Back and Hip Pain

M. Andrew Greganti, MD
Back Pain
 Accounts for 2.5% of medical visits – second most common
reason for office visits in US
 Prevalence varies widely – 1.2 to 43%
 Risk factors:
Female gender
Physically strenuous or sedentary work – lifting over 25 lbs
Low educational level
Job dissatisfaction
Somatization disorder, anxiety, depression
Workers’ Compensation Insurance
Genetic background
Cultural differences
 Generally good, especially if expectation is to improve
– most do get better with no intervention
 Less than 5% have serious underlying pathology
 A cause can be found only in a minority of patients
 Chronicity seems to correlate with:
 Female gender
 Increasing age
 Pre-existing psychosocial factors
Clinical Evaluation
 Key concepts:
 Most patients have mechanical low back pain – no
infectious, inflammatory, or neoplastic cause.
 Degenerative disc disease plays a substantial role but
exactly how much of one is unclear. Many patients
without pain have discs on MRI.
 Muscular and ligamentous sources of pain are
probably equally important.
 Tender fibro-fatty nodules (back mice) may play some
role but correlation with back pain remains in question.
 Consider 3 major concerns:
 Evidence for a systemic process – hx of cancer, age
over 50, weight loss, nocturnal pain, unresponsiveness
to Rx
 Evidence for neurologic compromise – cauda equina
syndrome, radiation of pain below the knee,
pseudoclaudication as in spinal stenosis, focal weakness
 Social or psychological distress contributing to
chronic, disabling pain
Physical Examination
 Check for spinal curvature – kyphosis, scoliosis, etc.
 Check for spinal tenderness
 Straight leg raising and crossed straight leg raising
 Evaluate for deficits in L4, L5, and S1 distributions.
 Lymph node, breast, and prostate exams if neoplasia is
 Check peripheral pulses
Diagnostic Imaging
 Imaging is essential in these situations:
 Progression of neurological findings
 History of trauma
 History of neoplasia
 Age <18 or >50
 Special situations:
 Injection drug use
 Immunosuppression
 Indwelling Foley catheter or recent GU procedure
 Concomitant steroid use
Plain Films, MRI, CT
 If symptoms persist for 4 to 6 wks with no
improvement, order two views of plain films
without obliques
 Implications of spondylosis, spondylolisthesis,
 Order MRI or CT to evaluate progressive
neurologic deficits, to evaluate for cancer, or to
evaluate patients with refractory symptoms –
greater than 12 wks of persistent pain
Treatment of Back Pain
 Bed rest is not indicated – may actually delay
 NSAIDS and narcotics have similar efficacy – use of
NSAIDS should be limited to 2 to 4 wks
 Adverse effects more common in older patients
 Acetaminophen is probably as good as NSAIDS.
 Muscle relaxers are more effective than placebo for
short-term relief
 NSAIDS + muscle relaxants may be better - based
on observational data.
Treatment of Back Pain
 Opioids are effective in acute back pain but
obviously have multiple side effects and are
 Tramadol is a non-opioid and works on the opioid
receptor – is worth a trial.
 Oral glucocorticoids probably are not beneficial for
acute pain.
 Lidocaine patches, anticonvulsants, antidepressants
are of limited effectiveness in acute pain.
Treatment of Back Pain
 Epidural injection:
 Efficacy remains unclear – conflicting results from
controlled trials
 Probably best in radiculopathy secondary to HNP – has
short-term (at 6 wks) but no long-term benefit at 3 , 6, or 12
 Not of proven benefit in spinal stenosis and nonspecific
 No difference in translaminar, transforaminal, and caudal
 2 of 7 trials found epidural injection vs placebo associated
with lower rates of subsequent surgery.
 Adverse events: dural puncture, bleeding, infection
Treatment of Back Pain
 Local or trigger point injection rarely works
 Facet joint steroid injection doesn’t help at 1 and 3
 Medial branch of dorsal ramus nerve blocks are of
unknown efficacy
 Sacroiliac joint steroid injection was more
effective than anesthetic injection in one small
 Probably does work for spondyloarthropathies
 Rx effectiveness of piriformis syndrome using injected
steroids remains unclear
Treatment of Back Pain
 Chemonucleolysis for HNP should only be used in
patients who do not want surgery – not often done in
 Paravertebral botulinum toxin injection was
superior to placebo at 3 and 8 weeks
 Evidence for the efficacy of radiofrequency nerve
ablation remains inconsistent – would only
consider in the most refractory situations
 Prolotherapy should not be used
Treatment of Back Pain
 Exercise is not good for acute pain in contrast to more
chronic pain.
Encourage mobilization as soon as possible.
Physical therapy is, in general, very helpful but no
difference in heat/cold, ultrasound, electrical stimulation
TENS effectiveness is very questionable at best.
Spine manipulation by chiropractors may be helpful.
Accupuncture is probably equivalent to NSAIDS.
Traction does not help lumbar pain.
Hip Pain
 Basic issues:
 The major dilemma is to differentiate among gluteus
medius superficial and deep bursitis and osteoarthritis
 The hip is “fixed” by the pelvic girdle, making it more difficult
to differentiate pain originating in the lumbar spine and knee
from hip pain.
 The gluteus medius and gluteus minimus muscles
abduct the hip and attach at the greater trochanter.
 The gluteus maximus extends the hip and attaches just
distal to the greater trochanter
 The iliopsoas muscle, the major hip flexor, attaches at the
lesser trochanter.
Clinical Presentation of Hip Pain
 Hip pain with weight bearing and improvement
with rest is most compatible with DJD.
 Constant pain and pain while supine are more
likely with infectious, inflammatory, and
neoplastic processes.
 Lateral hip pain is often from the joint or from the
greater trochanteric bursa, especially if there is point
 Hip joint pain is more often anterior
 Lateral paresthesias raise the possibility of meralgia
Clinical Presentation of Hip Pain
 Anterior hip or groin pain is most often seen in
DJD of the hip joint.
 Important to differentiate DJD from osteonecrosis
 If not worse with repetitive hip flexion, have to consider
inguinal hernia and intraabdominal process.
 Anterior thigh pain just above the knee presents the
most difficulty
 Posterior hip pain is not usually from the hip.
More commonly is secondary to lumbar disc,
sacroiliac disease, facet joint disease.
Clinical Presentation of Hip Pain
 Trochanteric bursitis is caused by exaggerrated
movement of the gluteus medius tendon and tensor fascia
lata over the lateral femur.
 More likely to develop with leg length discrepancy, knee
arthritis, ankle sprain, LS spine stiffness
 Point tenderness over trochanteric bursa
 Hip DJD presents with groin pain worse with
movement, limited internal rotation (<15 º), limited
flexion (<115 º)
 Osteonecrosis presents in the groin, thigh, or buttock
 Rest pain is common as is nocturnal pain
Hip Examination
 Observe patient’s gait - ? antalgic, short leg limp,
Trendelenburg gait
Passive internal and external rotation - ? endpoint
stiffness – endpoint pain raises osteonecrosis, occult
fracture, acute synovitis, metastatic disease
Fabere or Patrick test
Straight leg raising to evaluate lumbar origin
Check sensation lateral thigh - ? meralgia
Evaluate L4, L5, and S1 nerve root distribution
Check for tenderness over the sacroiliac joint
Check leg pulses
Evaluation of Hip Pain
 AP of pelvis and hip films
 MRI if occult hip or pelvic fracture is suspected – also
to evaluate early osteonecrosis
 Local anesthetic blocks of sacroiliac joint,
trochanteric area below gluteus medius tendon, lateral
femoral cutaneous nerve
Treatment of Hip Pain
 Very similar to Rx of back pain
 Acetaminaphen, tramadol, NSAIDS
 Physical therapy
 Joint replacement

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