Diagnosis of Hip, Buttock, and Back Pain

In general, true hip pain manifests as groin pain that sometimes radiates to the knee. Thigh pain, buttock pain, and pain radiating below the knee are more often attributable to disorders of the lumbar spine or buttock and proximal thigh musculature.

LOW BACK PAIN

Chronic nonspecific low back pain may result from peripheral injury to various neural and non-neural anatomic structures in the lumbar region. Pain generators may include the vertebral column, surrounding muscles, tendons, ligaments, and fascia, or the neural structures such as the lumbosacral roots. Hip osteoarthritis, trochanteric bursitis, ischial bursitis, sacroiliac dysfunction, piriformis syndrome, and osteitis condensans ilii are examples of somatic conditions that will refer pain to and from the low back. Hip-joint pathology and bursitis of the greater trochanter can mimic mechanical or radicular LBP, both in its onset and symptoms.

It is crucial to distinguish radicular pain from somatic referred pain because their management is significantly different. Somatic referred pain is the result of noxious stimulation of structures in the lumbar spine, such as intervertebral disks, facet joints, or sacroiliac joints, and never of the nerve roots. It has a dull, gnawing quality, and is difficult to localize. Conversely, radicular pain is elicited by ectopic discharges from a dorsal root. The most common cause of such pain is disk herniation complicated by the inflammation of the affected nerve. It is described as lancinating or shocking, and it can involve allodynia in case of nerve damage and neuropathy. Finally, radiculopathy is a condition characterized by motor and sensory loss in dermatomal distribution due to conduction block along the nerve, and it often accompanies radicular pain.

LBP associated with lumbosacral radiculitis is classically characterized by unilateral lower extremity pain and paresthesias. The onset of pain or paresthesias is typically abrupt and often reported as more severe in the leg versus the low back region. The patient may exhibit decreased truncal range of motion.

Lumbar spinal stenosis is a distinctive syndrome in which the cauda equine and exiting nerve roots are compromised due to degenerative changes. The distinctive experience of pain evoked with standing and walking is known as neurogenic claudication. In contrast to radiculitis, this pain typically remits in the seated (and recumbent) posture or with forward flexion at the waist. This symptom pattern is the leading indication for spine surgery in older adults.

Spondylolisthesis is a common, painful condition that exists when there is disruption of the normal segmental alignment of a vertebral body in relation to the adjacent level, usually from failure (e.g., fracture of the pars interarticularis) of the posterior vertebral elements. Patients may present with dull, achy back pain that radiates posteriorly to or below the knees. Lumbosacral tenderness, reduced lateral bending, and hamstring tightness are also common findings.

Vertebral compression fractures are also a common cause of LBP, especially in the elderly. Point tenderness is common in early fractures and often is associated with muscle spasm.

BUTTOCK PAIN

In the low back, referral pain patterns commonly manifest with hip or leg symptoms. A classic example of a referral pain pattern in the lumbosacral spine is low back pain associated with aching buttock pain. The lumbosacral region and buttocks are both innervated by L4-S1. However, the buttock is innervated by the ventral rami of these nerve roots (the superior and inferior gluteal nerves), and the lumbosacral region is innervated by the dorsal rami.

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