When Hip Arthritis Starts Costing You Your Back

Let me start with the sentence you have probably said out loud, and the half of it that is wrong.

"My back goes because of my hip."

The first half is right. Your hip has been sore for five years. It has changed how you stand, how you walk, and how much you do. Your back has been picking up the slack.

The second half is wrong, and it matters. It is not that your hip has damaged your back. Nothing has been worn out or knocked out of place. Your back hurts because of how you have had to move, and because of how much you have stopped moving. Those are two very different problems, and the second kind is the kind that changes.

This guide is not saying your pain is in your head. Your pain is completely real. Both lots of it.

One thing before you start. This guide assumes I have examined you and ruled out the serious causes. If nobody has examined you yet, read section 17 first.

Read it in chunks. There is no test at the end.

The short version

• Your hip arthritis is real. It is a genuine change in a joint. It is also common, and it is not a countdown to disaster.
• Your low back pain is a different thing. It is not damage. It is the cost of a year of moving less and holding yourself tighter.
• Pain is an alarm, not a damage meter. After five years of a sore hip, that alarm has learned to go off more easily.
• The pictures do not explain the pain. Hip X-rays and back scans are poor at telling who hurts and who does not.
• Guarding is the big one. Bracing your back to protect your hip works for a week. Over years it becomes the problem.
• What you lost in the last year matters more than what the X-ray shows. Walking and general activity were doing a job for your back. That job stopped.
• Walking is the single best thing you can get back. Even short walks. Even slow ones.
• It comes in spells for nearly everyone. A flare is not a setback. It is the normal shape of this.
• Moving is safe. Resting is the thing that costs you.

1. Pain is an alarm, not a damage meter

Most people think of pain like a fuel gauge. More pain means more damage. Less pain means it is healing.

That is not how it works, and knowing this changes things.

Pain is produced by your brain. It is your body's alarm system, and its job is protection, not measurement. Your brain takes in signals from the tissues, then weighs them against everything else it knows. How tired you are. How worried you are. What happened last time. What you think this means.

Then it decides how loud to make the alarm.

This is why the same hip can feel fine on a good morning and awful on a bad afternoon. The joint did not change between breakfast and teatime. The alarm setting did.

You already know this is true, even if you have never put it that way. You have had days where you have done more and hurt less. That is not you imagining things. That is the system working exactly as designed.

2. The pain gate

In 1965, two researchers called Melzack and Wall described something that still explains more than almost anything else in pain science.

There is a gate in your spinal cord. Signals from the body have to pass through it to reach the brain. The gate can open wider, letting more through. It can close, letting less through.

Here is the part that is useful to you. Movement and touch close the gate. Signals from moving joints and working muscles travel on faster nerve fibres than pain signals. They get there first. They crowd the gate.

This is why you rub a bumped elbow without being told to. It is why a hot water bottle helps. It is why gentle movement often eases your back more than lying still does.

And things open the gate too. Poor sleep. Stress. Worry about what the pain means. Sitting still for hours.

You have more control over this gate than you have been led to believe.

3. When the alarm gets more sensitive

Your hip has been sore for five years. Your back has been flaring on and off for one.

When a system deals with pain signals day after day, it gets better at producing them. Not because anything is going wrong, but because that is what nervous systems do. They become efficient at what they practise.

The technical name is central sensitisation. In plain terms, the volume knob has been turned up and left there.

What it looks like in real life:

• Pain out of proportion to what you did
• Pain that spreads wider than it used to
• Ordinary things starting to hurt, like sitting or standing still
• Pain that lingers long after the activity ended
• Good days and bad days that seem to bear no relation to what you did

None of this means the damage is worse. It means the alarm is more sensitive.

And here is the good news. Sensitivity is trainable in both directions. The same system that learned to be loud can learn to be quieter. It just takes the right input, given regularly, over time.

4. Your hip is real. Your back is not damaged.

This is the most important section in the guide, so it is worth slowing down for.

Osteoarthritis in a hip is a genuine change in a joint. The cartilage thins, the bone underneath changes, the joint capsule stiffens. That is real. You are not imagining it, and nobody should tell you it is nothing. Your low back is a different story. When I examine a back like yours, I do not find damage. I find a back that is stiff, tender, working hard, and short of practice. That is not the same thing at all.

Doctors call this non-specific low back pain. That is an unhelpful name, because it sounds like nobody knows what is going on. It actually means something quite specific: no single structure is injured, and no serious disease is present. It is the commonest sort of back pain there is, and it is the sort that responds best to what you do.

So you have two things happening at once. A joint that has genuinely changed, and a back that is sore because of how you have been living around that joint.

They need different explanations, and they respond to different things. But movement helps both.

5. What the pictures actually show

If you have had an X-ray of your hip, or a scan of your back, this section matters.

On hips. A large Dutch study looked at people arriving at their GP with hip or knee complaints, and X-rayed them. Definite arthritis showed up in about 13 in 100 of the painful hips. It also showed up in about 10 in 100 of the hips that did not hurt at all. The researchers concluded that the X-ray gave the doctor very little help in working out who actually had the problem.

On backs. Researchers have scanned thousands of people with no back pain whatsoever. Disc wear showed up in about 7 in 10 of the forty year olds, 8 in 10 of the fifty year olds, and nearly 9 in 10 of the sixty year olds. Disc bulges showed up in half, then 6 in 10, then 7 in 10. Not one of these people had any back pain.

Read those two paragraphs again. The pictures are common findings, like grey hair. They show what a joint looks like. They do not show what it feels like, and they are poor at predicting who will hurt.

This does not mean your X-ray was pointless. It rules things out, and that is worth having. It just cannot tell you how much you will hurt, or what you are capable of.

The most important sentence in this guide: what you can do is decided far more by your strength, your confidence and your habits than by what a picture shows.

6. How a sore hip sends trouble to the back

Now the mechanism. This is the bit nobody usually explains, and once you see it you cannot unsee it.

A stiff hip has to be made up for somewhere, and the somewhere is your low back.

Think about what happens when you walk. Your hip is supposed to swing backwards as you push off. If it will not go that far, you still need to get your body over that leg. So the pelvis tips, and the low back arches a little more. Every single step.

Researchers looking at people with hip arthritis found exactly this. The hip loses the ability to straighten fully. The body compensates by leaning the trunk forward and by rotating more through the pelvis and low back. And in one review, loss of hip movement was found to be an independent risk factor for developing low back pain.

Then there is the limp. A shortened stride on the painful side. Landing differently. Spending less time on that leg. None of that is wrong of you. It is exactly what any sensible body does with a sore joint. But it loads your back in a pattern it never used to have.

And there is the sitting, the leaning on worktops, the way you get out of a chair, and the side you always favour. Small things, repeated thousands of times a year.

None of this is damaging your back. It is giving your back an unfamiliar job to do, over and over, without a rest. That is usually enough on its own to make a back sore.

7. Guarding: the protection that became the problem

This is the one you will recognise.

When something hurts, you tighten around it. You hold the muscles of your low back and your tummy on, all the time, to stop anything moving too far. It is automatic. You did not choose it.

Researchers have measured this. They put people with long lasting back pain on a treadmill and recorded the muscle activity. Compared with people without back pain, the muscles down the spine and across the front of the abdomen were working harder, the whole way through the walk. The authors called it exactly what it is: guarding.

For a short spell, guarding is clever. It limits movement while something settles.

• Over years, it stops being clever. Here is what it costs you.
• Muscles that never switch off get tired and sore. That is true of any muscle. Hold your arm out for ten minutes and see.
• A back held stiff stops sharing the load. The movement that should be spread across many joints gets concentrated.
• A stiff back does not get the gate-closing signals. Remember section 2. Movement closes the gate. A back that barely moves does not send those signals.
• The tightness itself starts to hurt. And then it feels like proof that something is wrong, which makes you tighten more.

That last loop is the trap. Pain leads to guarding. Guarding leads to more pain. The pain seems to confirm that guarding was necessary.

Breaking it does not take force. It takes repeated, unremarkable, unthreatening movement. Which is the whole of the next few sections.

8. What the last year changed, and why it matters most

Your hip has been sore for five years. Your back started flaring in the last one. That gap is the clue, and it is worth taking seriously.

What changed in the last year is how far you can walk and how much you exercise.

Most people think of that as a fitness problem. It is bigger than that.

Walking was doing several jobs for your back, quietly, every day:

• It was moving your low back through small ranges, thousands of times
• It was sending a steady stream of gate-closing signals
• It was keeping the muscles that support your spine in practice
• It was stopping you sitting for long stretches
• It was giving your nervous system regular evidence that movement is safe

When the walking dropped, all five of those stopped at once. Your back did not become damaged. It became out of practice, under-used, and over-protected, all at the same time.

This is why I think the walking matters more than the hip X-ray. The X-ray describes something you cannot change. The walking is something you can.

9. Why it comes in spells

You have had repeated bouts. That probably feels like failure, or like something is being missed. It is neither. It is the normal shape of this problem.

A careful study followed people who had recovered from a bout of back pain and watched what happened next. Within twelve months, 69 in 100 had another bout. About 40 in 100 had one that limited what they could do.

More than two-thirds. In people who had genuinely recovered.

Let that take some pressure off. Recurring bouts are not a sign that something is wrong with you, that your treatment failed, or that you are heading downhill. It is what this condition does.

What the same research found about who recurs more is more useful. Three things stood out: spending a lot of time in awkward positions, sitting for more than five hours a day, and having had more than two previous bouts.

Two of those three are about how much of the day you spend still. That is not a coincidence, and it is not out of your hands.

So the goal changes. Not "never have a flare again", which is not on offer to anyone. Instead: flares that are shorter, further apart, less alarming, and that cost you less. That goal is realistic, and it is worth aiming at.

10. Building walking back when the hip is the limit

Everything above points the same way. So here is the practical part.

A large trial in Australia tested exactly this. They took people who had recently recovered from back pain and gave half of them a walking programme, building towards five walks a week of at least thirty minutes. The other half carried on as usual.

The walking group went a median of 208 days before their next bout. The usual care group went 112 days. Close to twice as long, from walking.

Now the obvious objection: your hip does not let you walk thirty minutes. Fair. So we do not start there.

Short and often beats long and occasional. Four walks of eight minutes does more for a back than one walk of half an hour, and it is far kinder to a hip. Your back wants frequency. Frequency is what it lost.

• Some things that genuinely help:
• Flat and firm. Save the hills and the soft ground for later.
• Use a stick or a pole if it lets you walk further. There is no prize for refusing. A walking pole that buys you ten more minutes is a good trade, and it also unloads the hip.
• Turn around before you have to. Get home with something left. The walk that ends in a struggle teaches your nervous system that walking is dangerous.
• Judge it by tomorrow, not by today. A bit more ache during and just after is fine and expected. The question is whether you are back to your normal baseline within about 24 hours. If yes, that dose was right. If it takes two days to settle, it was a little much.
• Add about one tenth a week. If you are comfortably doing ten minutes, go to eleven. This is slower than you want and faster than it feels.
• Count the total, not the trip. Three tens is thirty.

The aim is not to walk through the hip pain. It is to find the dose your hip will accept, and then give your back that dose regularly.

11. Strength, and an honest word about the evidence

Strength work matters here for two reasons: a stronger hip has to work less hard per step, and a stronger back tolerates the compensating it is being asked to do.

The national guidance for the UK is clear. NICE names therapeutic exercise as one of the core treatments for osteoarthritis, alongside weight management, information and support. It says exercise should be tailored to you, and it specifically mentions local muscle strengthening and general aerobic fitness. It also says manual therapy, which is part of what I do, should be considered for hip osteoarthritis alongside exercise, not instead of it.

Now the honest bit, because you deserve it.

A major review published this year looked again at all the trials of exercise for hip arthritis. It found the average benefit on hip pain was smaller than researchers previously believed. Around seven points on a hundred point scale, where about twelve points is usually needed for a person to actually notice a difference in daily life.

I would rather you heard that from me than found it yourself and wondered what else I had left out.

Here is what I take from it, and why I am still asking you to do this.

• That is an average. Some people in those trials got a lot out of it. Some got nothing. Averages hide both.
• It measured hip pain. Your back is the thing flaring, and the case for movement there is considerably stronger. The walking trial in section 10 is the example.
• It measured pain, not function. Getting off a low chair, managing stairs, carrying shopping, staying steady on your feet. Those things respond to strength whatever the pain does.
• The same review still concluded exercise is a reasonable first choice, because the risk of harm is very low and the wider benefits are real.
• And nothing else on offer does better. This is not a case of exercise versus something more effective.

So: strength work two days a week, on the hip and the trunk, for the reasons above. Not because I have promised it will take your hip pain away.

12. What turns your pain up and down

Both your hip and your back respond to more than load.

Things that turn the volume up:

• Poor sleep. The strongest one, and the most ignored. A bad night makes tomorrow hurt more, reliably.
• Stress and worry. Not because you are weak. Stress hormones genuinely make nerves more excitable.
• Sitting still for long stretches. Especially in a chair that lets you sink into one position.
• Fear of what the pain means. Believing you are grinding a joint away makes the alarm louder. It is not true, and it is expensive.
• Doing far too much on a good day. See the next section.

Things that turn it down:

• Regular movement, spread through the day. More than one big effort.
• Getting your sleep sorted, even partially.
• Warmth. A hot water bottle on the hip or the back is not a trick. It is section 2 in action.
• Company and things you enjoy. Distraction closes the gate. There is real science behind this.
• Understanding what is going on. Which is most of why this guide exists.

13. Pacing, flare-ups, and the boom and bust trap

The pattern: a good day arrives, you feel almost normal, so you do everything you have been putting off. You pay for it for three days. Then you rest, feel better, and do it again.

Each cycle teaches your nervous system that activity is dangerous. It is not. It is the size of the jump that caused the trouble. Pacing means deciding in advance, not by feel. On a good day, do your planned amount and stop. Bank the rest. It is dull and it works.

When a flare comes, and it will:

• Do not go to bed. Bed rest makes back pain worse and last longer. This is well settled.
• Keep moving, smaller. Shorten the walk. Do not cancel it.
• Do not go looking for what you did wrong. Often there is nothing. Flares happen after a poor week of sleep, a stressful fortnight, or for no reason at all.
• Expect a few days to a couple of weeks. Then expect it to settle, because it has every time so far.
• Do not start the guarding again. This is the real risk of a flare. Not the pain, but the tightening that outlasts it.

Your track record is evidence. Every previous flare has settled. That is data, and it is yours.

14. A word about painkillers

NICE gives fairly firm advice on osteoarthritis, and it surprises people.

• Paracetamol and weak opioids like codeine are not recommended routinely. Only occasionally, for short term relief, when other things have not worked.
• Anti-inflammatory gels are the first choice for a knee. For a hip, which sits deeper, they are less useful.
• Anti-inflammatory tablets can be considered if gels are not suitable, at the lowest dose for the shortest time, and usually with something to protect your stomach.
• Nothing here is a long term plan, and none of it changes the joint.

Two practical points.

Anti-inflammatories are not free. They matter for the stomach, the kidneys and blood pressure. If you take blood pressure tablets, water tablets, or anything for your heart, ask your pharmacist before you start. Pharmacists are excellent at this and you do not need an appointment.

Timing beats dose. If you are going to use something, use it to unlock a walk you would otherwise not do. Painkillers that let you move are doing a job. Painkillers that let you sit still more comfortably are not.

15. What treatment does, and what it does not

I would rather be straight with you about this. What hands-on treatment does well:

• Eases pain in the shorter term, which buys you room to move
• Reduces the guarding in section 7, which is hard to release on your own
• Improves how a stiff area moves, which helps the compensating
• Gives your nervous system clear evidence that the area can be touched and moved without disaster

What it does not do:

• It does not reverse arthritis in a hip. Nothing does, and anyone who tells you otherwise is selling something.
• It does not put anything back in place. Nothing is out of place.
• It is not a course you complete and then you are fixed.

Where it fits, according to national guidance and to me: alongside exercise, not instead of it. The treatment opens a window. What you do in that window is what changes the year ahead.

You should expect me to be clear about what I am treating, to change the plan if it is not working, and to tell you when you no longer need me.

16. The goals worth aiming at

Not "no pain in my hip". That is not on the table, and chasing it will make you miserable.

These are:

• Walking most days, at whatever distance your hip accepts, without dreading it
• Flares that are shorter and further apart, and that no longer frighten you
• Getting out of a chair without planning it
• Knowing the difference between a sore day and a problem, so you stop scanning for signs of decline
• A back that is not braced all day, because it no longer feels it has to be
• Doing the things you stopped doing this year, in whatever adapted form works

Every one of those is achievable without a single thing changing on your X-ray.

17. When to get urgent help

Almost all back and hip pain is not an emergency. A few things are.

Go straight to A&E, or call 999

Do not wait to see if these settle. If you are offered a routine appointment, say you are worried about cauda equina syndrome and ask to be seen today.

• Numbness or a changed feeling between your legs, around your back passage or genitals. Including toilet paper feeling different when you wipe.
• Trouble starting to wee. Not being able to feel it coming out. Losing the feeling of a full bladder. Any new loss of control of your bladder or bowels.
• Numbness or pain down both legs at once, or pain that has spread from one leg to the other.
• New or quickly worsening weakness in one or both legs, or your legs giving way.
• A hip or leg you suddenly cannot stand on at all, especially after a fall.
• Severe pain straight after a bad fall or accident.

Contact your GP or NHS 111 today

• A hip or back that is hot, red or swollen, with a fever or shivering, or feeling generally unwell. A joint infection needs treating quickly.
• Weakness that is getting worse, especially if your foot is starting to drag or catch.
• Sudden severe back pain after a minor fall, a bump, a cough or a sneeze, or with no cause at all. Especially with osteoporosis, long term steroid use, or a previous broken bone from a minor injury. This can be a spinal fracture. It is common, treatable, and often missed.
• Losing height, or your upper back becoming noticeably more rounded, alongside back pain.
• Back or hip pain with weight loss you cannot explain, night sweats, or a past history of any cancer.
• Pain that is much worse at night, wakes you every night, and is not eased by any change of position.

Worth mentioning at a normal appointment

• Any fall, even one that did not hurt you. Falls predict falls, and your GP can refer you to a falls prevention service.
• Hip pain that has clearly got worse over recent months, or that now wakes you regularly. Worth a review, not an alarm.
• Whether you have had a bone density scan, if you have broken a bone from a minor fall since you were fifty.
• How far you can now walk before you have to stop, and what makes you stop. It is the most useful single thing you can tell me.

Everything else, including a bad flare-up, can wait for a normal appointment.

18. If you want to read or watch more

Start here

• Tame the Beast. A five minute animation by Professor Lorimer Moseley. The best possible starting point. tamethebeast.org
• Flippin' Pain. A UK campaign about long lasting pain. flippinpain.co.uk

On arthritis

• Arthritis UK (until recently called Versus Arthritis). Good, plain information on hip osteoarthritis, and a set of hip exercises. arthritis-uk.org
• NHS advice on osteoarthritis. nhs.uk/conditions/osteoarthritis
• NHS activity guidelines for older adults. nhs.uk/live-well/exercise/physical-activity-guidelines-older-adults

Practical help

• The Pain Toolkit, by Pete Moore. Very good on pacing and boom and bust. paintoolkit.org
• Recovery Strategies, by Greg Lehman. A free illustrated workbook. greglehman.ca/recovery-strategies-pain-guidebook
• Age UK, on staying steady, and strength and balance exercises. ageuk.org.uk

The research behind this guide

• Melzack R, Wall PD. Pain mechanisms: a new theory. Science, 1965. The original pain gate paper.
• Brinjikji W et al. Imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 2015. The back scan figures in section 5.
• Rondas et al. Association between hip pain and radiographic hip osteoarthritis in primary care: the CHECK cohort. British Journal of General Practice, 2022. The hip X-ray figures in section 5.
• Wang et al. The low back pain in patients with hip osteoarthritis. Annals of Joint. The compensation mechanism in section 6.
• van der Hulst et al. Lumbar and abdominal muscle activity during walking in subjects with chronic low back pain. Journal of Electromyography and Kinesiology, 2010. The guarding findings in section 7.
• da Silva et al. Recurrence of low back pain is common: a prospective inception cohort study. Journal of Physiotherapy, 2019. The recurrence figures in section 9.
• Pocovi NC et al. An individualised, progressive walking and education intervention for the prevention of low back pain recurrence (WalkBack). The Lancet, 2024. The walking figures in section 10.
• NICE guideline NG226. Osteoarthritis in over 16s: diagnosis and management, 2022. The treatment and painkiller advice in sections 11 and 14.
• Hall M et al. Exercise for osteoarthritis of the hip. Cochrane Database of Systematic Reviews, 2026. The honest figures in section 11.

Bring any of this to your next appointment. Especially the parts that did not sit right, or that felt uncomfortably familiar.

This guide is general information. It does not replace the advice I give you in clinic.