RSM-REM-010
Written by Hironori Ikeda, MSc Sports Medicine
RSM International Academy · Chiang Mai, Thailand
What Should You Assess When Hip Pain Might Be Coming From the Back?
The client may point to the groin, buttock or side of the hip, limp during walking, hesitate in a squat or describe pain that changes when the back moves. Pointing to the hip does not establish whether the complaint comes from local hip tissue, the hip joint, lumbar referral or a neural presentation.
I first compare the client’s painful task with hip motion and lumbar movement before deciding where treatment belongs. Reproduce the functional problem, compare hip flexion and rotation, observe gait, then add lumbar or neural testing only when the symptom behavior supports it. Trauma, inability to bear weight, systemic symptoms, progressive neurological loss or suspected fracture changes the plan and may require referral.
In this article, you will learn how to assess hip pain versus pain referred from the back, decide which region deserves the next test, choose an appropriate remedial treatment direction and re-test the same hip ROM or functional task.
In This Article
- What Should You Assess When Hip Pain Might Be Coming From the Back?
- In This Article
- 1. Clinical Problem & Differential: Hip Pain or Referred Pain
- 2. Hip, Lumbar & Neural Comparison
- 3. Differential Assessment: Hip ROM, Lumbar Motion & Neural Tests
- 4. Treatment Scope: Match Local Treatment to the Supported Source
- 5. Symptom Re-Test: Repeat the Original Hip or Functional Task
- Related RSM Clinical Blogs
- Study Remedial Massage at RSM
1. Clinical Problem & Differential: Hip Pain or Referred Pain
People rarely arrive with pain confined to an anatomical diagram. Hip-joint disorders may be felt in the groin, buttock, thigh or knee. Lumbar structures can refer symptoms around the hip, and neural presentations can travel into the leg. Gluteal tendon, proximal hamstring, iliopsoas and adductor problems add further overlap.
History gives the first direction. Groin pain, limping and restricted hip internal rotation increase suspicion of a hip source, while symptoms linked strongly to lumbar flexion, extension or repeated spinal movement may point toward the back. Pain below the knee, tingling, numbness or weakness makes a neural screen more important. None of these details is decisive alone.
Ask about onset, trauma, load change, morning stiffness, night pain and the precise task that hurts. Record one baseline such as walking speed, stair ascent, squat depth, getting out of a chair, hip flexion or rotation. If there was a fall, the person cannot bear weight, or there are systemic or progressive neurological signs, stop and refer.
2. Hip, Lumbar & Neural Comparison
A local muscle or tendon presentation is usually linked to a specific load. Resisted contraction, stretch or compression may reproduce the familiar pain. A hip-joint presentation more often shows a meaningful movement restriction, commonly internal rotation or flexion, together with groin-dominant pain or difficulty with weight-bearing tasks. Lumbar referral may change with spinal movement even when local hip palpation is tender.
The hip and spine should not be assessed as separate islands. Hip-spine literature consistently describes overlapping symptoms and recommends a full history and examination to identify the primary pain generator. A contemporary review of musculoskeletal mimics of lumbosacral radiculopathy makes the same practical point: many non-neural conditions resemble root pain, and pattern recognition must be paired with examination.
Neural features deserve their own comparison. Map sensation, check relevant strength, observe reflexes when within scope, and use straight-leg raise or slump only when the history supports it. A positive result means reproduction of the recognizable neural symptom with appropriate structural differentiation—not merely posterior-thigh stretch.
Hip flexors, extensors and rotators change the femur's position relative to the pelvis, while the lumbar region contributes to trunk motion. To compare them, I keep the pelvis supported during a comfortable hip rotation, then assess the relevant lumbar movement separately. Reproduction of the same complaint under one condition can redirect the examination without proving a single pain generator.
3. Differential Assessment: Hip ROM, Lumbar Motion & Neural Tests
A clear sequence reduces guessing:
- Observe gait and the person’s functional baseline.
- Compare active and passive hip flexion, internal rotation and external rotation.
- Note range, end feel and location of the familiar symptom.
- Use FADIR or FABER selectively. These tests may help provoke or localize symptoms, but neither identifies a diagnosis by itself.
- Compare lumbar flexion, extension and side bending. Add repeated movement only when appropriate and monitor whether symptoms centralize, peripheralize or remain unchanged.
- Use straight-leg raise or slump if pain travels, sensation changes, or weakness is reported.
- Compare resisted gluteal, hip-flexor, adductor or hamstring loading when the history suggests a local tissue source.
Keep the examination proportional. More tests do not create more certainty when they all provoke nonspecific discomfort. Select the smallest set that can distinguish the leading possibilities.
In my own assessment, I change the hip position gradually and compare the passive end feel with the client's active movement. Before deeper work, I first find a position in which guarding reduces and the joint can be moved comfortably; forcing end range or chasing a click gives me less useful information. A blocked or pinching sensation, a strong stretch and an electric or spreading symptom are not treated as the same response; each sends the next test in a different direction.
4. Treatment Scope: Match Local Treatment to the Supported Source
If hip motion is limited and the familiar symptom changes with hip testing, local work may address protective muscle tone, relevant soft-tissue load and comfortable movement exposure. If lumbar movement consistently changes the complaint, treatment and education should reflect the lumbar contribution rather than concentrating only on the painful buttock. When neural findings dominate, avoid aggressive pressure over a nerve and consider referral or co-management. If contact newly provokes sharp, electric or spreading pain, tingling or numbness, stop contact and reassess; do not repeat the pressure to confirm a nerve target.
The treatment dose should be understandable: a defined region, tolerable pressure, a movement strategy and a reason for each choice. Do not promise to “realign the hip” or “put a disc back.” Those claims exceed what an immediate manual response can establish.
When findings remain mixed, say so. A provisional working hypothesis is safer than false precision. Persistent groin pain with marked loss of motion, worsening weight-bearing pain, progressive weakness or an unclear response warrants assessment by an appropriately qualified medical professional.
If supported hip rotation reproduces the familiar groin or hip symptom, I investigate that finding before treating a tender lumbar region. If lumbar movement changes the complaint while local hip loading remains quiet, I change the clinical emphasis. Any manual input is then confined to a relevant, identified muscle region; the painful location alone does not choose the contact.
5. Symptom Re-Test: Repeat the Original Hip or Functional Task
Return to the original measure. If hip internal rotation was the baseline, repeat it in the same position and record range and symptom location. If the problem was a squat or stair, repeat the same depth, speed and support. Comparing a different movement after treatment creates a good story but weak evidence.
Interpret the response carefully. Easier motion or reduced familiar pain supports the relevance of the chosen intervention. It does not prove that one tissue was the sole cause. No change directs the next decision: reconsider the hypothesis, change the treatment dose, assess another region or refer.
Related RSM Clinical Blogs
Browse all Remedial Massage clinical guides
▷ Back Pain With Leg Symptoms: Root, Sciatic or Gluteal? — Remedial Massage · Broaden the differential assessment.
▷ Limited Hip Internal Rotation: Muscle, Capsule or Pelvis? — Deep Tissue Massage · Examine supported hand position and tissue contact.
▷ Low Back Pain While Cycling: Hip ROM, Trunk Endurance & Bike Position — Sports Massage · Connect the findings with the sport task and training exposure.
Study Remedial Massage at RSM
In practical training, learn to explain why a hip complaint may require a lumbar comparison before local treatment. Work through the task, anatomical landmarks and hand-position choices with a clear reason for the next assessment.
▷ Remedial Massage — course details and entry requirements
About the Author
Hironori Ikeda, MSc Sports Medicine
Founder and lead instructor of RSM International Academy, Chiang Mai, Thailand. His teaching connects functional anatomy, clinical palpation, movement assessment and sports medicine manual therapy.