Is It Your Back, Hip, or Knee? Sometimes the Pain Is Lying to You!
By Mark C. Engasser, MD — Board-Certified Orthopedic Surgeon
One of the things I've learned over my years as an orthopedic surgeon is that patients are usually very good at telling you where they hurt.
They're not always as good at telling you where the problem actually is.
And that's understandable. If your knee hurts, you naturally assume something is wrong with your knee.
But what if the problem is actually in your hip?
Or perhaps your hip hurts, but the real culprit is a pinched nerve in your lower back.
As we get older, arthritis and degenerative changes become increasingly common. Unfortunately, they don't always respect anatomical boundaries.
And on the pickleball court, where knees, hips, and backs get plenty of exercise, this can lead to some confusing symptoms.
The Hip That Pretends to Be a Knee
Here's one of my favorite examples from orthopedic practice.
A patient comes in complaining of knee pain. They've tried medications, knee braces, physical therapy, and perhaps even an injection.
But their knee examination is relatively normal.
Then I examine their hip.
The hip has limited motion, particularly internal rotation, and moving it reproduces their familiar pain.
An X-ray reveals significant hip osteoarthritis.
The knee wasn't necessarily the problem. The hip was sending pain to the knee.
This phenomenon is called referred pain.
The hip and knee share portions of their nerve supply, particularly through branches associated with the femoral and obturator nerves. As a result, the brain can sometimes interpret pain originating in the hip as coming from the thigh or knee.
In some patients, knee pain is the primary complaint even when the hip is the major source.
This is why a good orthopedic examination should include the joints above and below the painful area.
Hip Arthritis: Not Always Pain in the Hip
Osteoarthritis of the hip typically causes discomfort in the groin, but it may also produce pain in the buttock, thigh, or knee.
Patients often notice difficulty putting on socks, tying shoes, getting into a car, or rotating the leg.
One particularly useful examination finding is restricted internal rotation of the hip.
If rotating the hip reproduces the patient's pain, that can be an important clue.
Of course, not everyone with hip arthritis has the same symptoms, and an X-ray showing arthritis doesn't automatically prove it's responsible for the pain.
That's where the examination becomes so important.
Spinal Stenosis: When Your Back Causes Leg Pain
Now let's consider another common condition in older athletes: lumbar spinal stenosis.
As we age, degenerative changes in the spine can narrow the spaces through which the spinal nerves travel.
This may produce pain, heaviness, tingling, numbness, or weakness in the buttocks and legs.
Interestingly, some patients have relatively little back pain.
Their main complaint may be leg discomfort when standing or walking.
A classic feature is that symptoms improve when they sit down or bend forward.
You may have heard of the shopping cart sign.
A patient who has difficulty walking upright may feel much better leaning forward over a shopping cart.
Why? Because bending forward generally increases the available space for the spinal nerves.
Some patients with spinal stenosis can ride a bicycle more comfortably than they can walk a similar distance.
So if a fellow pickleball player tells you their legs hurt when they walk but feel better when they sit, don't automatically blame the knees.
The problem may be in the lumbar spine.
Sciatica: Pain That Travels
A compressed or irritated spinal nerve can produce pain radiating down the buttock, thigh, calf, and sometimes into the foot.
This is commonly called sciatica, although the precise nerve involved can vary.
The pain may be accompanied by burning, tingling, numbness, or weakness.
A patient with an L3 or L4 nerve problem may experience discomfort around the anterior thigh or knee, potentially mimicking knee disease.
An L5 or S1 nerve problem may produce symptoms farther down the leg, sometimes involving the ankle or foot.
This is why a painful knee, calf, or ankle isn't always a local joint problem.
However, pain traveling down the leg is not automatically sciatica. Peripheral neuropathy, vascular disease, and local joint disorders can produce overlapping symptoms.
And Sometimes the Knee Really Is the Problem!
We shouldn't forget the obvious possibility.
Knee osteoarthritis is extremely common, particularly among older pickleball players.
Typical symptoms include pain around the joint, stiffness after sitting, swelling, difficulty with stairs, and discomfort during weight-bearing activity.
Examination may reveal tenderness, restricted movement, crepitus, or changes in alignment.
Unlike referred pain from the hip, knee arthritis often produces findings directly at the knee.
But there's another complication: A person can have arthritis in the back, hip, and knee at the same time.
The challenge is determining which condition is responsible for most of the symptoms.
Hip-Spine Syndrome: When Two Problems Overlap
Orthopedic surgeons sometimes use the term hip-spine syndrome to describe patients with both hip disease and lumbar spine problems.
These conditions can produce remarkably similar complaints.
A patient may have significant hip arthritis on X-ray and lumbar spinal stenosis on MRI.
Which one should be treated first?
The answer depends on the history, physical examination, neurological findings, and occasionally diagnostic injections.
For example, an image-guided injection of local anesthetic into the hip joint may temporarily relieve pain if the hip is the major source.
That can help clarify the diagnosis when both the hip and spine show abnormalities.
The important point is that an abnormal MRI or X-ray doesn't necessarily identify the cause of the symptoms.
Treating an image rather than the patient can be a costly mistake.
A Few Clues Worth Remembering
These are clues, not definitive diagnoses.
Why This Matters Before Surgery
Imagine undergoing treatment for knee pain, only to discover later that the major problem was severe hip arthritis.
Or considering hip replacement when most of the discomfort is actually coming from lumbar spinal stenosis.
These situations can occur.
Before major surgery, it's important to be reasonably confident that the proposed operation addresses the primary source of the patient's symptoms.
Sometimes treating one problem reveals that another condition also needs attention.
And occasionally the correct decision is to treat neither surgically, at least initially.
Dr. Engasser's Perspective
One of the most valuable lessons from my orthopedic career is that a careful history and physical examination often tell us more than an impressive collection of MRI scans.
When evaluating knee pain, examine the hip.
When evaluating hip pain, consider the lumbar spine.
When evaluating leg pain, remember the nerves, joints, and circulation.
And when several abnormalities appear on imaging, don't automatically assume the worst-looking one is causing the symptoms.
For senior pickleball players, this is particularly important because degenerative changes become increasingly common with age.
My advice: Don't just ask where it hurts. Ask where the pain is coming from.
The next time someone on the pickleball court complains about their knee, you might ask whether anyone has examined their hip.
Of course, if you start performing orthopedic examinations between games, you may find yourself with a longer waiting list than the paddle rack.
And remember: New or progressive leg weakness deserves prompt medical assessment. New bladder or bowel dysfunction, particularly with saddle numbness, requires emergency evaluation.
Dr. Pickleball's Musings provides general medical education and commentary and does not replace individualized medical evaluation.