In a patient with a known partial‑thickness left gluteus minimus tear and moderate left‑sided and mild right‑sided L2‑L3 neuroforaminal narrowing with Modic type 1/2 changes, if the hip examination is not convincing for a gluteus minimus tear, could the hip pain actually be referred from the lumbar spine or sacroiliac joint?

Yes, Hip Pain Can Be Referred from the Lumbar Spine or Sacroiliac Joint

When the hip examination does not convincingly demonstrate findings consistent with a gluteus minimus tear, the pain is likely referred from the lumbar spine, especially given the documented L2-L3 neuroforaminal narrowing with Modic changes. 1

Understanding the Clinical Context

Your patient presents with a diagnostic dilemma where imaging shows both hip pathology (partial gluteus minimus tear) and spinal pathology (L2-L3 neuroforaminal narrowing with Modic changes), but the physical examination doesn't support the hip as the pain generator. This scenario is common and requires systematic evaluation.

Key Diagnostic Principle

The American College of Radiology emphasizes that imaging findings alone are insufficient for diagnosis and must be combined with symptoms and clinical examination findings. 2 Incidental imaging findings are extremely common in asymptomatic individuals, meaning your patient's partial gluteus minimus tear may be an incidental finding rather than the pain source. 2

Distinguishing Hip from Spine/SI Joint Pain

Pain Location Patterns

• Intra-articular hip pathology typically presents with anterior groin pain, not lateral hip or buttock pain. 2
• Lateral hip pain is the hallmark of greater trochanteric pain syndrome (gluteus medius/minimus pathology), which distinguishes it from intra-articular hip problems. 2
• Lumbar spine pathology commonly refers pain to the groin, buttock, and lateral hip regions, making it a frequent mimicker of hip pathology. 1

Critical Physical Examination Findings

• Trendelenburg's sign is the most sensitive (72.7%) and specific (76.9%) physical finding for detecting gluteus medius/minimus tears. 3 If this sign is absent, the likelihood of a symptomatic abductor tear decreases substantially.
• A negative FADIR test (flexion-adduction-internal rotation) helps rule out intra-articular hip pathology. 2
• Pain on resisted hip abduction suggests abductor tendon pathology, but has lower diagnostic accuracy than Trendelenburg's sign. 3

Diagnostic Algorithm for Your Patient

Step 1: Assess for Red Flags Immediately

• Exclude cauda equina syndrome by assessing for urinary retention, fecal incontinence, and saddle anesthesia, which would require urgent MRI within hours. 1
• Check for fever, unexplained weight loss, or history of cancer. 1

Step 2: Determine Most Likely Pain Source

Given your patient's presentation:

• The L2-L3 neuroforaminal narrowing with Modic type 1/2 changes is highly significant. Modic changes indicate active inflammatory processes in the vertebral endplates and are associated with discogenic pain. 1
• Lumbar disc degeneration with referred pain is one of the most common causes of groin and hip region pain. 1
• If the hip examination is unconvincing (negative Trendelenburg, no weakness on resisted abduction, no gait abnormality), the partial gluteus minimus tear is likely incidental. 2, 3

Step 3: Use Diagnostic Injections

Imaging-guided diagnostic injections are the gold standard for distinguishing pain sources when clinical examination is equivocal. 4

• An intra-articular hip injection relieving pain confirms the hip joint as the source. 4
• A trochanteric/peritrochanteric injection relieving pain suggests abductor tendon pathology. 4
• Lack of relief from hip-directed injections strongly suggests spinal or SI joint origin. 4
• All injections should be image-guided for accuracy. 4

Step 4: Advanced Imaging Strategy

• If radiographs were not already obtained, start with AP pelvis and lateral hip views to screen for alternative diagnoses. 1, 2
• MRI of the lumbosacral spine (not just the hip) is indicated to fully evaluate the L2-L3 neuroforaminal narrowing, disc degeneration, and nerve root compression. 1
• The hip MRI showing the partial gluteus minimus tear has already been performed, but correlation with clinical findings is essential. 4

Critical Pitfalls to Avoid

• Do not assume that imaging findings equal the pain source. Multiple pathologies frequently coexist, and asymptomatic tears of the gluteus medius/minimus are common in the general population. 2, 5
• Do not rely solely on MRI findings without correlating with physical examination. A partial-thickness gluteus minimus tear without corresponding clinical signs (Trendelenburg gait, weakness, lateral hip tenderness) is likely incidental. 3
• Remember that tendinopathy of hip abductors can mimic other important conditions including avascular necrosis and stress fracture, but also that spinal pathology is a common mimicker of hip pain. 5
• Lumbar spinal stenosis and neuroforaminal narrowing are frequently underdiagnosed causes of hip region pain, particularly when clinicians focus exclusively on hip imaging findings. 1

Most Likely Scenario in Your Patient

Given the unconvincing hip examination despite documented gluteus minimus pathology on imaging, combined with significant L2-L3 neuroforaminal narrowing and Modic changes, the lumbar spine is the most probable pain generator. 1 The partial gluteus minimus tear represents an incidental finding that does not correlate with the clinical presentation. Proceed with diagnostic injection (either hip-directed to rule out hip source, or epidural/nerve root block to confirm spinal source) and consider focused treatment of the lumbar pathology. 4, 1