One of the most common reasons hip pain doesn't get better is simple: it isn't coming from the hip. The lower back (lumbar spine) can refer pain into the hip, buttock and outer thigh, so the hip feels sore while the real driver sits higher up. When this is missed, people receive hip treatment that can't work — because the source was never the hip.
Telling the two apart is one of the most valuable things a specialist assessment does.
How back-referred hip pain behaves
Clues it may be coming from your back:
- Pain that spreads or moves — into the buttock, outer thigh, sometimes down the leg — rather than staying in one clear spot.
- Pain that changes with back positions: sitting, bending forward, arching backwards, rotating the spine.
- Nerve-type symptoms — pins and needles, numbness, burning, or pain that radiates down the leg in a clear line.
- Local hip movements don't reproduce it, but back movements do — a key differentiator on examination.
How hip-joint pain behaves (for contrast)
True hip-joint pain has a fairly different pattern. The most common features:
- Groin-dominant pain — often shown with the "C-sign" (cupping the side of the hip with the thumb in the groin and fingers wrapping around the outer edge).
- Worse with deep flexion (deep squatting, low chairs), prolonged sitting, and twisting or pivoting.
- Stiffness and a sense the hip "won't go" — particularly into internal rotation or deep flexion.
- Local hip tests reproduce the pain — impingement tests, resisted movements, range-of-motion testing.
The full location guide — what different hip-joint problems feel like and how they behave — is on the broader hip pain causes pillar page.
Quick contrast: back vs hip
Two patterns to keep in mind when you're working out whether the hip or the back is the source:
| Feature | Back-referred | Hip-joint |
|---|---|---|
| Where it sits | Spreads / moves — buttock, outer thigh, sometimes down the leg | Deep, central groin (the "C-sign") |
| What triggers it | Back positions — sitting, bending, arching, rotating the spine | Deep flexion, prolonged sitting, twisting or pivoting on the leg |
| Nerve symptoms | Common — pins and needles, numbness, burning | Uncommon |
| What reproduces it | Back movements on examination | Local hip tests on examination |
Either can be the source — and they often coexist. A specialist assessment screens both, because back and hip problems frequently overlap, and the most accurate plan usually targets whichever is the dominant driver.
Why this matters so much
Treating the hip when the back is the source — or vice versa — is the classic reason "I've done months of physio and I'm no better" happens. The fix isn't more of the same treatment; it's identifying the right source first, and then building a plan around it.
It's also why generic exercise sheets often underperform. If the driver is the lumbar spine, hip strengthening alone can't address it. If the driver is the hip joint, lower-back mobility work won't help either. The diagnosis drives the plan.
How a specialist tells the difference
A proper assessment screens both the hip and the lumbar spine, because the two often coexist and the dominant driver isn't always obvious. Typically this includes:
Movement testing — what reproduces your symptoms, where and when. Strength and neural screening — for weakness, nerve involvement, or pattern changes. Joint provocation — specific hip and back tests to identify which structure is firing up the symptoms. The plan is then built around the actual driver, not the most obvious one.
Red flags
Some features around "hip" pain need urgent medical assessment rather than physiotherapy:
Cauda equina symptoms — emergency
New leg weakness, numbness around the saddle area (inner thighs, buttocks, between the legs), or changes in bladder or bowel control need emergency medical assessment — these can indicate cauda equina syndrome, which is a time-critical surgical emergency.
Other reasons to seek medical care promptly
- Severe, worsening, or sudden pain — particularly at night or at rest.
- Unexplained weight loss, fever, or feeling generally unwell alongside the pain.
- History of cancer, recent infection, or significant trauma.
When to see a specialist
If "hip" pain spreads, comes with nerve symptoms, or hasn't responded to hip-focused treatment, get both the hip and the back assessed. A specialist who screens both can identify the dominant driver — and stop the cycle of treatment that doesn't work because it isn't targeting the right structure.
Hip pain that hasn't shifted with hip treatment?
John Gravenall offers specialist hip and groin assessments in London, the Midlands, and online — screening both the hip and the lumbar spine.
Book a specialist hip assessment →Frequently Asked Questions
Can lower back problems cause hip pain?
Yes. The lumbar spine commonly refers pain into the hip, buttock and outer thigh — sometimes with nerve-type symptoms like pins and needles or numbness. The hip can feel genuinely sore while the real driver sits higher up.
How do I know if my hip pain is from my back or my hip?
Back-referred pain tends to spread or move, change with spine position, and may come with nerve symptoms (pins and needles, numbness, pain down the leg). Hip-joint pain is usually groin-dominant, worse with sitting and deep flexion, and is reproduced by local hip tests.
Why hasn't my hip physio worked?
A frequent reason is that the pain is referred from the back, so hip-only treatment can't address the source. Treating the wrong structure is the classic reason 'months of physio and no better' happens — the fix is identifying the right source first.