The first one is the most overlooked of the lot, and completely under-diagnosed. We see people who’ve had back pain for twenty years, and nobody ever checked their hips.

The hips cause back pain in two ways. The first is the way they move. If you lose rotation in the hip — something like a hip impingement — that movement has to come from somewhere, so your body borrows it from the joint next door: your lower back. Every time that happens, you’re stressing the facet joints, the discs, everything. The hip won’t move, so the back overworks to cover for it.

The second way is that the hip itself can refer pain. Things like a labral tear — a cartilage tear in the hip — can actually mimic lower back pain. So here’s your tell: if you get a lot of tightness in your hips, especially in the front of the hips, or any groin pain, be highly suspicious that the hip might be driving your back.

The second is a lack of range in a straight leg raise. Here’s what that means: lie on your back, keep the leg straight, and lift it up. We want that to get to around ninety degrees.

When people don’t have that range — when they’re tight — the same thing happens as with the hips. The movement gets borrowed by the lower back. Picture someone bending forward to pick up the shopping: they need that length down the back of the leg. If they haven’t got it, they hit the end of their range fast, and the lower back takes the strain. So not having ninety degrees on a straight leg raise is another big one.

The third one surprises people: foot posture. People with really collapsed arches — flat feet — very often end up with lower back pain.

Here’s why. When the foot flattens, it rotates the whole leg inward. The knee rolls in, the hip rolls in, and that then tilts the pelvis forward. When the pelvis tilts forward, it increases the arch in your lower back. Too much arching over time, and the facet joints start to wear. So a lot of that facet joint degeneration can actually start all the way down at the feet.

And here’s what these people usually tell you. Alongside the back pain, they’ve often had knee pain, shin pain, calf tightness, or a history of heel pain too. That’s the giveaway it’s coming from the feet.

The fourth one is a leg length discrepancy — simply, one leg being slightly longer than the other. That creates an uneven distribution of force through the pelvis, so one side is always taking more load than the other.

And here’s the key giveaway: with this one, the pain is almost always on the same one side of the lower back. So if your back pain is stubbornly one-sided, every single time, a leg length difference is worth looking into.

So there are your four mechanical drivers: the hips, tight hamstrings and a poor straight leg raise, foot posture, and a leg length difference. Notice the thread running through all of them. Each one forces your lower back to do a job it was never meant to do — to move more than it should, and to take load it shouldn’t.

Do that for long enough, and that’s when the disc bulges and the facet joints wear. Those structures are the symptom you feel. These mechanical drivers are the cause. And that’s exactly why just treating the disc so often doesn’t work long term — if you don’t fix what’s overloading it, it just keeps happening.

So if your back pain keeps coming back no matter what you try, this is usually where the answer lies. Get the hips, the hamstrings, the feet, and your leg length checked, and you start solving the actual problem instead of just chasing the pain. That shift — from treating the symptom to addressing the mechanical cause — is what turns short-term relief into lasting results.

Joe Sharp
BSc (Hons) Physiotherapy