appear in people without pain. It is ordered when the result will change the treatment decision.
My back hurts — why are you examining my hip?
Because some of the pain attributed to the back actually comes from the hip or the sacroiliac joint. Distinguishing this early avoids treatment aimed at the wrong place.
Should I rest?
No. Prolonged rest delays recovery. The evidence-based recommendation is to stay active within what the pain allows and to progress from there.
Does every disc herniation need surgery?
No. Most improve without surgery within weeks or a few months. Surgery is considered when leg pain is disabling and persistent, or when there is a neurological deficit.
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 is surgical spine, I refer you to the specialist with the work-up already under way.
References
- Foster NE, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368-2383. DOI
- Buchbinder R, et al. Low back pain: a call for action. Lancet. 2018;391(10137):2384-2388. DOI
- 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
Book your assessment
Book a consultation with Dr. Kushner at COMEDSA. Bring any previous imaging for a complete assessment.
Educational information reviewed by Dr. Michael Kushner Shrem. It does not replace an in-person medical assessment.