Back Pain? Could Be Your Hips

If your back hurts, you might want to get your hip replaced. That’s the message of a recent study, that suggests a total hip replacement solved accompanying back pain in more than four out of five cases.

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We’ve all heard the song before: “The hip bone’s connected to the…back bone!” If you’ve ever had hip pain that’s led to back pain—and a surprising number of us have—you know it’s not just a cute singalong for kindergarteners.

Hip replacement back painHip replacements also take care of accompanying back pain in more than four out of five cases.“Anything that causes the hip to be stiff or not move in a normal way will put pressure on your back,” says Jonathan M. Vigdorchik, MD, hip and knee surgeon at Hospital of Special Surgery. A study Dr. Vigdorchik led, presented as an e-poster at the American Academy of Orthopaedic Surgeons’ annual meeting, suggests that lower back pain resolved in 82% of patients after a total hip replacement (also known as total hip arthroplasty, or THA).

Benjamin Bjerke, MD, a spine surgeon with Capital Orthopedics in Des Moines, Iowa agrees with this idea, adding: “Your body is really designed to be a fluid chain, with fluid motion connecting your toes to your neck. When a segment like your hip stiffens up, it puts more stress on the neighboring segments—in this case the spine–and vice versa.”

Patients with less spine arthritis had better pain reduction than those with more severe arthritis. This information may provide better insight into the complex relationship between the hips and lower back and lead to more accurate diagnoses and better treatment decisions.

What’s the Pain Connection?

Your hip moves with your lower back during daily activities like sitting or bending. Tight muscles or wear-and-tear from osteoarthritis can reduce hip movement, forcing your lower back to adjust.

“The way people compensate is by increasing the curvature of their lower back. When someone has severe arthritis of their hip, they end up putting a lot of stress on their lower back and that may result in low back pain,” explains Neil P. Sheth, MD, Chief of Orthopedic Surgery at Pennsylvania Hospital, who was not associated with the study.

It turns out people with advanced hip osteoarthritis (which is a breakdown of joint cartilage and the most common type of arthritis) also have low back pain up to 50% of the time, and that percentage could be even higher.

“I’d say 80 to 90% of people with hip or knee arthritis will end up with low back arthritis,” says Dr. Sheth. Although it’s not clear why this occurs, some osteoarthritis (OA) risk factors such as obesity and high-impact activities) can be modified via lifestyle changes. Others, such as injury/trauma, age, being female, or congenital conditions like hip dysplasia, can’t be avoided.

Hip osteoarthritis isn’t the only hip issue that can also cause lower back pain. Here are a few others.

Sacroiliac (SI) joint dysfunction: SI joint connects the sacrum section of the spine to the bones of the pelvis. It serves as a shock absorber between your upper body and your pelvis, and can stiffen over time. SI joint pain affects between 15 to 25% of patients with lower back pain. Symptoms include lower back pain that may travel to the buttocks or groin, stiffness, instability and worsening pain when climbing stairs, rising from a seated position, or running.

Piriformis syndrome: Affects about 200,000 Americans each year and may be misdiagnosed since symptoms overlap with other conditions. For example, when the piriformis muscle (connects the sacrum to the top of the thigh bone, or femur) tightens or irritates the sciatic nerve, symptoms mimic sciatica with pain in the buttocks and numbness and tingling that may travel down the back of the leg.

Diagnosis – Is it Your Hip, Back or Both?

Your doctor may use some combination of a comprehensive physical exam, X-rays, and diagnostic injections to get to the bottom of your pain problem. “Usually patients will get a hip and lumbar spine X-ray, but often miss the thoracic spine, pelvis and hip areas. We’re making sure to get that middle segment to see how the spine and hips work together,” says Dr. Vigdorchik.

Dr. Bjerke states, “It’s critical to understand the hip-spine connection. All of my spine patients have X-rays of the hips to make sure we don’t neglect problems there. There’s such an overlap in symptoms with these two that the other area may be overlooked.”

A diagnostic injection of lidocaine into the hip joint can help pinpoint pain. This can be done in the doctor’s office using ultrasound or X-ray to guide the needle. “If there’s no pain relief from the hip injection, I’m very nervous to do a hip replacement because the pain may be coming from their back,” adds Dr. Vigdorchik.

A critical part of the diagnosis isn’t just the imaging, Dr. Bjerke explains: “the most important part of my patients’ visit is taking a good history of their symptoms. Sometimes the X-rays and MRI may show what looks like a problem, but the symptoms are coming from somewhere else.”

Treatment Options for Hip and Back Pain

Prior to a total hip replacement, some nonsurgical methods should be considered. Dr. Sheth says all diagnoses should start with conservative treatment.

“There are some things you can do with physical therapy, gait training and core strengthening that can help your spine better tolerate hip arthritis,” he says.

In addition, weight loss, activity modification (walking instead of running, for example), anti-inflammatory medication and cortisone injections may all help reduce pain. However, with end-stage arthritis, when you get that agonizing bone-on-bone grinding of the joint, Dr. Sheth says there are very few non-surgical options.

A total hip replacement may be the only option for patients who have persistent pain, difficulty walking and limited mobility. The procedure removes damaged cartilage and bone from the hip joint (including the head of the thighbone and the socket where it fits) and replaces it with artificial parts. As Dr. Vigdorchik’s study suggests, a total hip replacement also takes care of lower back pain in the majority of cases.

hip replacement back pain surgeryA total hip arthroplasty replaces bone and cartilage with metal and plastic polymer components.

Making Good Decisions

It’s never a bad idea to ask for a second opinion. “I always encourage my patients to educate themselves as much as possible on their condition,” says Dr. Bjerke. “As a spine surgeon, I never discourage patients from seeing a hip specialist if they ask.” He also advises that “sometimes your specialist can be overly focused on his or her area of expertise. I think that subconsciously we want the patient’s problem to be something in our specialty that we can fix, but often it’s another body part than what we treat.”

Although the hip and spine relationship remains complex, researchers are making strides towards better diagnoses, which may lead to better treatment decisions. The most important information for patients is that “they understand and their doctor understands where their pain is coming from – the hip, the back or both,” explains Dr. Vigdorchik. “I think doctors need to be cognizant that these conditions co-exist. The pain map can overlap and by doing one surgery, you can affect the symptoms of the other joint. You shouldn’t be operating in a bubble. You should be thinking outside the box.”


Updated on: 09/29/20
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