What is the best management approach for a 46-year-old runner with chronic lower back and hip pain unresponsive to physical therapy?

Management of Chronic Lower Back and Hip Pain in a 46-Year-Old Runner

A multimodal approach combining targeted physical therapy for hip abductor strengthening, pain neuroscience education, and appropriate activity modification is the most effective management strategy for this patient with chronic lower back pain radiating to the hip and groin. 1

Assessment of Current Presentation

This 46-year-old runner presents with:

• Chronic lower back and hip pain present for years
• Pain radiating to the groin with left hip internal rotation
• High activity level (40 miles/week running)
• Previous negative workup (normal scrotal ultrasound, negative DRE)
• Unsuccessful physical therapy to date

The pattern of pain with internal rotation of the left hip radiating to the groin, combined with normal lumbar facet and sacroiliac joint examination, strongly suggests a hip-related component to the patient's back pain.

Treatment Algorithm

1. Risk Stratification

• Apply the STarT Back tool to assess risk for developing persistent disabling pain 1
• Based on the chronic nature and functional impact, this patient likely falls into medium-high risk category

2. First-Line Interventions

• Targeted Physical Therapy:

  • Hip abductor strengthening program (3-4 times weekly for 8-10 weeks) 2
  • Hip mobility exercises focusing on internal rotation
  • Core stabilization exercises
  • Gait and running mechanics assessment and correction

• Pain Education:

  • Provide education on pain neuroscience and the relationship between hip dysfunction and back pain
  • Explain the biomechanical connection between hip rotation limitations and lower back stress

• Activity Modification:

  • Temporarily reduce running volume by 30-50% while addressing biomechanical issues
  • Cross-train with non-impact activities (swimming, cycling)
  • Implement proper warm-up and cool-down routines

3. Second-Line Interventions

• Nonopioid Pain Management:

  • NSAIDs for short-term pain control if not contraindicated 1
  • Topical analgesics as needed

• Manual Therapy:

  • Joint mobilization for hip and lumbar spine
  • Soft tissue mobilization for hip external rotators and flexors

4. Advanced Interventions (if no improvement after 12 weeks)

• Referral to multidisciplinary pain management team 1
• Consider referral to sports medicine specialist for further evaluation
• Potential diagnostic imaging (MRI) to rule out labral pathology or other hip structural issues

Evidence-Based Rationale

The British Pain Society pathway recommends a structured approach to chronic back pain, with early risk stratification using the STarT Back tool and appropriate referral based on risk level 1. For patients with chronic pain, nonpharmacologic approaches are strongly preferred as first-line treatment 1.

Research shows that patients with lower back pain often have associated hip dysfunction, particularly weakness in hip abductors 2. A targeted approach focusing on hip strengthening has shown significant improvements in pain (3-7 point reduction on pain scales) and function in patients with this presentation 2.

Monitoring and Follow-up

• Reassess every 2-3 weeks during active treatment
• Document objective measures:
  • Hip range of motion
  • Hip abductor strength
  • Pain levels during running and daily activities
  • Functional capacity

Pitfalls to Avoid

1. Continuing ineffective treatments: If the current PT approach isn't working after 4-6 weeks, change the strategy rather than continuing the same interventions 3

2. Missing serious pathology: While mechanical causes are most likely, be vigilant for red flags suggesting more serious conditions 4:

   • Night pain unrelieved by position change
   • Unexplained weight loss
   • Pain that worsens when supine
   • Progressive neurological symptoms

3. Focusing only on the lumbar spine: The hip-spine connection is critical in runners, and treating only the back will likely be unsuccessful 5

4. Returning to full activity too quickly: A graded return to running is essential to prevent recurrence

By implementing this comprehensive approach that specifically targets hip dysfunction while addressing the back pain, this patient has the best chance for meaningful improvement in both pain and function.