The Forgotten Condition That Could Be Causing Your Hip Pain

Why Physical Examinations are Important

Hip pain is commonly seen in physical therapy.  Hip pain could impact your ability to walk, golf, twist in the car, get out of the car, get out of a chair, and so on.  However, it might be somewhat surprising to find out that it can often be difficult to determine the cause of your hip pain.  This is because the lower back can commonly refer pain into your hip.  When in doubt, it might seem like getting a medical image like an x-ray or MRI would be helpful.  Unfortunately, it is too often the case that those imaging modalities don’t help.  The reason for this is somewhat unexpected – it is common for people to have imaging findings in both the lower back1and the hip2 while still being pain-free!  Instead, it makes sense to do a physical examination of the hip and regions that can refer into the hip in order to determine whether one area is more sensitive and therefore more likely to be the cause.

Thoracolumbar Junction Syndrome

When doing a physical examination, one less-recognized area that can refer into the hip is the thoracolumbar junction (or the T12-L1 area).  This is where your lower back and middle-back meet and where more rotation happens in your spine.  “Thoracolumbar Junction Syndrome” was first described in 1972 by French physician Robert Maigne.3  Maigne later went on to describe how nerves in the region can refer pain down to the region of the sacroiliac joint, lateral hip, and groin on the same side.4  He found that manually examining the thoracolumbar junction and the skin over the iliac crest of the hip region was helpful in determining if this was a diagnosis worth considering.4  In theory, patients that have this condition could have hip pain with twisting of their trunk, and may have a feeling of stiffness or pain in their middle back in addition to their hip.  With Robert Maigne’s aging (and his eventual death in 2012), this condition floated on in relative obscurity.

The New Case Series

In this month’s Journal of Orthopaedic & Sports Physical Therapy, our own Seth Peterson and colleagues published a report of 3 patients who were diagnosed with Thoracolumbar Junction Syndrome and successfully treated in physical therapy.5  The patients seen all had chronic hip pain at the time they were seen, with many of them already having had imaging or been offered injections.  One of the patients was considering surgery and was able to avoid surgery after physical therapy.  The number of sessions until relief of symptoms in these patients was 6, 8, and 4.5 The approach used in these patients consisted of a thorough physical examination of their hips, lower backs, and middle backs, followed by joint mobilization and exercise directed at the thoracolumbar junction.5

How Well Do We Try to Avoid Surgery?

In the same journal this month was a case by Jodi Young and colleagues who tracked patients with a specific type of hip issue before surgery.6  Frighteningly, they found that nearly 2 of every 3 patients who had hip surgery had no physical therapy beforehand.6  Of the patients that did have physical therapy, the median number of sessions was only 2. 6 These results suggest that there are likely a large number of patients who could avoid the costs and risks associated with surgery if they attempted a reasonable amount of physical therapy beforehand.  Taken together with the other case report, there may even be patients who end up with surgery on a hip problem found on imaging when in fact the issue is being referred from a different bodily region.

What Should You Do?

If you are struggling with hip pain, it makes sense to start with a provider who can do a thorough physical examination of the hip and regions that can refer into the hip.  If you are considering surgery or other risky or invasive procedures, physical therapy may offer an option that is both less risky and just as effective in many cases.

Please feel free to share this blog post with anyone who you think may need this information and please message me directly with any specific questions!

1. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331(2):69-73. doi: 10.1056/NEJM199407143310201.
2. Heerey JJ, Kemp JL, Mosler AB, et al. What is the prevalence of imaging-defined intra-articular hip pathologies in people with and without pain? A systematic review and meta-analysis. Br J Sports Med. 2018;52(9):581-593. doi: 10.1136/bjsports-2017-098264.
3. Maigne R. Orthopedic Medicine: A New Approach to Vertebral Manipulations. Springfield, IL: Charles C. Thomas; 1972.
4. Maigne R. Diagnosis and Treatment of Pain of Vertebral Origin: A Manual Medicine Approach. Baltimore, MD: Williams & Wilkins; 1995.
5. Meadows J, Denninger T, Peterson S, Milligan L, Zapanta J. Short-term Response to Treatment Targeting the Thoracolumbar Junction in Patients With Hip Pain: A Case Series. J Orthop Sports Phys Ther. 2019;49(8):611-619. doi: 10.2519/jospt.2019.8309.
6. Young JL, Wright AA, Rhon DI. Nonoperative Management Prior to Hip Arthroscopy for Femoroacetabular Impingement Syndrome: An Investigation Into the Utilization and Content of Physical Therapy. J Orthop Sports Phys Ther. 2019;49(8):593-600. doi: 10.2519/jospt.2019.8581.