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Is it hip pain or spine pain? A diagnostic dilemma. Hip and spine pathologies often present with overlapping symptoms, making diagnosis and treatment difficult and challenging. As the population ages, the incidence of hip arthritis and lumbar spine arthritis or stenosis increases, complicating differentiation between the two. Patients often ask, “Doctor, is it my hip or my spine causing the pain?”

Our responsibility as physicians is to identify the primary source of pain. Is it the hip or the spine? We must first address the dominant source of discomfort.

Hip-spine syndrome is gaining recognition. This term describes cases where both hip and spine issues coexist with overlapping signs and symptoms.

Determining whether the pain stems from the hip, the spine, or both can be difficult for the treating physician. Many patients consult multiple doctors, undergo extensive imaging, and receive various procedures without relief.

A key clinical principle: consider the possibility of dual pathology.

A thorough history and physical examination are essential.

Imaging studies—sometimes advanced—and even diagnostic procedures may be necessary before considering surgical intervention. Deciding between hip or spine surgery is complex.

Pause. Take time to fully evaluate the patient.

If surgery is pursued, determine which condition should be treated first.

Patients must be informed that addressing one issue may unmask or fail to relieve symptoms from the other pathology that may require treatment later.

We must aim to diagnose both conditions to avoid misdiagnosis and delays in treatment.

For a patient with a known spine disorder, always ask if hip symptoms are also present—and ask them to identify the exact location of their pain.

Conversely, if a patient presents with a hip problem, ask about spine-related symptoms.

Orthopedic care is often divided between subspecialists: the hip specialist focuses on the hip, and the spine specialist focuses on the spine.

Even when a spine MRI shows abnormalities, it doesn't confirm that the spine is the source of pain—many individuals have positive MRI findings but remain asymptomatic. This is why patients with hip-spine syndrome often experience delays in both diagnosis and management.

Hip-spine syndrome can be straightforward—where one condition clearly dominates—or complex, when even after detailed evaluation, the primary pain source remains unclear.

Patients often present with both hip and lumbar spine imaging abnormalities. Common complaints include:

• Groin pain
• Buttock pain
• Thigh pain
• Low back pain
• Knee pain

Further studies, such as diagnostic injections or EMG, may be required. Sometimes, symptoms in one region are caused by pathology in the other.

For example, hip arthritis and hip flexion contracture may lead to increased lumbar lordosis, resulting in foraminal stenosis. Scoliosis can create pelvic obliquity and femoral head subluxation, complicating total hip replacement.

A serious concern is misdiagnosis of hip-spine syndrome, where the wrong pathology is targeted first, leading to unnecessary costs and ineffective treatments.

Symptoms of lumbar spine and hip disorders can mimic each other.

Referred pain from the spine to the hip may involve lumbar nerve roots like the obturator, femoral, and sciatic nerves. If symptoms persist after treating the presumed primary pathology, reassess for a secondary source.

Common presentations of hip arthritis include groin and hip pain, limping, and antalgic gait.

Groin pain makes a hip disorder seven times more likely than an isolated spine condition.

The buttock is the most frequent area for referred pain in isolated hip disorders, followed by thigh and groin—rarely the lumbar region.

Pain radiating below the knee can be seen in both hip and spine conditions—reported in 47% of hip arthritis cases.

Pain over the greater trochanter is usually hip-related, and rarely spinal in origin.

When a patient says, “I have hip pain,” always ask them to point to the specific location.

Patients often refer to the buttock as “hip,” which differs from the physician’s anatomical definition. Ask: “Is your pain in the front, side, or back?”

Generally, hip arthritis causes pain during weight-bearing, limited range of motion, and pain with hip rotation. A patient who limps, has groin pain, and limited hip motion likely has hip arthritis. Among adults over 45, hip arthritis affects about 27%, with symptomatic cases in roughly 10%.

Clinical exam findings must correlate with X-ray and MRI results. Seeing arthritis on an image doesn’t confirm it as the pain source.
Spine problems, such as lumbar stenosis, also present with difficulty walking.
If paresthesias or radicular symptoms exist, the focus should shift to spine evaluation.