What should I do for constant left lumbar and left hip pain that is keeping me from sleeping?

Management of Constant Left Lower Back and Left Hip Pain Disrupting Sleep

You need immediate evaluation to rule out serious pathology, followed by a structured approach starting with NSAIDs, heat therapy, and activity modification while avoiding bed rest—and if pain persists beyond 4-6 weeks despite conservative management, imaging with plain radiographs should be obtained. 1, 2

Immediate Assessment: Rule Out Red Flags

Before proceeding with treatment, you must exclude serious conditions that require urgent intervention: 2, 3

• Cauda equina syndrome: Check for urinary retention, fecal incontinence, saddle anesthesia, or loss of anal sphincter tone—these require emergency MRI and surgical evaluation 1, 2
• Infection: Assess for fever, recent infection, or IV drug use 1
• Cancer: Consider if you have unexplained weight loss, age over 50, or history of cancer 1
• Compression fracture: Suspect if you're older with osteoporosis or steroid use 1
• Progressive neurologic deficit: Check for progressive weakness, numbness spreading down the leg, or loss of reflexes 1, 3

Determine Pain Pattern: Back vs. Hip vs. Radicular

Your clinical presentation requires distinguishing between three possibilities: 1, 4

• Radicular pain (sciatica): Pain radiating down the leg in a nerve root distribution, worsening with certain positions, suggests disc herniation—most commonly at L4/L5 or L5/S1 levels 1
• Hip pathology: Anterior, lateral, or posterior hip pain that may be intra-articular (labral tear, osteoarthritis) or extra-articular (greater trochanteric pain syndrome, gluteus medius tendinopathy) 4
• Referred pain: Lumbar spine pathology can refer to the hip region, and hip pathology can refer to the lower back 4

Key distinction: If pain radiates down your leg in a dermatomal pattern and worsens with sitting or certain movements, radiculopathy from disc herniation is likely. 1 If pain is localized to the hip joint or lateral hip without leg radiation, hip-specific pathology is more probable. 4

First-Line Treatment (Start Immediately)

Pharmacologic Management

NSAIDs are your primary medication with the strongest evidence for moderate pain relief: 1, 2, 3

• Start naproxen 375-500 mg twice daily or ibuprofen 400-600 mg three times daily 5
• Add acetaminophen as adjunctive therapy (up to 3000-4000 mg daily in divided doses) 1, 2
• Consider a skeletal muscle relaxant for short-term use (3-7 days) if muscle spasm is prominent, though be aware of sedation 1, 2

Avoid opioids as first-line therapy—use only if NSAIDs are insufficient, at the lowest dose for the shortest time. 1, 3

Non-Pharmacologic Management

These interventions have good evidence and should be started immediately: 1, 2, 3

• Superficial heat: Apply heating pad or warm compress to affected area—this has good evidence for moderate benefit 1
• Stay active: Avoid bed rest completely, as remaining active is more effective than rest 1, 2, 3
• Activity modification: Avoid prolonged sitting, heavy lifting, or positions that worsen pain 1, 6

Sleep Management

Since pain is disrupting your sleep, address this specifically: 7

• Optimize sleep hygiene: regular exercise during the day, stress management, avoid caffeine/nicotine/alcohol before bed, maintain consistent sleep timing 7
• Consider a short course of muscle relaxant at bedtime if muscle spasm is contributing to sleep disruption 2
• Position yourself to minimize pain: side-lying with pillow between knees often helps with both back and hip pain 7

Timeline for Imaging and Specialist Referral

Do NOT rush to imaging unless red flags are present: 1, 2, 3

Imaging Algorithm

• No imaging initially: If no red flags, start conservative management first 1, 2
• Plain radiographs at 4-6 weeks: If pain persists despite conservative therapy, obtain AP pelvis and frog-leg lateral hip views to evaluate hip pathology, plus lumbar spine films if radicular symptoms are present 7, 1, 5
• MRI at 6+ weeks: If symptoms persist beyond 6 weeks with conservative management AND radiographs are negative/equivocal, obtain MRI lumbar spine without contrast (if radicular symptoms) or MRI hip without contrast (if hip-specific symptoms) 7, 1
• Immediate MRI: Only if severe/progressive neurologic deficits, suspected cauda equina, or red flags for cancer/infection 1, 2

Specialist Referral Timeline

Refer based on severity and response to treatment: 7, 1

• Within 2 weeks: If pain is severe, disabling, and prevents normal daily activities 7
• Within 3 months: If radicular pain is not severe but persists despite conservative management 7
• Immediate referral: If progressive motor weakness, cauda equina symptoms, or multiple-level neurologic deficits 1

What to AVOID

Critical pitfalls that worsen outcomes: 1, 3

• Do NOT get epidural steroid injections: The most recent high-quality BMJ guideline provides a strong recommendation AGAINST epidural injection of local anesthetic, steroids, or their combination for radicular spine pain 1
• Do NOT rest in bed: Bed rest worsens outcomes and delays recovery 1, 2, 3
• Do NOT rush to imaging: Early routine imaging does not improve outcomes, cannot identify a precise cause in most cases, and incurs unnecessary expense 1
• Do NOT use long-term opioids: Evidence is inconclusive for benefit, and risks of dependence and adverse effects are substantial 3

Expected Timeline and Prognosis

Most patients improve within the first 4 weeks with conservative management: 1, 2, 6

• Expect substantial improvement in the first month with NSAIDs, heat, and activity modification 1
• If no improvement by 2 weeks, reassess and ensure compliance with conservative measures 7
• If no improvement by 4-6 weeks, obtain imaging and consider specialist referral 1, 6
• Surgery is rarely needed—only for persistent functional disability with confirmed structural pathology after at least 6 weeks of conservative therapy 1

Addressing Psychological and Social Factors

Since pain is affecting your sleep and daily function, assess these factors: 7

• Pain-related fear and avoidance of activities can perpetuate disability 7
• Catastrophizing (rumination, magnification, helplessness) worsens pain perception 7
• Work stress, economic problems, and social support affect pain outcomes 7
• Consider brief psychological intervention if pain persists beyond 6-8 weeks despite physical treatments 7