When your low back pain is actually a hip problem.
One of the most common patterns I see in athletes with low back pain has very little to do with the back itself. They come in pointing at the lumbar spine, often convinced something is structurally wrong, and when we put them through a basic movement screen we find the same two things over and over: limited hip flexion and limited hip internal rotation.
When the hip can't access the range it needs, the lumbar spine ends up picking up the slack. That could be happening in running, cycling, weight training or even yoga. With enough repetition, that borrowed motion is what becomes painful.
Why the hip matters so much for the low back
The hip is a ball and socket joint built for a large amount of motion in every direction. In a healthy hip we expect to see somewhere in the neighborhood of 120 degrees of flexion and 40-50 degrees of internal rotation. Those numbers matter because almost every athletic movement you can think of asks the hip to move through some combination of flexion and rotation. Squatting, running, climbing and descending on the bike, transitioning edge to edge on skis, getting under a bar in the gym. All of it.
When that motion isn't available at the hip, the body often still finds a way to complete the task. It just borrows the motion from somewhere else. The most convenient place to borrow from is the lumbar spine. The lumbar spine is nearby and generally the range of motion is easy to access.
The lumbar spine is not designed to be moving, under load, in the same way your hip or your knee does. It is designed to be stable. Yes, there is range of motion available at the lumbar spine and we do need that mobility during sport but when we ask it to repeatedly flex, extend, and rotate to make up for what the hip can't do, the tissues around it can get irritated. This shows up as that nagging low back pain that feels worse after sport, worse the day after a hard session, and never quite resolves with rest alone.
What this pattern looks like in the clinic
Two athletes that come to mind from this past month had nearly identical presentations. Both with persistent low back pain. Both had been told by other providers to work on core strength. Both had been doing exactly that for months with no real improvement.
When we screened them, here is what we found:
Limited hip flexion. I look for an athlete to be able to pull the knee toward the chest with the pelvis staying neutral. When the pelvis has to posteriorly tilt early to achieve that motion, we know the hip flexion range is restricted. This means anytime they squat below parallel, get into a deep hinge, or pick something off the ground, the lumbar spine has to flex to finish the movement.
Limited hip internal rotation. Tested in supine with the knee bent to 90 degrees, I want to see 40-50 degrees of internal rotation. When I see 20 degrees or less, which is common, the athlete cannot rotate over a planted leg without compensating somewhere up the chain. The lumbar spine is the most picking up the slack, often rotating and extending to allow the trunk to clear.
When you combine these two limitations and ask the athlete to repeat them under load thousands of times in a sport, low back pain is a predictable outcome.
Why core strength alone usually does not fix it
A strong trunk is a great thing. But a strong trunk wrapped around a stiff hip still has to deal with the stiff hip. If the motion needed for the sport is not available at the hip, no amount of plank variations will change where that motion has to come from. The lumbar spine will keep taking the load.
This is one of the reasons we see athletes who have done months of dedicated core work and still have the same symptoms. They have addressed stability but not the underlying mobility issue forcing the spine to move when it should not have to.
What to work on
Here are the drills I most commonly assign for this pattern. Start gentle, work through a controlled range, and prioritize keeping the pelvis quiet so the hip is actually doing the work.
90/90 hip rotations. One of the best ways to access internal and external rotation in a position that is meaningful to sport. Focus on rotating from one side to the other without using your hands to push off the floor.
Hip flexion mobility with inferior glide. The band pulling the hip down, toward your feet is doing all the work here. Relax your hip and allow the band to create space between the femur and pelvis.
If you have been chasing low back pain with stretches and stability drills and not getting anywhere, take a closer look at what your hips are doing. The fix is often a level lower than where the pain is showing up.
