Differentiating Sciatica from Hip Osteoarthritis: Diagnostic Challenges and the Role of the Athena Sign

Abstract

Background/Objectives: Sciatica and hip osteoarthritis (OA) are common causes of lower extremity pain and functional impairment. Because both conditions may produce overlapping symptoms, distinguishing them can be challenging. Misdiagnosis may lead to inappropriate treatment, delayed intervention and unnecessary procedures. In addition, the frequent coexistence of hip and lumbar degenerative pathology, commonly referred to as hip–spine syndrome, further complicates diagnostic evaluation. This review aims to examine current diagnostic strategies used to differentiate lumbar radiculopathy from hip OA and to introduce the Athena Sign, which is presented as a preliminary, hypothesis-generating clinical observation requiring prospective validation. Methods: A narrative review of the literature was performed focusing on the pathophysiology, clinical presentation, differential diagnosis, physical examination and imaging evaluation of sciatica and hip OA. Particular emphasis was placed on clinical examination techniques and diagnostic injections used to identify the primary pain generator. Results: Both conditions share overlapping symptom patterns and inflammatory mechanisms, which may obscure the source of pain. Careful assessment of gait, hip range of motion, neurological findings and provocative maneuvers remains essential for accurate diagnosis. Imaging findings should be interpreted in conjunction with clinical examination due to the high prevalence of asymptomatic degenerative changes. The Athena Sign, observed with internal and external rotation of the hips in a prone position with the knee flexed, is associated with anterior intra-articular hip pathology and may provide an additional diagnostic indicator in patients with ambiguous hip–spine presentations. Conclusions: A systematic diagnostic approach integrating clinical examination, imaging and targeted diagnostic injections is essential for distinguishing between lumbar radiculopathy and hip OA. Recognition of dynamic clinical findings such as the Athena Sign may further improve diagnostic accuracy and guide appropriate management in patients presenting with overlapping hip and lumbar symptoms.