Dr. Reed Jarvis, DC | Owner & Chiropractor, The Resilience Lab | Louisville, TN
When someone tells me their hip hurts, the first thing I want to know is exactly where. Because what people call hip pain can be coming from at least seven different anatomical locations, and only one of them is the actual hip joint. In a clinical study where patients were asked to indicate where their hip pain was located, only 20% pointed to the hip joint itself. The rest were pointing to surrounding structures including the lumbar spine, sacroiliac joint, bursa, iliac crest, and soft tissue.
That ambiguity matters. Because treating the wrong structure is one of the main reasons hip pain doesn't resolve.
Where hip pain actually comes from
The hip region is a complex neighborhood. The lumbar spine, sacroiliac joint, hip flexors, gluteal musculature, and the actual ball-and-socket joint of the hip all overlap in the same general area and can all generate pain that feels like it's coming from the hip.
The most common causes of posterior hip pain, pain in the back of the hip and buttock, include referred pain from the lumbar spine, sacroiliac joint dysfunction, piriformis syndrome, gluteal muscle pain, and proximal hamstring issues. The lumbar spine alone, particularly through the L3 nerve root and its innervation of the hip region, is the single most common cause of posterior hip pain. Many people walking around with what they think is a hip problem are actually dealing with a lumbar spine issue that's referring pain into the hip region.
Anterior and lateral hip pain has a different set of contributors. Hip flexor strains and psoas dysfunction, greater trochanteric pain syndrome from gluteus medius tendinopathy or IT band friction, intra-articular pathology like a labral tear or femoroacetabular impingement in younger active people, and osteoarthritis in older adults all present in different locations around the hip and require different assessment and treatment approaches.
The sacroiliac joint connection
The sacroiliac joint sits where the lower spine meets the pelvis. It plays a critical role in transferring load between the upper body and the legs and absorbing torsional forces during movement. When it's not functioning properly, it generates pain in the low back, buttock, hip, and sometimes down into the groin or lateral thigh.
SI joint dysfunction is one of the most commonly missed contributors to hip pain. The pain pattern overlaps significantly with lumbar disc pathology and hip joint pathology, which is exactly why a thorough clinical assessment that includes specific SI joint provocation tests matters. Tenderness over the SI joint combined with positive provocation testing helps distinguish it from other sources.
Hip mobility and lumbopelvic stiffness
One of the most important and frequently overlooked relationships in hip pain is between lumbopelvic mobility and hip joint demand. When the lumbar spine and pelvis are stiff and restricted in their movement, the hip joint is forced to compensate by taking on more range of motion than it's designed to handle. That increased demand creates mechanical stress at the hip over time.
This pattern is particularly relevant in active people who train regularly. Inadequate lumbar rotation and pelvic mobility during running, lifting, or sport-specific movements creates compensatory hip loading that accumulates over hundreds of reps into tissue irritation and pain. Addressing the lumbopelvic restriction is as important as treating the hip itself.
The psoas and hip flexors are frequently involved as well. A chronically shortened or overloaded psoas alters pelvic position, increases anterior pelvic tilt, and places the hip in a position of reduced mechanical efficiency. Dry needling into the psoas and iliopsoas complex is one of the most effective interventions for releasing this pattern and is difficult to access through any other manual technique.
What a thorough assessment looks like
Hip pain assessment at The Resilience Lab goes well beyond the hip. It includes a lumbar spine evaluation, SI joint provocation testing, hip mobility and strength assessment, lumbopelvic movement quality, and palpation of the surrounding musculature. The goal is to identify exactly which structures are contributing to the pain pattern before any treatment begins.
Hip flexor length and activation, gluteus medius and maximus strength, and the ability to dissociate hip movement from lumbar movement all tell us important information about what's driving the problem. Imaging is useful for ruling out structural pathology but a normal MRI or X-ray doesn't mean the pain isn't real. It means the source is likely in the movement system rather than the joint itself.
How we treat it
Treatment depends entirely on what the assessment reveals. For lumbar-referred hip pain, treatment targets the lumbar spine and nerve root with chiropractic adjustments, soft tissue work, and functional rehab. For SI joint dysfunction, specific manipulation of the SI joint combined with gluteal and core strengthening produces consistently good results. For hip flexor and psoas involvement, dry needling, active release, and progressive hip mobility work addresses the root issue. For gluteus medius tendinopathy or greater trochanteric pain syndrome, load management and progressive tendon loading rehab alongside soft tissue treatment is the evidence-based approach.
The common thread across all of them is identifying exactly what's driving the pain and building a treatment plan around that, not around the most convenient diagnosis.
