What could be causing my severe back, hip, and thigh pain that feels like burning?

Burning Pain in Back, Hips, and Thighs: Diagnostic Approach

Your burning pain radiating from the back through the hips and thighs most likely represents lumbar radiculopathy (sciatica) or neurogenic claudication from spinal stenosis, and you need immediate evaluation for red flag symptoms that could indicate cauda equina syndrome or other serious pathology. 1

Immediate Red Flag Assessment

You must be evaluated urgently for the following warning signs that indicate serious conditions requiring immediate intervention 1:

• Urinary retention or incontinence (90% sensitive for cauda equina syndrome) 1
• Fecal incontinence or loss of sphincter control 1
• Bilateral leg weakness or motor deficits at multiple levels 1
• Saddle anesthesia (numbness in the groin/rectal area) 1
• Progressive neurologic deficits 1

If any of these are present, you require emergency surgical evaluation. 1

Additional Serious Conditions to Rule Out

Your physician should specifically assess for 1, 2:

• History of cancer (increases probability of spinal metastases from 0.7% to 9%) 1
• Unexplained weight loss (associated with malignancy) 1
• Age over 50 years (higher risk for cancer and compression fractures) 1
• Fever or recent infection (suggests spinal infection) 1
• Intravenous drug use (risk factor for vertebral infection) 1
• Chronic steroid use or osteoporosis (risk for compression fracture) 1
• Significant trauma 1

Most Likely Diagnoses Based on Your Symptoms

The burning quality of pain radiating from back to hips and thighs suggests nerve involvement 1:

Lumbar Radiculopathy (Sciatica)

• Pain radiating below the knee in sciatic nerve distribution is the hallmark 1
• Over 90% of symptomatic disc herniations occur at L4/L5 or L5/S1 levels 1
• The straight-leg-raise test has 91% sensitivity for herniated disc 1
• A positive crossed straight-leg-raise test (pain when lifting the unaffected leg) is 88% specific for disc herniation 1

Neurogenic Claudication from Spinal Stenosis

• Leg pain and weakness with walking or standing, relieved by sitting or forward bending 1
• Age over 65 years increases likelihood (positive likelihood ratio 2.5) 1
• Symptoms worsen with downhill walking (positive likelihood ratio 3.1) 1

Hip Pathology with Referred Pain

• Anterior hip pain can refer to the thigh 1, 3
• Greater trochanteric pain syndrome causes lateral hip and thigh burning 3
• Hip joint pathology typically causes groin pain that may radiate to the thigh 1, 3

Initial Imaging Strategy

Start with plain radiographs (AP pelvis and lateral views) as your first imaging test. 1 This is the standard recommendation across all major guidelines for both back and hip pain. 1

If radiographs are negative, equivocal, or nondiagnostic 1:

• MRI without contrast is the next appropriate study for evaluating nerve root compression, disc herniation, spinal stenosis, and soft tissue pathology 1
• MRI should never be ordered based on imaging findings alone—it must correlate with your clinical symptoms 1
• Imaging can be delayed 4-6 weeks if no red flags are present, as most nonspecific back pain resolves with conservative treatment 1, 2

When Imaging Should NOT Be Delayed

Obtain imaging immediately if 1:

• Red flags are present (as listed above) 1
• Myelopathy symptoms exist 1
• Progressive neurologic deficits develop 1
• You have risk factors for serious pathology (cancer history, osteoporosis, chronic steroids) 1

Diagnostic Injections

Image-guided diagnostic injections can help localize the pain source 1:

• Intra-articular hip injection relieving pain confirms hip joint pathology 1
• Trochanteric injection helps diagnose greater trochanteric pain syndrome 1
• These should always be performed under imaging guidance (fluoroscopy or ultrasound) 1

Critical Pitfalls to Avoid

Do not assume burning pain is always from the spine—hip pathology commonly refers pain to the thigh and can mimic radiculopathy. 1, 3 The ACR guidelines specifically address this overlap and recommend evaluating both the spine and hip when the pain distribution is ambiguous. 1

Incidental imaging findings are extremely common in asymptomatic people—disc bulges, herniations, and degenerative changes correlate poorly with symptoms. 1 Your diagnosis must be based on the combination of symptoms, examination findings, and imaging, never imaging alone. 1

Routine imaging provides no clinical benefit for acute uncomplicated back pain without red flags—it does not improve outcomes and may lead to unnecessary interventions. 1, 2