Is Hip Pain Coming from the Back or the Hip?

Summary: Whether hip pain originates from the lower back or the hip joint is distinguished by evaluating together the location of pain, its radiation to the leg, its relationship to movement, associated symptoms and findings on physical examination. Since muscle, nerve, spine and tissues surrounding the hip can produce similar complaints, examining only the point where pain is felt is insufficient.

Hip pain from the lower back or the hip—determining the likely source of pain is a clinical differential diagnostic question. In adults, hip pain is evaluated by dividing it into 3 anatomical regions: anterior, lateral and posterior; posterior hip pain may also be referred from extra-articular structures such as the lumbar spine, sacroiliac joint or piriformis muscle (Hip Pain in Adults: Evaluation and Differential Diagnosis, 2021; PMID 33448767).

For example, pain near the groin may suggest hip joint involvement, whereas pain starting from the lower back and radiating to the hip and leg may be related to nerve root compression. However, these clues alone do not establish a diagnosis: details such as worsening on sitting, becoming more apparent when walking, being triggered by specific movements, numbness or weakness gain meaning when considered together with physical examination findings.

Is Hip Pain Coming from the Back or the Hip?

Hip pain can originate from both the lumbar spine and the hip joint and surrounding tissues. Problems associated with nerves in the lower back, facet joints or discs can refer pain to the hip; the hip joint, tendons and muscles can also produce similar complaints. The distribution of pain, its relationship to movement and examination findings help determine the source.

When people say 'hip', not everyone describes the same region. Some point to the groin, others to the outer side of the hip, and still others to the area just below the lower back. This distinction is important; because when evaluating hip pain in adults, the region can be considered under 3 main headings:

• Anterior region and groin: Pain related to hip joint problems is often felt here. Movements that flex the hip, such as tying shoelaces, getting into a car or rising from a low chair, may exacerbate symptoms.
• Lateral aspect of the hip: May be related to tendons, muscles and soft tissues on the side of the hip. Lying on that side or prolonged walking may increase symptoms.
• Posterior region and superior hip: The lumbar spine, sacroiliac joint, piriformis muscle or adjacent nerve structures are evaluated. Pain may sometimes radiate to the back of the thigh or down the leg.

The lower back and hip are not two independent regions. The posture of the spine can alter the load bearing on the hip joint, and movement limitation in the hip can change how the lower back functions. This presentation, in which both regions produce symptoms simultaneously, is referred to in the literature as hip-spine syndrome (PMID 22751162 — Hip-spine syndrome, 2012).

For this reason, a definitive source cannot be determined based solely on the question 'is the pain in the lower back or the hip?' For example, pain localised to the groin and worsening on hip rotation may suggest a joint-related cause, whereas pain starting from the lower back and radiating to the hip, leg or foot may be related to nerve involvement. However, these clues do not establish a diagnosis; the lower back, hip joint, muscle strength, sensation and reflexes must be evaluated together.

Source: PMID 33448767 — Hip Pain in Adults: Evaluation and Differential Diagnosis (2021); PMID 24444505 — Evaluation of the patient with hip pain (2014).

How to Distinguish Between Lower Back Pain and Hip Pain?

Lower back pain and hip pain are distinguished by evaluating together the distribution of pain on history and examination, accompanying numbness or weakness, movement restriction in joints and neurological findings. Groin-localised joint pain more strongly suggests hip origin, whilst burning or electric sensation extending from the lower back to the leg suggests nerve root involvement.

In evaluation, the predominant characteristics of pain are first compared:

Feature evaluated	Findings suggesting lower back pain	Findings suggesting hip pain
Radiation pattern	Can radiate from lower back to hip, thigh, calf or foot	Often felt in the groin; may be referred to the front of the thigh or the knee
Nature of pain	May be burning, electric, sharp, or stabbing in quality	May present as deep aching, stiffness or sensation of catching within the joint
Associated findings	Numbness, tingling, sensory changes or weakness may accompany	Difficulty may be evident in activities such as putting on socks, tying shoelaces or getting into a car
Focus of examination	Spine movements, reflexes, sensation and muscle strength are evaluated	Range of motion of the hip joint, groin pain and gait pattern are examined

Hip pain on examination is addressed across 3 anatomical regions: anterior, lateral and posterior. Pain felt in the anterior region and groin suggests intra-articular structures; tenderness on the lateral aspect points to muscles and tendons around the hip; posterior hip pain may direct attention to the lower back, sacroiliac joint or piriformis area. This classification helps organise diagnostic evaluation. Hip Pain in Adults: Evaluation and Differential Diagnosis (2021), PMID 33448767.

Lower back and hip problems can occur together in the same person. In this condition, referred to as hip-spine syndrome, symptoms from both regions may overlap. For this reason, evaluation proceeds in the following order:

• The region where pain began and the path it takes towards the leg are determined.
• Hip joint and lumbar spine movements are examined separately.
• Sensation, reflexes and muscle strength are compared.
• Muscles around the hip, the piriformis region and the sacroiliac joint are evaluated.
• Prominent findings on examination are matched with appropriate imaging results.

For example, groin pain combined with marked restriction of hip movement suggests joint-related evaluation. Conversely, electric sensation starting from the lower back and extending to the foot, accompanied by numbness and weakness, is investigated in terms of nerve root involvement. If both sets of findings are present together, the diagnosis requires joint evaluation of the lower back and hip.

What Do the Location of Pain and Its Relationship to Movement Tell Us?

The region where pain is felt and which movement worsens it provide clues as to whether the source may be the lower back, hip joint or surrounding muscles and tendons. Pain localised to the groin suggests the hip joint; pain radiating from the lower back to the hip or leg may suggest the spine and nerve structures. However, a single finding does not establish a definitive diagnosis.

When hip pain is evaluated, the region is examined across 3 main areas: anterior, lateral and posterior. This anatomical distinction helps narrow down possible causes; it does not replace physical examination. Hip Pain in Adults: Evaluation and Differential Diagnosis (2021), PMID 33448767.

Location or behaviour of pain	Possible source it may suggest	Clue observed during evaluation
Groin and front of the hip	Hip joint	Increases when putting on shoes, pulling up socks, squatting or getting into a vehicle
Outer side of the hip	Muscles, tendons and soft tissues around the hip	Becomes more pronounced when lying on the painful side, climbing stairs or during prolonged walking
Back of the hip and lumbosacral region	Lumbar spine, sacroiliac joint or piriformis region	Changes with prolonged sitting, lumbar movements or radiation down the back of the leg
Pain extending from the lower back through the hip to the leg	Nerve root involvement	Accompanied by numbness, tingling or weakness
Increasing groin pain with first steps or weight-bearing	Hip joint or surrounding structures	Begins after rest and changes with walking

These correspondences are not precise boundaries. For example, pain from the hip joint may sometimes be felt in the thigh or near the knee. Lower back pain may also present as pain over the hip. Conditions where low back and hip problems occur together are discussed in the literature as hip-spine syndrome. Hip-spine syndrome (2012), PMID 22751162.

To understand the relationship with movement, the following details can be noted:

• When bending the lower back forwards or backwards: If hip-region pain changes, the relationship to the lumbar spine is assessed.
• When the hip is rotated: Worsening of deep groin pain may be a sign related to the hip joint.
• When climbing stairs or standing on one leg: The muscles and tendons on the outer side of the hip may produce more symptoms under load.
• When sitting for prolonged periods: Pain in the back of the hip may be related to the piriformis region, sacroiliac area, or structures originating from the lower back.
• When walking: Whether pain is felt on the first step, after a certain distance, or continuously helps to guide the diagnostic evaluation.
• With coughing or straining: If pain radiating from the lower back to the leg increases, the possibility of nerve structure involvement is investigated further.

Keeping a daily log can provide more informative detail than asking "where does it hurt?" during examination. The location of the pain, the movement that triggered it, its distribution and severity on a scale of 0–10 can be recorded over several days. The difference between the right and left side as well as accompanying symptoms such as numbness or weakness should also be noted separately.

Pain that decreases or increases with movement alone does not determine its source. Differentiation is made through physical examination, assessment of hip and low back range of motion, muscle strength and sensory examination. When deemed necessary, imaging findings are interpreted together with this clinical assessment.

What Are Other Causes of Hip Pain?

Hip pain may develop due to the sacroiliac joint, muscles and tendons, piriformis muscle, tissues surrounding the hip joint or referred pain from internal organs, in addition to the lumbar spine. Whether the pain is on one side or both sides, whether it changes with sitting or walking, and the presence of accompanying symptoms narrow down the likely source.

When assessing pain around the hip, the region is considered in three anatomical areas: front, side and back. Complaints felt over the hip and behind the hip may be related more to surrounding tissues or structures close to the spine rather than the joint itself (PMID 33448767 — Hip Pain in Adults: Evaluation and Differential Diagnosis (2021)).

Frequently evaluated causes include:

• Sacroiliac joint pain: Originates from the joint that connects the lower spine to the pelvis. Pain is most often felt near the lower back–hip junction; it may become more pronounced during prolonged standing, climbing stairs, or turning in bed. Changes in weight distribution during pregnancy can also affect this area.

• Piriformis syndrome and deep hip muscles: The piriformis muscle sits deep in the hip, near the sciatic nerve. Tenderness in this region may accompany pain radiating from the hip to the back of the thigh, numbness, or complaints that increase when sitting. Pain location alone does not make a diagnosis (PMID 31102324 — Piriformis Syndrome: A Narrative Review of the Anatomy, Diagnosis, and Treatment (2019)).

• Muscle and tendon strains: Can develop following sudden twisting movements, unfamiliar exercise, carrying loads, or remaining in the same position for extended periods. Pain that is triggered by specific movements, worsens with pressure, and decreases during rest may be related to these tissues.

• Tendon and bursa problems on the outer side of the hip: Involvement of the tendons around the outer projection of the hip bone and the bursa may cause pain that increases, in particular when lying on the side or walking. Pain may spread between the upper hip and the outer part of the thigh.

• Facet joints of the spine: Pain arising from the small joints at the back of the lumbar vertebrae can begin on one side of the lower back and radiate to the hip area. Backward bending, twisting, or prolonged standing may worsen the complaint (PMID 38072795 — Facet joint disorders: from diagnosis to treatment (2024)).

• Referred pain: The kidneys and urinary tract, abdominal structures, or gynaecological conditions may sometimes be felt as hip or side lower back pain. If fever, urinary symptoms, abdominal pain, nausea, or unusual bleeding are present, causes beyond the musculoskeletal system should also be considered.

In the same person, low back, sacroiliac joint and hip region problems can coexist. This overlap creates the clinical presentation known as hip-spine syndrome; which structure contributes more to the complaint cannot be determined by pain description alone (PMID 22751162 — Hip-spine syndrome (2012)).

When Should Healthcare Facilities Be Visited Without Delay?

If sudden weakness, changes in bladder or bowel control, severe trauma, fever, altered consciousness or marked circulatory disturbance in the leg accompany hip or lower back pain, seek medical care without delay. These symptoms may be associated with conditions such as nerve compression, fracture, infection or vascular problems that require urgent assessment.

Symptoms Requiring a Call to 112 or Emergency Department Attendance

In the following cases, contact 112 or attend the emergency department rather than waiting at home:

• Sudden weakness developing with pain radiating from the lower back to the hip or leg
• Inability to start urination, incontinence of urine or faeces
• New-onset numbness in the anal and genital region
• Inability to get up after a fall, traffic accident or direct blow
• Leg suddenly appearing cold, pale or purple
• Pain accompanied by chest pain, shortness of breath, fainting or altered consciousness
• General condition rapidly worsening with hip or lower back pain

When loss of bladder or bowel control, loss of muscle strength, and numbness around the genital area occur together, it may indicate severe compression of the nerves in the lower part of the spine. In this case, waiting until the following day is not appropriate.

Conditions Requiring Same-Day Assessment

Although some symptoms do not require calling 112, they do require same-day medical evaluation:

• Hip pain accompanied by fever, chills, or marked malaise
• Redness, increased warmth, or rapidly developing swelling around the hip
• New pain that markedly prevents weight-bearing
• Pain that wakes the patient at night and does not improve with position change
• Lower back and hip pain developing in a patient with a history of cancer, immunosuppressive disease, or recent infection
• Groin or hip pain beginning after a minor fall in an older person
• Severe new-onset lower back and hip pain during pregnancy accompanied by vaginal bleeding, fever, or fainting sensation

Particularly after a fall, the possibility of a fracture cannot be completely excluded even if the person can walk. Progressive increase in pain, inability to bear weight on the leg, or noticing the leg is shortened or turned outward requires rapid evaluation.

What Should Be Done While Waiting?

If emergency signs are present, the person should not be forced to walk, and unnecessary movement should be avoided after a fall or injury. If consciousness changes, shortness of breath, or sudden weakness occur, call 112; inform the healthcare team about when symptoms started and how they have changed since then. Even if there are no emergency signs, if pain significantly limits daily activities or worsens over time, planned orthopaedic assessment should not be delayed.

How is the Diagnosis of Lower Back and Hip Pain Established?

The diagnosis is made by listening to the location, radiation, and relationship of the pain to movement, and then evaluating the examination of the lower back, hip, and nervous system together. Depending on the findings, X-ray or magnetic resonance imaging may be requested. A single examination manoeuvre or imaging finding does not always explain the source of pain on its own.

What are the stages of assessment?

First, when the pain started and how it affects daily activities are asked. The following details guide in understanding the lower back–hip relationship:

• Whether the pain is felt in the groin, the side of the hip, above the hip, or around the lower back
• Whether the pain radiates to the leg, and if there is numbness, tingling, or weakness
• How the pain changes during sitting, walking, climbing stairs, bending forward, or putting on shoes
• Whether it wakes the patient at night, started after trauma, or has worsened over time
• Previous surgery on the lower back, hip, or spine

Hip pain can be addressed on examination across three anatomical regions: front, side, and back. Pain felt in the front and groin suggests the hip joint; tenderness on the side suggests surrounding tendons; and back hip pain may suggest the lower back, sacroiliac joint, or piriformis region. This classification narrows the possible source but does not establish a definitive diagnosis. Source: PMID 33448767 — Hip Pain in Adults: Evaluation and Differential Diagnosis (2021).

What is examined during physical examination?

During examination, the lower back and hip are not examined separately but as a movement chain:

• Gait pattern and weight transfer between the two legs are observed.
• Movement of the lower back forwards, backwards, and sideways is evaluated.
• The inward and outward rotation of the hip and the range of flexion are measured.
• Muscle strength, reflexes, and sensation in the legs are tested.
• Certain movements are observed to see whether they reproduce or trigger pain in the groin, lower back, or leg.

Problems in both the lower back and hip region may exist simultaneously. In a condition called hip-spine syndrome, the purpose of examination is not to attribute every imaging finding to the cause of pain, but to identify a finding that matches the patient's complaint. Source: PMID 22751162 — Hip-spine syndrome (2012).

When is Imaging Required?

X-ray provides information about bone structure, joint space, and signs of osteoarthritis. Magnetic resonance imaging can help in more detailed evaluation of cartilage, tendons, muscles, ligaments, and nerve tissues. Which method will be used is determined by the physical examination findings, trauma history, and the suspected source of pain.

When imaging findings do not match physical examination findings, re-evaluation may be performed. This is because a finding may be present on the image; however, the hip or lower back pain the person feels may originate from a different tissue.

How Does Pain Radiating from the Lower Back to the Hip Resolve?

The resolution of pain radiating from the lower back to the hip depends on whether the pain is related to the nerve root, muscle, piriformis, sacroiliac joint, or spinal structures. Treatment may begin with regulation of daily activities, exercises tailored to the individual, and physiotherapy. If progressive neurological signs are present, assessment is not delayed; intervention or surgery comes into consideration only in specific circumstances.

Two different types of pain in the same region may not resolve using the same method. For example, a complaint of pain radiating from the hip to the leg with prolonged sitting and pain that increases during lower back movements may arise from different sources. Therefore, not only the location of the pain but also its radiation pattern, whether numbness or weakness is present, and which movement causes changes are considered.

The following approaches may be considered in the treatment plan:

• Regulation of daily activities: Instead of remaining in the same position for long periods, changing position at short intervals and temporarily limiting movements that significantly increase pain may be necessary. Complete immobility, however, may negatively affect muscle strength and movement capacity.
• Exercise and physiotherapy: Stabilisation exercises that improve control of the muscles around the lower back, range of motion work, and nerve mobilisation in appropriate patients can be used. In individuals with nerve root complaints due to lumbar disc herniation, the effect of lumbar stabilisation combined with thoracic mobilisation was examined in a 2020 randomised controlled trial (PMID 32675390 — Efficacy of the lumbar stabilization and thoracic mobilization exercise program on pain intensity and functional disability reduction in chronic low back pain patients with lumbar radiculopathy: A randomized controlled trial (2020)).
• Evaluation of piriformis and surrounding muscles: In pain that originates deep in the hip and radiates to the leg, piriformis syndrome may be considered in differential diagnosis. Stretching, muscle relaxation, and sciatic nerve mobilisation are not applied the same way in every person; they are planned according to examination findings.
• Medication treatment: Pain relief or anti-inflammatory medicines may be evaluated by the physician taking into account the patient's age, accompanying conditions and other medicines they are using. The initiation, dose or discontinuation of medication should not be changed by personal decision.
• Interventional methods: In pain thought to originate from the nerve root, facet joint or sacroiliac joint, methods such as injection may be evaluated for diagnostic and therapeutic purposes in selected patients.
• Surgical evaluation: In cases of progressive muscle weakness, significant nerve compression or continued loss of function despite other methods, surgical options may be considered. The decision is made not on imaging findings alone, but by considering examination findings and impact on daily life together.

Trying one-size-fits-all exercises found on the internet for pain radiating from the lower back to the hip may not be appropriate. A movement that provides relief in one person may increase symptoms in another person with nerve root involvement. If during movement the pain spreads further into the leg, new numbness develops or muscle strength diminishes, exercise should be stopped and professional healthcare evaluation should be obtained.

In any surgical or interventional procedure, results may vary from one person to another. The method to be applied is determined by the source of pain, examination and imaging findings, accompanying conditions and the patient's functional needs.

How Can the Lower Back and Hip Region Be Protected in Daily Life?

Protecting the lower back and hip region requires regular movement, avoiding staying in the same position for long periods, carrying loads close to the body and maintaining muscle strength through appropriately tailored exercises. The aim of daily habits is to reduce repetitive loading on the spine and hip; when pain occurs, the focus should be on readjusting movement rather than pushing through discomfort.

The main habits supporting the lower back and hip region throughout the day are as follows:

• Position should be changed frequently: Taking short movement breaks every 30–60 minutes when sitting or working standing helps prevent muscles and joints from being under the same load for long periods.
• Screen and work surface should be adjusted: Positioning the screen at eye level, keeping feet on the floor and having a chair that supports the lower back reduces the need to lean forward when working.
• Load should be held close to the body: When picking up objects from the floor, bend at the knees and hips instead of twisting from the waist, distribute the load between both hands and avoid rotating the body during lifting.
• Exercise should progress regularly: Walking, exercises to strengthen the hip muscles and lumbar stabilisation exercises can be planned according to the individual's physical condition. If pain radiates to the leg during a particular exercise or increases noticeably, the movement should be reassessed.
• Repetitive loading should be reduced: Rather than being sedentary for a full day and then exercising intensely the next day, a movement schedule spread across the week with gradual progression is preferable.
• Footwear and floor should be considered: In jobs requiring long periods standing, shoes that provide balanced foot support and, where possible, varying work positions may help manage loading on the hip and lower back area.

Exercise programmes used for lower back pain are not the same for everyone. There are controlled studies examining lumbar stabilisation work in patients with chronic lower back pain and nerve root involvement; however, the type and dose of exercise should be determined according to examination findings (PMID 32675390 — Efficacy of the lumbar stabilization and thoracic mobilization exercise program on pain intensity and functional disability reduction in chronic low back pain patients with lumbar radiculopathy: A randomized controlled trial, 2020).

The criterion for a protective approach is not simply "standing upright". Even a seemingly comfortable position can increase symptoms if maintained unchanged for long periods. A more functional goal is the ability to shift between different positions throughout the day, maintain movement capacity and recognise loading on the lower back or hip early when pain begins.

Frequently asked questions

Does hip pain radiate to the lower back?

Yes, pain originating from the hip joint and surrounding muscle, tendon or ligament tissue can radiate to the lower back region. Similarly, problems in the spine, sacroiliac joint or nerve roots can also be perceived as hip pain. Since the location of pain alone is insufficient to determine its source, physical examination is important.

What does hip pain indicate?

Hip pain may be associated with joint osteoarthritis, muscle–tendon problems, bursitis, nerve involvement from the lower back or sacroiliac joint dysfunction. Pain felt in the groin region more commonly suggests hip joint involvement, whilst tenderness on the outer side of the hip may indicate surrounding soft tissue problems. Precise differentiation is made through detailed history and physical examination.

Which department should be visited for hip pain?

For initial evaluation of hip pain, a visit to the orthopaedic and traumatology or physical therapy and rehabilitation department can be considered. If there is numbness, loss of strength or pain radiating from the lower back to the leg, the spine and nerve roots are also evaluated. Following trauma with inability to weight-bear on the affected side or obvious deformity, emergency department attendance is recommended.

Which condition causes pain radiating to the hip?

Lower back disc herniation, joint problems in the lumbar spine, sacroiliac joint dysfunction and piriformis syndrome can cause pain radiating to the hip. Hip joint osteoarthritis and surrounding muscle–tendon problems can also produce similar symptoms. The relationship of pain to movement, its direction of radiation and accompanying neurological findings help distinguish the source.

What does worsening hip pain on sitting suggest?

Hip pain that worsens on sitting may suggest nerve involvement around the piriformis muscle, lower back-related problems or soft tissue dysfunction around the sitting bones. In prolonged sitting with pain that radiates towards the back of the leg, neurological examination may be necessary. Diagnosis should not be made on a single symptom alone; the duration of pain and accompanying findings should be evaluated together.

Can hip pain on walking originate from the lower back?

Yes, hip pain on walking can originate from the lumbar spine or nerve roots. Pain from the lower back can radiate to the hip and leg; numbness, tingling or weakness may accompany it. Pain beginning in the groin area and worsening with hip movements, however, requires separate evaluation of the hip joint.

How are piriformis syndrome and lower back disc herniation distinguished?

Piriformis syndrome and lumbar disc herniation are distinguished by clinical examination, where the point of pain onset, manner of radiation, muscle strength, sensation and reflexes are assessed. In piriformis syndrome, hip pain worsened by sitting may be more prominent, whereas in lumbar disc herniation, pain radiating from the lower back to the leg, numbness or weakness may be seen. If there are changes in urinary or faecal control, numbness around the groin, or progressive weakness, urgent evaluation is required.

This section is for general information purposes; it does not replace medical examination and diagnosis.