Can radiculopathy cause trochanteric pain syndrome?

Radiculopathy as a Cause of Trochanteric Pain Syndrome

Yes, radiculopathy can cause trochanteric pain syndrome, particularly lumbar radiculopathy involving the L2 and L3 nerve roots, which can present with lateral hip pain that mimics primary trochanteric pain syndrome. 1

Pathophysiological Relationship

Radiculopathy can manifest as lateral hip pain through several mechanisms:

• Referred Pain Patterns: Lumbar nerve root compression (particularly L2, L3) can refer pain to the lateral thigh and hip region 1
• Altered Biomechanics: Radicular pain can cause compensatory gait and posture changes that increase stress on the greater trochanteric region 2
• Diagnostic Confusion: The pain distribution from lumbar radiculopathy can overlap with the presentation of primary trochanteric pain syndrome 1, 2

Diagnostic Considerations

Key Clinical Features to Differentiate:

• Radiculopathy with Secondary Trochanteric Pain:

  • Pain radiating from back/spine to lateral thigh
  • Presence of sensory disturbances (paresthesias)
  • Positive straight leg raise test (91% sensitivity but only 26% specificity) 3
  • May have associated motor weakness in specific myotomes
  • Pain exacerbated by activities that increase intradiscal pressure

• Primary Trochanteric Pain Syndrome:

  • Localized tenderness over greater trochanter
  • Pain with direct pressure over trochanteric region
  • Pain with resisted hip abduction
  • Pain when lying on affected side

Diagnostic Approach

1. Thorough Neurological Examination:

   • Assess for sensory deficits in dermatomal patterns
   • Test knee strength and patellar reflexes (L4)
   • Evaluate great toe and foot dorsiflexion strength (L5)
   • Test foot plantarflexion and ankle reflexes (S1) 3

2. Selective Diagnostic Injections:

   • Peritrochanteric injection with local anesthetic can help differentiate primary trochanteric pain from referred pain 1, 2
   • Selective nerve root blocks can confirm radicular etiology 1

3. Imaging:

   • MRI lumbar spine is appropriate for persistent symptoms after 6 weeks of conservative management 3
   • Ultrasound can identify trochanteric bursitis and rule out other soft tissue pathologies

Clinical Pitfalls

• Misdiagnosis: Studies show that patients with lateral hip pain are frequently misdiagnosed with trochanteric bursitis when the actual cause is lumbar radiculopathy 1
• Delayed Treatment: In one study, four patients were incorrectly treated for hip/knee joint disease when the actual cause was L3 radiculopathy 4
• Overlooking Comorbidity: GTPS and radiculopathy can coexist, complicating diagnosis and treatment 5

Management Approach

1. For Suspected Radiculopathy with Trochanteric Pain:

   • Initial conservative management with NSAIDs and physical therapy for 6 weeks 3
   • If symptoms persist, obtain MRI of lumbar spine to evaluate for nerve root compression
   • Consider selective nerve root blocks for both diagnostic and therapeutic purposes

2. For Confirmed Coexisting Conditions:

   • Address both the radiculopathy and trochanteric pain syndrome
   • Peritrochanteric glucocorticoid injections can provide significant relief even in patients with concurrent radiculopathy 2, 5
   • In a study of patients with both LSDD and GTPS, 90% noted significant pain reduction following trochanteric injections 5

3. Surgical Considerations:

   • Surgery for lumbar pathology should be considered if radicular symptoms persist despite conservative management
   • Failure to identify GTPS before spine surgery may lead to persistent postoperative pain 5

Recent Evidence

A 2024 study demonstrated that among patients with lumbar spine degenerative disease who also had GTPS, 79.5% experienced increased hip pain early after spine surgery. This highlights the importance of identifying and treating GTPS before spine surgery to improve outcomes 5.

Remember that both conditions can coexist, and treating only the radiculopathy or only the trochanteric pain syndrome may result in incomplete symptom resolution.