Hip Pain: The Joint Everyone Blames on the Back

Hip pain is the most consistently mislabelled complaint in musculoskeletal practice. Patients point at their buttock and say hip.

Patients with genuine hip joint arthritis get treated for months as a back problem. People with a painful tendon on the outside of the hip get told they have bursitis and receive treatment aimed at the wrong structure.

Meanwhile the actual hip joint sits deep in the groin, quietly, where almost nobody points. This guide sorts out which is which, gives you self-tests you can run at home, and sets out clearly when it is not a physiotherapy problem at all.

The one finger test: start here

Before anything else, do this. Point with one finger at the exact spot that hurts most, not a vague circle with your palm.

If your finger lands deep in the front crease of the groin, you are pointing at the hip joint. If it lands on the bony point on the outside of your hip, the one you can feel through your trousers, you are pointing at tendons where they attach, not at the joint.

If it lands on your buttock or on the dimple just to the side of your lower spine, you are pointing at the sacroiliac region or referred spinal pain. Many patients with true hip joint problems will also cup their hand around the side of the hip in a C shape while describing the pain, which clinicians call the C-sign, and it is a useful clue rather than a diagnosis.

True hip joint pain: what it feels like

Pain coming from inside the hip joint has a recognisable signature. It is usually felt in the groin, often described as deep and aching, sometimes radiating down the front of the thigh towards the knee, and occasionally the knee is the only place a person feels it, which sends everyone chasing the wrong joint.

It typically worsens with rotation of the hip, which is why the classic complaints are difficulty getting in and out of a car, trouble putting on socks and shoes, and pain turning over in bed. Stiffness in the morning that eases with movement is common.

Deep squatting is often uncomfortable. Walking distance gradually shrinks.

If that description sounds like yours, the hip joint deserves proper assessment rather than another round of back treatment.

Gluteal tendinopathy: the side-of-hip problem

Pain on the outer point of the hip is one of the most common presentations in adults, especially in women from their forties onwards and in runners. The structures involved are usually the gluteus medius and minimus tendons where they attach onto the bony prominence, and it is a tendon load problem rather than the joint.

The giveaway symptoms are very consistent: pain when lying on that side at night, pain when standing on that leg to put on trousers, pain on stairs, and pain after sitting cross-legged or with knees together and feet apart, which compresses the tendon against the bone. It is frequently labelled bursitis, which has become an overused catch-all.

Genuine isolated bursitis exists, but tendinopathy is the more common driver, and the treatment differs. Tendons respond to progressive loading and to removing compression, which means the advice to stretch the outside of the hip aggressively often makes it worse.

Our tendon primer is here.

When the back is the real culprit

The lumbar spine refers pain into the buttock and thigh routinely, and it is the most common reason a person believes they have a hip problem when they do not. Clues that the spine is involved include pain that changes with spinal position rather than hip position, symptoms that travel below the knee, pins and needles or numbness, a history of back pain preceding the hip symptoms, and pain that is worse after sitting or bending rather than after rotation of the hip.

Nerve root irritation from the lower back can produce buttock and leg symptoms that feel deeply hip-like. If that pattern fits you, read sciatica: symptoms, causes and treatment and lower back pain: causes and red flags.

The sacroiliac joint, and why it gets over-diagnosed

The sacroiliac joint sits where the base of the spine meets the pelvis, and pain from it is typically felt in a small area just below and to the side of the dimples at the bottom of the back, sometimes spreading into the buttock or the back of the thigh. It can genuinely be a pain source, particularly after pregnancy, after a fall onto the buttock, or in inflammatory conditions.

It is also over-diagnosed, because no single test identifies it reliably and it is a convenient label for anything in that region. A careful clinician uses a cluster of tests together and considers the lumbar spine and hip at the same time, rather than declaring an SI joint problem on one manoeuvre.

Self-tests you can run at home

None of these confirm a diagnosis, but they give you useful information to take into an assessment. Try them gently and stop if anything provokes sharp pain.

• The rotation test. Lying on your back, bring the hip and knee to ninety degrees, then let the knee fall inward across your body while the foot goes outward. Deep groin pain or pinching here points towards the hip joint or impingement.
• Single-leg stand. Stand on the painful leg for thirty seconds. Pain reproduced on the outer point of the hip suggests gluteal tendon involvement. Watch whether the opposite side of the pelvis drops, which suggests weakness.
• Side-lying check. If lying on the affected side for a few minutes reliably reproduces the pain, gluteal tendinopathy moves up the list considerably.
• The slump or bend check. If sitting slumped or bending forward changes your buttock pain more than any hip movement does, suspect the lumbar spine.
• Log roll. Lying flat and relaxed, have someone gently roll the whole leg inward and outward with the knee straight. Because this moves the joint without stressing surrounding muscles, groin pain here is a reasonable pointer to the joint itself.

Hip osteoarthritis: what to expect and what actually helps

Hip osteoarthritis usually shows up as gradually increasing groin pain and stiffness, worse after activity, with a slow loss of range that people often notice first as difficulty with socks or with sitting cross-legged. On imaging it appears as joint space narrowing and other degenerative changes, though it is worth knowing that imaging findings and symptoms correlate poorly, and plenty of people have changes on a scan with no pain at all.

What consistently helps is exercise. Strengthening the hip and thigh muscles, maintaining range, managing body weight where relevant, and staying active are the foundations recommended by guidelines internationally.

Medication and injections have a supporting role for symptom control, and joint replacement is reserved for advanced cases where function has genuinely gone. For a wider view of the medical options, see PRP, steroid injections and surgery for joint pain.

Femoroacetabular impingement in younger, active people

Femoroacetabular impingement, usually shortened to FAI, describes a situation where the shape of the ball and socket causes the two to make contact earlier than usual during certain movements, particularly deep flexion combined with rotation. It typically shows up in active people in their twenties and thirties, often footballers, hockey players, dancers and people who squat deeply, as groin pain with pinching at the bottom of a squat and discomfort in prolonged sitting.

The important nuance is that the bony shape alone is not a diagnosis, since many people with the same shape have no symptoms whatsoever. It becomes a clinical problem only when the shape, the load and the symptoms line up.

Management usually begins with modifying the aggravating range, strengthening the hip and trunk, and adjusting sport technique, with surgery considered in selected cases that do not respond.

Muscle strains: hip flexor and adductor

Not everything deep in the front of the hip is joint. Hip flexor and adductor strains are common in sports involving sprinting, kicking and rapid changes of direction, and they feel more superficial and more clearly linked to a specific moment than joint pain does.

You can usually recall the incident. They hurt on resisted testing, meaning pain when you actively lift the knee against resistance or squeeze the knees together.

They respond to graded loading rather than rest, and the biggest mistake is returning to sprinting or kicking before strength has been restored, which is the classic route to a recurring groin problem that lasts a season. Our general principles are in muscle strain versus tear.

What a good hip assessment involves

A thorough assessment is largely about ruling structures in and out in sequence. Expect a detailed history that establishes exactly where the pain sits, what provokes it, what the twenty four hour pattern is, and what your activity demands are.

Then a physical examination covering hip range of motion in all directions, a cluster of specific tests for the joint, tendons and sacroiliac region, strength testing of the glutes and hip flexors, a screen of the lumbar spine because it refers so commonly into this area, and observation of walking and single-leg control. Imaging is ordered only when the history and examination genuinely raise a question that imaging can answer, and not as a default.

At SattvaRig this feeds into an objective mobility and strength assessment so that progress is measured rather than guessed.

What treatment looks like once you know the source

Treatment diverges completely depending on the diagnosis, which is precisely why this article spends so long on sorting them out. Gluteal tendinopathy needs load management, removal of the positions that compress the tendon such as sitting cross-legged and standing hanging on one hip, and progressive strengthening of the glutes.

Hip osteoarthritis needs range maintenance and consistent strengthening with activity modification. Referred lumbar pain needs the spine treated, not the hip.

FAI needs range modification, strength and technique work. Strains need graded loading and a proper return-to-sport progression.

Hands-on treatment, dry needling and taping have supporting roles for symptom control in several of these, but in every single case the durable result comes from the loading programme. Anyone offering a passive-only plan for hip pain has skipped the part that works.

The bottom line

Hip pain is a location puzzle before it is a treatment question. Groin points to the joint, the outer bony point to the tendons, buttock and belt-line to the spine or sacroiliac region, and each of those takes a different plan.

Do the one finger test, try the simple self-checks, and note what makes it worse across a whole day rather than in one moment. Then get it assessed properly, because months spent treating the wrong structure is the single most expensive thing that happens to people with hip pain.

You can map your symptoms on the free interactive body scanner, or book an assessment in Ahmedabad and get a straight answer.