by Dr. David Borenstein M.D. 12/2019
The question of the source of pain that radiates from the low back to the leg is a common one, especially with older individuals. The common complaint is that the pain runs from “my hip” (which is actually a buttock) down my thigh and seems to end somewhere near my knee. Exactly what makes this pain better or worse is not exactly clear. The pain seems to get worse with walking and better with sitting. The use of over-the-counter medications seems to have a marginal effect.
In individuals over 50 years of age, both lumbar spinal stenosis (LSS) and hip osteoarthritis (OA) are common degenerative musculoskeletal conditions. (1,2) Spinal stenosis is a narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine. Spinal stenosis occurs most often in the lower back and the neck. Because both OA and LSS are common, individuals can develop both conditions simultaneously. X-ray evidence of hip OA is present in about 1/3 of patients with symptomatic LSS, and LSS is present in about 1/4 of patients with symptomatic hip OA. (3,4) Although these conditions are present anatomically, associated clinical symptoms may take extended periods of time to appear.
Is it the back or the hip that hurts? Both areas can generate complaints that overlap in regard to historical symptoms and physical signs. One would think that since it has been an extended period of time that humans have decided to be on two limbs versus four, that this problem would have been solved. But that is not the case since differences of opinion existed as to the specific findings that were associated with each disorder. Errors could occur where the interpretation of patient complaints could be attributed to the wrong diagnosis.
In order to develop a consensus in regard to the historical and physical findings associated with hip arthritis and lumbar spinal stenosis, a survey was complete by 51 of 66 invited musculoskeletal physicians. (6)
The survey inquired about the value of 83 symptoms and physical findings for the diagnosis of hip OA and LSS. Of these, the most valued 32 symptoms and 13 physical examination items were applied to patients with symptomatic hip OA or LSS. Positive likelihood rations (+LR) were calculated for each items’ ability to differentiate hip OA from LSS. A +LR>2 was considered useful in favoring one diagnosis over the other.
No one symptom or sign was identified that could exclusively determine either diagnosis. All symptoms were reported by some patients with each diagnosis, however 11 of 32 symptoms were determined to be useful in discriminating between the two sources of pain.
Eight symptoms favor hip OA over LSS, In decreasing order of diagnostic value they are:
- Groin pain
- Pain that decreased with continued walking
- Pain getting in and out of a car
- Pain with dressing the symptomatic leg
- Difficulty reaching the foot of the symptomatic leg while dressing
- Pain that occurs immediately with walking
- Knee pain
- Pain that decreased with continued walking.
Symptoms that favor a diagnosis of LAA in decreasing order of diagnostic value are:
- Leg tingling and or numbness
- Some pain in both legs
- Pain below the knee.
- Painful and restricted range-of-motion with any of 5 hip movements, limited weight-bearing on painful leg with standing, and an observed limp.
- Four of 5 neurological deficits (sensory, motor, or reflex) favored the diagnosis of LSS over hip OA.
This study highlights the importance of your doctor carefully evaluating an individual’s gait, the hip, and lower extremity neurological function for differentiating LSS from hip OA. Patients aware of the clinical importance of the character and locations of their symptoms can help in the diagnostic process. Awareness of the findings of this study by patients and physicians may reduce the frequency of diagnostic errors.
Jordan JM et al. Prevalence of hip symptoms and radiographic and symptomatic hip osteoarthritis in African Americans and Caucasians: the Johnston County Osteoarthritis Project. J Rheumatol 2009;36:809-1
Kalichman L, et al. Spinal stenosis prevalence and association with symptoms: the Framingham Study. Spine J 2009;9:545-50
Moreland LW et al. Spinal stenosis: a comprehensive review of the literature. Semin Arthritis Rheum 1989;19:127-49
Sembrano JN et al. How often is low back pain not coming from the back? Spine2009;34:E27-E32
Saito J et al: Difficulty in diagnosis the origin of lower leg pain in patients with both lumbar spine stenosis and hip joint osteoarthritis. Spine 2012;37:2089-3
Rainville J et al. Comparison of the history and physical examination for hip osteoarthritis and lumbar spinal stenosis. Spine J. 2019;19:1009-16
David Borenstein, MD
Executive Editor TheSpineCommunity.com