Back Pain a Predictor of Poor Knee Replacement Outcomes

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knee replacement outcomes

One of the hardest things for the modern orthopedic surgeon to do is to look outside of the joint that he or she is treating to another area that may be involved in the pathology. As an example, to see how a back problem can lead to knee or hip arthritis. To some degree this is a bad side effect of our overspecialization, as you often have surgeons who focus solely on the knee, hip, foot, shoulder, or spine. However, the research of the last decade really doesn’t support that these joints should be considered in isolation. Take, for example, a study published last week that shows back pain is a good predictor of poor knee replacement outcomes.

The Body Is Connected

My life as a physician is so much simpler when all I think about and examine is one joint. For example, the right knee. The office visit is quicker, the options for therapy defined, the number of questions limited. If only it were really that simple.

The body is one machine. There really is no such thing as a hip or a knee or a spine. These are simply specialized parts of the whole machine. What impacts the spine affects the hip, and this influences the knee and so on. In particular, since the nerves that tell every muscle how to move each joint and that carry position-sensor information (e.g., my knee is bent at 80 degrees) live in the spine, it would make common sense that anything that impacts these nerves could and should impact a joint. So chronic back pain causing irritation of the nerves impacts the hip, knee, and hip. However, to most orthopedic surgeons, this common-sense idea is like speaking ancient Greek. They simply don’t often draw this connection. The good news is that the reality of the scientific literature is beginning to smack them upside the head with data that they hopefully will be hard-pressed to ignore. Take, for example, this new study linking back pain to poorer knee replacement outcomes.

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Your Back Pain Impacts Your Knee…and Knee Replacement Outcomes

The new study looked at more than 1,000 knee replacements over two years. In almost 700, the patients were asked to fill out a spine-function questionnaire. Fifty-four percent of the knee replacement patients questioned had daily low-back pain. While patients without back pain demonstrated good results on their functional knee questionnaires (Oxford and Knee Society), patients with low-back pain reported significantly poorer knee replacement outcomes. In addition, the study showed that patients with back pain also had more pain and lower knee function before the knee replacement.

Despite these findings, I can count on both hands the number of times that I have seen an orthopedic surgeon talk to a prospective knee replacement patient about his or her low-back issues or even ask whether the patient has back pain. Far fewer times has a surgeon imaged the low back as part of his or her work-up for the knee. Why does this happen? See above. In our managed-care, hyperspecialized world, the physician looking at the knee often doesn’t really believe it’s his or her job to look at the low back.

The upshot? We have a big problem. Unlike our clinic where we frequently perform an exam on the low back, hip, knee, and ankle in a patient presenting with knee pain—the average orthopedic surgeon has between 5–15 minutes face time booked with a new patient. There simply isn’t the time or the inclination to look. So if you’ve been told you need a knee replacement, be aware that back pain can be a predictor of poor knee replacement outcomes! In addition, in our experience, newer regenerative-medicine techniques can often get rid of the need for the knee replacement, but often by also treating issues that may live in the low back!

This blog post provides general information to help the reader better understand regenerative medicine, musculoskeletal health, and related subjects. All content provided in this blog, website, or any linked materials, including text, graphics, images, patient profiles, outcomes, and information, are not intended and should not be considered or used as a substitute for medical advice, diagnosis, or treatment. Please always consult with a professional and certified healthcare provider to discuss if a treatment is right for you.

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27 thoughts on “Back Pain a Predictor of Poor Knee Replacement Outcomes

  1. Carol Harriff

    I am a type 2 diabetic with both bad knees and stenois of the back.. My fear is that if I have knee replacement that I will not have the right amount of exercise I can do because of back pain. I have had to shots in my back, which I did not see any change. I am currently get shots in both knees which helps some. Both I cannot stand for more than a couple of minutes before my back and knee require that I sit down to stop the pain. So how can I get enough exercise to prevent blood clots if I can’t stand for any length of time.

    1. Regenexx Team Post author


      Skipping the surgery and getting your back and knees treated with your own stem cells and platelets would likely be the ideal solution. Two important issues to consider are steroid shots escalate the situation and Diabetes is associated with chronic pain after knee replacement. Please see: and

  2. PRY

    It is an interesting text BUT it doesn’t say HOW the back pain influences the hip/ knee replacement. What is the link between the 2?

    1. Regenexx Team Post author

      There are nerves in the low back that literally operate your legs and feet, to the extent that if you have a particular knee or foot problem we know to check out L4, or L5, or S1, etc. Removing the knee joint doesn’t change the fact that the low back nerve signals going to operate the now artificial knee, are still not working properly.

  3. Mr P.T.Nicolaou

    I am awaiting surgery for a posterior thorn lateral ligament in the right knee. I had the left knee operated upon 21/2 years ago which took away the pain, but feels weak. I am concerned with the future, and at the age of 58, of osteoarthritis. I understand that your clinics are not based in London, England or are there?

    I would appreciate your prospective and your results in this area.

    Kind regards
    Mr Nicolaou

    1. Regenexx Team Post author

      Mr. Nicolaou,
      Would love to say that your symptoms were very unusual, however, your concerns have basis. Traditional ligament surgery generally involves “replacing” the ligament, which is never as strong as the original and changes the biomechanics of the knee often leading to arthritis. So the best option is to treat the torn ligament in place with image guided injections of your own platelets and or stem cells. Here is some additional info about treating the knee ligaments: Unfortunately, we don’t yet have Regenexx Providers in the UK or Europe. Here is the list of providers in the USA, Australia and India: Please let us know if we can be of assistance.

  4. ann g williams

    thankyou for the info. I had Knee replacement 1 1/2 yrs. ago. the orthopod treated me very badly after the surgery never did I think that would happen I am going to see a pain md next week OH YES, I have had back issues for years. told ortho that and she said no problem !!!!!!

    1. Regenexx Team Post author


      Believe it or not, sadly, she probably didn’t know!

  5. Rob

    I just had total knee replacement three weeks ago and I have been active daily and doing PT at home. Things are going well but my lower back is very tight and stiff and sore. I do some stretching and core strength building exercises to make it feel better but it’s still not great or back to normal. I know it’s only been 3 weeks but anyone else similar?

    1. Regenexx Team Post author

      Was your low back thoroughly examined or was a low back injection tried to make sure it did not resolve your knee pain before surgery?

  6. elizabeth wade

    I had my 2nd knee replacement-6 weeks ago. I have had lower back pain, especially since I am weaning myself from pain meds now. I had to do Physical Therapy after my 1st knee replacement (5 years ago). It looks like that’s where I’m headed again. My current Physical Therapist for my recent replacement has said this is a very common complaint. I have worse back pain now than knee pain :( Let’s share information.

  7. Flora

    I have degenerative disc disease; how can stem cell replacement help?


    1. Regenexx Team Post author

      To treat degenerative Disc Disease, we generally inject the ligaments and facet joints with platelet procedures rather than the disc itself, because it is more effective. Please see:

  8. B holbrook

    I am 3 years out on double tkrs, Have back pain and hip pain in left hip. Wish I had only done one knee. It was better on the first one. the second knee did not go as well. I am 65 and feel like a cripple. for the most part confined to my 1 level home even though I spend 30 minutes a day on a tread mill walking and I have an infrared spa to sit in. Surgery isn’t the answer for all our ailments. Learned that from this experience. I won’t submit to surgery on Joints/bones in the future

  9. Carla Herling

    Hi. I had a total knee replacement surgery to the left knee on March 8th. I was seen in January by Neurosurgery because my right side of my body seemed weaker. According to the tests, I did have some damage to the spinal cord, but nothing new. So I come out of the surgery, and they have me in a bed. I can’t sleep in a bed, it hurts my back and hips. But they don’t have one available. Another thing that happens when my back hurts is that I lose control of my bladder. I haven’t moved anywhere and I am in excruciating pain, with the back, sacroiliac joint and hip pain being the worse. I complained about my pain and a doctor from the Pain Clinic came and basically blew me off and said that I was just being hypersensitive to the pain. Not what I wanted to hear. I wanted something more along the lines of “I understand that you are in pain, let’s see what we can do to get rid of it.” I am a disabled Army veteran, so I had the surgery at the Minneapolis VA Medical Center. I’m home now, and they still don’t know what’s causing the back pain. My ring and pinky fingers on both hands have gone numb, that’s why I think something is pinched somewhere. This is all very unusual and incredibly painful to go through. Thank you.

    1. Regenexx Team Post author

      So sorry to hear about your situation. It’s for these reasons that all non invasive solutions should be exhausted before joint replacement, and why it’s crucial to have a thorough back exam before knee replacement. Thank you for your service Carla! Once you’re recovered, there is a Regenexx provider in Minneapolis who can do a thorough back exam:

    2. Carri

      So sorry to hear how you’ve been treated. Please go see a chiropractor. I too have lower back pain and especially more after my bike in January. I am searching for exercises to do to help with the muscle imbalance. This is all very common after knee surgery. Take heart.

      1. Regenexx Team Post author

        Dr. Centeno has 3 complimentary e-books, Orthopedics 2.0, The Spine Owner’s Manual and the Knee Owner’s Manual that you might find helpful as they explain the inter-related biomechanics of the body and contain self assessment tests as well as exercises

  10. Christine Drake

    itit it is 5 months since my tkr which went well. my progress has been slow my bend is 95 and straighten 2. i would like to be able to do more walking but have only to stand for a few mins when the back ache starts and i cant wait to sit back down i still make myself walk short distances. i mentioned my lower back pain before surgery to my gp who just z we cant give you a new back and the OS said probably due to unbalanced gait end of conversation. i really dont know what to do for the best as know i need to be active. i am still having seeing a physiotherapist who’s only convern is to bend and staighten not interested in my back pain.

    1. Regenexx Team Post author

      Sorry to hear that. Very unfortunately, it is not unusual. Please let us know if you’dlike to see if we can help with your back. Please see:

  11. Gwendoline Blake

    I had severe back pain about 2 weeks after my left knee was replaced. I had no problems beforehand and the operation was deemed to be successful and my rehab was progressing well. In the last of my 3 weeks in hospital the pain of my back in moving from a lying position to a standing one was excruciating. I still dont dare lie in my bed. I sleep in a recliner chair. Has my surgeon ‘overworked’ the leg with the knee replacement while I was under anaesthetic perhaps, testing it out?

    1. Regenexx Team

      Hi Gwendoline,
      Sorry to hear that, but there is not a way to diagnose the issue without examining you.

  12. Virginia

    Help!! I had a knee replacement over a year ago.. the doctor insists it’s my back and to go see him. My bone scan shows
    Loosening but he says it only show some activity but can’t explain. He says my knee is fine but I’m in constant pain! Up my thigh, down my calf, discoloration of my ankle. Now he wants a second opinion. I feel I should, but with a doctor of my choice..I am not a whiner, but this doctor makes me feel like an idiot I have follow all the rules ie: therapy etc.. What should I do?

    1. Regenexx Team

      Hi Virginia,
      Low back issues are often causative in knee problems and a thorough back exam should be part of the diagnostic process before Knee replacement. At the moment, however, a second opinion to rule out problems with the knee replacement itself would be warranted.

  13. Truman Thacker

    Before my injury where I fell and broke my distal femur that resulted in a tkr my legs were weak and I told my dr and was diagnosed with arthritis later after the surgery I developed a limp that forced me to contort my body and thusly noted that from my hip to knee was significantly longer than the other good leg by an inch or more and now am experiencing a lot of pain in my lower back mostly on the opposite side but spreading to both sides where I can’t even bend at the waist but I did also had a giant sized monster tumor that was benignly in nature in my knee femur to shin and still hurts

  14. Raymond Porter

    I had knee surgery three years ago and to tell you the truth I wish I had never bothered i was left in so much pain that my surgeon took me back in and refurbished my knee cap as he said the arthritis was coming from there what a load of tosh .So when I told him it was no different he said well I am sorry there is not an operation i can give you to put it right. Then I was passed onto the pain clinic had a scan injections in my back that was very uncomfortable no difference still the same then I was released from the pain clinic and no further forward. The pain in my knee is really bad but the worst of it the pain in my knee and back when I go to bed are unbearable. What keeps cropping up is the alignment when the replacement was put in.I have told my own Doctor but he is not interested in a second opinion anyone got any ideas I’m at my wits end don’t want to go to bed.

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