Should you treat the hip for low back pain?

Low back pain continues to be one of the most common reasons patients seek physical therapy. The more concerning issue is that non-specific low back pain, which accounts for approximately 90% of all low back cases, is widely under diagnosed due to the complexity of the region. Once red flags and specific mechanisms of injury are excluded, any combination of musculoskeletal, neurological and psychosocial factors can elicit symptoms in the low back.

Recently, there has been a growing emphasis on the role of the hip, particularly when patients present with limited mobility, weakness or asymmetries. In the clinical setting, it is now common to hear that “tight hips are causing your back pain”, or “weak glutes are the problem.”

But an important question remains.

Does treating the hip actually improve outcomes in patients with low back pain?

A 2021 randomized controlled trial published by Burns et al set out to answer this directly.

The study

This randomized controlled trial study evaluated whether adding hip-specific treatment to standard low back physical therapy led to better outcomes.

Participants were 76 adults with 1) low back pain and 2) concurrent hip impairments, which included mobility and/or strength deficits of the hip. These participants were then divided into two groups:

Group 1 was given Lumbar Treatment Only (LBO).

Group 2 was given both Lumbar + Hip Treatment (LBH).

Both groups received standard physical therapy for the low back, including 1) exercise, 2) manual therapy and 3) patient education.

The hip-treatment group received additional interventions, including 1) hip strengthening, 2) mobility work and 3) manual therapy targeting the hip.

It is important to note that the lumbar treatment was not strictly standardized—it was based on clinician judgment, reflecting real-world physical therapy practice.

Outcome measures included 1) pain (Numeric Pain Rating Scale), 2) disability (Oswestry Disability Index), 3) fear-avoidance beliefs, and 4) functional improvement.

Patient follow-up was obtained at baseline, 2 weeks, discharge, 6 months and 12 months post-intervention.

The results

Both LBO and LBH groups improved significantly over time, but there was no additional benefit from hip treatment.

In other words, there were no meaningful differences between groups at any time point.

The interesting finding, however, was that the group receiving additional hip treatment had higher fear-avoidance beliefs at 2 weeks and discharge. This subtlety may suggest that additional treatment may not necessarily improve patient confidence or outcomes.

Limitations of the study: 1) variability in treatment approaches. The details of low back treatment were not included, and it was based on therapist discretion to mimic real-world applications. However, without standardization of what low back care entailed, we do not know whether there were inadvertently hip-involved interventions used within the LBO group. 2) The study was not blinded, meaning that patients and therapists knew which group they were placed under. This increased the risk of both observer and participant expectation bias, which could vastly affect the results. 3) The education aspect of care, while directed to be centered around the low back, may have also included the hip. 4) Small sample size and missing data at follow-up.

Clinical implications for physical therapists

At first glance, the study’s findings challenge the common assumption that, “if the hip is impaired, treating it will improve low back pain.” Rather yet, the study suggests that identifying and addressing a hip impairment does not necessarily benefit low back pain, and that improvements may be driven more by general movement, load tolerance and gradual return to activity.

The conclusions of the study suggest that, for most patients with low back pain, focusing treatment on the spine alone may be sufficient—even when hip deficits are present. But were the participants in the “low back only” group truly receiving treatment exclusive to the low back? Learning lumbopelvic awareness through a cat-cow exercise will also affect movements in the hip. Education on protection of the low back includes promoting movement in the hip to offload the spine. Even without targeted hip interventions, it is unlikely the hip was truly ignored. Unless we know that the experiment’s “low back only” group was truly limited to the lumbar spine (ie. core strengthening, spinal mobilizations) we should be cautious to jump to the conclusion that focusing on spine alone suffices.

Nonetheless, the study does provide standard procedures for the participants who received additional hip treatment. This included specific manual therapy procedures and a progressive exercise protocol for the hip. And even so, this group did not perform better than the other, strengthening the conclusion that adding hip-specific work does not necessarily provide additional benefit.

The focus is then as such: More is not always better. The goal is precision, not excess. Overcomplicating care can reduce clarity for the patient and shift focus away from meaningful progress. Therefore, while a patient can indeed have “tight hips”, “weak glutes”, or “muscle imbalances”, these are not always the primary drivers of pain. Training hip stability and mobility have almost become synonymous with low back pain protocols, and it’s important that we take a step back and acknowledge the distinction between the two.

Final thoughts? This study reinforces an important yet forgotten principle in rehabilitation: effective treatment is not about doing more—it’s about doing what matters most.

At The LAB Doctors of Physical Therapy, we build an evidence-based treatment program that is both effective and efficient. Click here to learn more about our services.

Citations

1.) Burns SA, Cleland JA, Rivett DA, O’Hara MC, Egan W, Pandya J, Snodgrass SJ. When treating coexisting low back pain and hip impairments, focus on the back: adding specific hip treatment does not yield additional benefits: a randomized controlled trial. J Orthop Sports Phys Ther. 2021;51(12):581-601.