Why Your Low Back Pain Likely Starts in Your Hips

Why Your Low Back Pain Likely Starts in Your Hips

You have done the sensible things. You stretched your hamstrings. You bought the lumbar pillow. You spent six weeks strengthening your core, and maybe you even had imaging done that came back unremarkable. The pain is quieter some weeks and louder others, but it has not actually left.

Here is the question worth asking: what if the tissue that needs attention is not in your back at all?

At LA Sports Performance Care in Manhattan Beach, one of the most common patterns Dr. Steve sees in patients with stubborn low back pain is a pair of hips that have stopped doing their share of the work. The back is where the pain announces itself. The hips are often where the story starts.

Your low back is picking up the slack

Your hips are built for motion in every direction. They flex, extend, rotate, and swing out to the side, and they are supposed to be the primary engine for most of what you do on your feet. Walking. Running the Strand. Popping up on a board. Loading and unloading a car seat with a toddler in it.

When a hip loses range, that motion does not simply disappear. Your body finds it somewhere else. The nearest available joints are the segments of your lumbar spine, which are designed for stability far more than for repetitive rotation and extension. Ask them to cover a few degrees of missing hip motion a few thousand times a week and they will do it. They will also start complaining about it.

This is what Dr. Steve means when he says the origin of pain is almost always upstream from where you feel it. The tissue that hurts is frequently the tissue that has been compensating, not the tissue that failed first.

Orthopedic medicine has a formal name for the two-way traffic between these regions: hip-spine syndrome, first described in 1983 and still an active area of research. A recent review of the relationship between the lumbopelvic spine and the hip notes that even when the primary source of pain seems obvious, the kinematics of the hip, pelvis, and lumbar spine are deeply interconnected, and clinicians who look at only one region routinely miss the driver.

What the research actually shows

This is not a fringe idea, and it is also not a magic bullet. The honest version of the evidence looks like this.

People with low back pain move their hips differently

A 2024 systematic review in BMC Musculoskeletal Disorders pooled observational studies measuring hip range of motion, strength, kinematics, and muscle activity in adults with nonspecific low back pain, and found measurable differences in hip biomechanics compared with people who are pain free. A 2025 study in the European Spine Journal went further and looked at how spinal and hip mobility relate to disability in people with chronic low back pain, not just to pain scores.

The glutes are frequently part of the picture

In a study of 150 patients with chronic nonspecific low back pain compared against 75 matched controls, researchers found that gluteus medius weakness and gluteal tenderness were significantly more common in the low back pain group, along with a higher rate of a positive Trendelenburg sign, which is the hip dropping when you stand on one leg. A separate systematic review of gluteus medius function reached similar conclusions across multiple studies.

For athletes, it is often about rotation and asymmetry

If your sport involves twisting, this part matters. Researchers comparing 48 athletes in rotation-related sports found that those with a history of low back pain had less total passive hip rotation and more side-to-side asymmetry than their pain-free peers. Similar associations between limited hip extension, limited internal rotation, and low back pain have been documented in tennis players, golfers, judo athletes, and elite hockey players. It is not always the total range that flags the problem. Sometimes it is the difference between your left side and your right.

And treating the hip helps a meaningful group of people

The strongest clinical evidence comes from the MASH trial, published in The Lancet Rheumatology in 2024. Researchers randomized older adults who had chronic low back pain alongside hip pain and hip weakness into two groups: one received hip-focused physical therapy, the other standard spine-focused care. Both groups improved meaningfully. The hip-focused group improved more on back-related disability at eight weeks, though that advantage had evened out by six months. The authors read the result as faster improvement from matching the treatment to the impairment.

A 2023 meta-analysis in the Brazilian Journal of Physical Therapy pooled eight trials covering 508 patients and found that hip strengthening and hip stretching both reduced pain and disability in the short term, while noting that the certainty of the evidence was low and longer-term effects are still unclear. A 2023 review focused specifically on hip strengthening came to a comparable conclusion.

The caveat we are not going to skip

Association is not causation, and the literature is genuinely mixed on how much of this is cause versus consequence. An earlier systematic review of hip range of motion and nonspecific low back pain rated the overall evidence as very low quality, with limited hip internal rotation the only impairment that reached statistical significance. Weak hips may contribute to back pain, or months of guarding a painful back may weaken the hips. Both are probably true depending on the person.

Which is exactly why the assessment matters more than the theory. The useful question is not whether hips cause back pain in general. It is whether your hips are contributing to your back pain.

Three ways tight hips load your low back

1. Lost hip extension

Hip extension is the motion of your leg traveling behind you, and you need roughly 10 to 15 degrees of it just to walk normally. Years of sitting shorten the front of the hip and quiet the glutes behind it. When extension runs out, the pelvis tips forward and the lumbar spine arches to finish the movement. If your back aches after a long walk or a run but feels fine sitting, this pattern is worth ruling out.

2. Lost hip rotation

Rotation is where the South Bay gets into trouble. A surf pop-up, a beach volleyball swing, a golf backswing, and a tennis serve all demand a lot of rotation, and the hips are supposed to supply most of it. When they cannot, the lumbar spine rotates to make up the difference. The same repeated twist through the same few segments is a durable recipe for a back that gets angry on the same side every time.

3. Weak lateral hip control

Every step you take is a moment of single-leg balance. If the muscles on the outside of the hip cannot hold the pelvis level, your torso shifts side to side to compensate, and the low back absorbs that shift thousands of times a day. This is the pattern that tends to show up as one-sided pain that gets worse with distance rather than intensity.

Four things you can check at home

None of these is a diagnosis. They are simply ways to notice whether your hips are the quiet variable in your back pain.

  • Single-leg stand. Stand in front of a mirror on one leg for 30 seconds. Watch your hips. If one side drops or your torso leans hard to compensate, your lateral hip control on the standing side probably needs work.
  • Seated rotation. Sit tall on a chair with your knees together, then let one foot swing outward while keeping the knee still. Compare sides. A noticeable difference between left and right is more meaningful than the absolute number.
  • Half-kneeling check. From a half-kneeling position, squeeze the glute of the down leg and gently shift forward without arching your low back. If you cannot get any forward travel without your back taking over, hip extension is likely limited.
  • The location test. Notice where the pain lives and when. Pain that arrives with walking, standing, or one-sided loading points more toward a hip contribution than pain that arrives with sitting or bending forward.

Why more stretching usually is not the answer

The instinct, once you suspect tight hips, is to stretch harder. That rarely holds. Range you gain passively on the floor does not automatically become range your nervous system trusts under load, and a hip can feel tight for reasons that stretching does not address: restricted joint mechanics, fascial adhesion through the surrounding tissue, or a muscle that is guarding because something nearby is not sharing the work.

This is where the approach at LA Sports Performance Care differs from a standard adjust-and-go visit. Over more than 25 years in practice, Dr. Steve has built an assessment that treats the hip, pelvis, and spine as one continuous system rather than three separate complaints. That usually means a combination of hands-on work to restore mobility in the joint and the surrounding fascia, and movement retraining so the range you regain becomes range you can actually use. Our personal training and integrated movement team handles that second half, which is the part that makes the change stick.

The research points the same direction. In the MASH trial, the effective intervention was not stretching alone. It was manual therapy paired with strengthening, matched to what the assessment actually found.

When it is worth getting looked at

Consider a full hip and spine assessment if your low back pain has lasted more than six weeks, if it keeps returning to the same spot, if it is clearly worse on one side, if imaging came back clean but the pain did not, or if you have been managing it with the same three stretches for years without real progress.

And if you have already been treated for the back specifically without lasting change, that in itself is useful information. It suggests the back may not be where the problem originates.


Ready to find out what your hips are actually doing? We see athletes and active adults from across the South Bay, including Manhattan Beach, Hermosa Beach, Redondo Beach, and El Segundo. Book an assessment with LA Sports Performance Care and we will look at the whole chain, not just the part that hurts.


This article is for general education and is not a substitute for individual medical evaluation.


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