Hip Pain Secondary to Back Pain

If your back is service connected and your hip hurts, you can claim the hip as secondary to the back. This claim has a step most secondary claims do not. Back conditions often send pain into the buttock, groin and outer hip, and VA treats that pain as part of the back. VA rates the hip on its own only when there is a hip condition: arthritis, bursitis, a tendon problem or another diagnosis of the hip itself. This page covers the research, how to tell the two apart, the rating, and the medical opinion that wins these claims.

Can back pain cause hip pain?

Yes, in two ways that lead to different claims. The first is referred pain: you feel it in the hip, but the source is the spine. The second is a separate hip condition that the back caused or made worse. The research on the second is thinner, and most of it shows back and hip problems occurring together rather than one causing the other.

• Surgeons named the "hip-spine syndrome" in 1983 (Offierski and MacNab, Spine), noting that disease at both the hip and the spine is not unusual in older people. Their "secondary" form described a hip deformity worsening the spine, the reverse of this claim.
• In 3,026 community adults aged 50 to 79 in the Multicenter Osteoarthritis Study (Segal and colleagues, Archives of Physical Medicine and Rehabilitation, 2007), people with low back pain had higher odds of greater trochanteric pain syndrome, pain and tenderness over the outer hip (odds ratio 2.79). It was a one-time snapshot, and the authors said a longitudinal study is needed to find causes.
• Of 252 patients referred to a spine center for low back pain (Tortolani and colleagues, Spine Journal, 2002), 20.2% had greater trochanteric pain syndrome, confirmed by their response to an injection. The authors warned that doctors often miss this diagnosis.
• The posture of the spine may matter for some hip disease. Women over 70 with rapidly destructive hip arthritis (44 patients) had less lumbar curve and more backward pelvic tilt than women with ordinary hip osteoarthritis (70 patients), and the authors suggested these factors may play important roles in the disease (Morimoto and colleagues, European Spine Journal, 2018).
• Gait is the usual theory, and the evidence on it is mixed. A 2022 review of 97 studies (Smith and colleagues, Journal of Sport and Health Science) found that people with persistent low back pain walk slower with shorter strides, but found no difference in how far the spine, pelvis or hips moved.
• Not every study supports a link. In a database study of 2,275,683 patients with hip osteoarthritis (Pirkle and colleagues, Journal of Neurosurgery: Spine, 2021), those who had a lumbar fusion were no more likely to need a hip replacement later.

In my read, the research shows that back and hip problems travel together and that spinal posture can change how the hip is loaded. It does not prove that a back condition caused any one veteran's hip arthritis; a medical opinion has to make that case from your records.

Hip pain from your back versus a hip condition

Pain that starts in the lower spine is often felt around the hip, and doctors have ways to tell the sources apart.

• Of 512 patients with a disc herniation low in the spine, 21 (4.1%) reported groin pain (Yukawa and colleagues, Spine, 1997).
• In 5 selected patients with groin pain alone and one degenerated lumbar disc (Oikawa and colleagues, Spine, 2012), numbing the hip joint did not relieve the pain, numbing the disc did, and spinal fusion improved it.
• Among 97 patients with lower-limb pain (Brown and colleagues, Clinical Orthopaedics and Related Research, 2004), a limp, groin pain or limited inward rotation of the hip pointed to a hip disorder. Patients with limited inward rotation were 14 times more likely to have a hip disorder, alone or with a spine disorder, than a spine disorder only.
• An image-guided injection into the hip joint can settle it: a 2020 review of 9 studies (Maldonado and colleagues, Orthopedics) reported 93.6% sensitivity and 95.0% specificity.

VA handles the three possibilities differently.

• Pain from the spine. The General Rating Formula for the spine applies "with or without symptoms such as pain (whether or not it radiates)," so pain that radiates from the back into the hip is part of the back rating. The sacroiliac joints at the back of the pelvis are rated with the lumbar spine: 38 CFR § 4.45 says they are "ratable on disturbance of lumbar spine functions," and sacroiliac injury is DC 5236 under the spine formula.
• Nerve findings in the leg. Note (1) to the spine formula says to evaluate "any associated objective neurologic abnormalities" separately. That is a radiculopathy or sciatica claim, not a hip claim.
• A condition of the hip. If an exam and hip imaging show a condition of the hip itself, such as osteoarthritis or greater trochanteric pain syndrome, it can be service connected secondary to the back and rated under the hip codes.

VA will not rate the same pain twice. Under 38 CFR § 4.14, "The evaluation of the same disability under various diagnoses is to be avoided." Board decision A25055221 (June 2025) shows the line: in one decision the Board granted radiculopathy of the right leg secondary to the back and denied both hips, because the records held no hip diagnosis, and an earlier bone scan of the hips and MRI of the right hip were normal. Board decisions are not precedential, but they show how the Board reasons.

How VA decides hip pain secondary to back pain

Secondary service connection is in 38 CFR § 3.310. VA grants it in two ways.

• Caused by. Your service-connected back condition caused the hip condition, at least as likely as not.
• Aggravated by. Your hip condition is aggravated by your service-connected back condition, meaning it would be less severe but for the back condition (M21-1 V.ii.2.D). VA rates only the part above the baseline, so the opinion should describe the baseline: how the hip was before the worsening, from the earliest medical evidence. The text of § 3.310(b) still mentions natural progress, but VA's current manual no longer applies that part, and the worsening does not have to be permanent.

The claim needs three things in the file: a current hip diagnosis, a service-connected back condition, and a medical opinion linking the two with reasoning. Without a hip diagnosis there is nothing to rate, and with one, the opinion decides the claim.

VA rating for hip pain secondary to back pain

The hip is rated under 38 CFR § 4.71a on measured motion, separately from the back. These are the common codes.

• DC 5252, limitation of flexion of the thigh: 40% when flexion is limited to 10°, 30% at 20°, 20% at 30°, 10% at 45°
• DC 5251, limitation of extension of the thigh: 10% when extension is limited to 5°
• DC 5253, impairment of the thigh: 20% when abduction is lost beyond 10°; 10% when you cannot cross your legs; 10% when you cannot toe-out more than 15° on the affected leg
• DC 5003, degenerative arthritis: arthritis shown on X-ray is rated on limitation of motion, and when that limitation is noncompensable, 10% applies to the hip as a major joint if the limitation is "objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion"

Ankylosis (DC 5250), a flail joint (DC 5254) and femur impairment (DC 5255) carry higher ratings, and a replacement is rated under DC 5054. The hip VA rating page covers those.

Painful motion counts. Section 4.59 states the intent "to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint." Section 4.40 says "a part which becomes painful on use must be regarded as seriously disabled," and § 4.45 counts weakened movement, excess fatigability, pain on movement and "disturbance of locomotion."

The hip and back ratings combine under 38 CFR § 4.25, larger rating first. A 20% back rating and a 10% hip rating combine to 28, because the 10% takes its share of the remaining 80. VA rounds 28 to 30%. If both hips are granted at compensable levels, the bilateral factor in § 4.26 adds 10% of their combined value before they combine with the back.

The C&P exam for hip pain secondary to back pain

The examiner is asked whether your hip condition is at least as likely as not caused by your back condition and, separately, whether the back aggravated it. An opinion that answers only the first question is inadequate under El-Amin v. Shinseki (2013).

A careful examiner does these things.

• Confirms a hip diagnosis with a hip exam and hip imaging, not lumbar imaging alone.
• Measures hip motion, including after repeated use. Section 4.59 says joints "should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint."
• Records your gait, posture and pelvic position, and asks how long you have walked or stood differently.
• Reviews other causes, such as age, an old hip injury, heavy work and weight.

Watch for two weak rationales: "your gait was normal today," and "hip arthritis is from aging." In Board decision A25050135 (June 2025), the VA examiner relied on both. The Board gave more weight to a private opinion that explained how degeneration in the spine tilts the pelvis, how the body compensates by extending the hips, and how that posture, over time, leads to arthritis of the hips. The Board called that opinion thorough, with a complete rationale supported by medical literature, and granted both hips. In my read, a gait seen on one day does not show how you have moved for years. C&P exam prep can help you describe your daily limits accurately.

Why hip pain secondary to back pain claims get denied

The gaps that lead to a denial are predictable.

• There is no hip diagnosis, or the only imaging is of the spine, so the pain is treated as part of the back.
• The only medical opinion is a negative VA opinion, and nothing in the file answers it.
• A private opinion states that the back altered your gait without explaining how, for how long, or why that would injure the hip.
• No opinion addresses aggravation, or the opinion skips the other causes in your file.

Nexus letter for hip pain secondary to back pain

A strong nexus letter for this claim does six things.

1. States that the doctor reviewed your records, including hip imaging, your back treatment and any notes on gait or posture.
2. Names the hip diagnosis and explains why it is a hip condition rather than pain referred from the spine: the exam findings, the imaging and, if done, the response to a hip joint injection.
3. Gives an opinion on causation: your hip condition is at least as likely as not caused by your service-connected back condition.
4. Gives a separate opinion on aggravation: your hip condition is aggravated by your service-connected back condition, meaning it would be less severe but for the back condition, and describes the baseline.
5. Explains the mechanism in your case, such as pelvic tilt, posture, a limp or years of favoring one side, and cites the research, including what it does not settle.
6. Deals with the other causes in your file directly.

These opinions break down on a conclusion with no reasoning, a review that missed the hip imaging, or silence on aggravation. Raven Nexus can organize your records and the research into a draft for your doctor to review. If your knees are also service connected, see hip pain secondary to knee pain, and for every condition claimed secondary to the back, see secondary conditions to back pain.

Questions veterans ask about hip pain secondary to back pain

What is the VA rating for hip pain secondary to back pain?

The hip is rated on its own under the hip codes, such as DC 5252 (10 to 40%) or DC 5003 for arthritis, and then combines with your back rating under 38 CFR § 4.25.

Can hip pain from my back get its own rating?

Not as a hip rating. Pain that radiates from the spine is part of the back rating, and nerve findings in the leg are rated separately as radiculopathy. The hip gets its own rating only when there is a diagnosed hip condition.

Do I need a hip X-ray or MRI for this claim?

You need a hip diagnosis, and imaging of the hip is the usual way to show one. Lumbar imaging alone invites a finding that the pain comes from the spine.

Is sciatica the same as hip pain secondary to my back?

No. Sciatica is a nerve problem from the spine, rated under the nerve codes. A hip claim needs a condition of the hip itself.

Can I claim both hips secondary to my back?

Yes, if each hip has a diagnosis and the opinion addresses each one. When both hips have compensable ratings, the bilateral factor applies.

Sources

• 38 CFR § 3.310, secondary service connection; M21-1 V.ii.2.D, aggravation of a nonservice-connected disability by a service-connected one.
• 38 CFR § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (including Note (1) and DC 5236) and DCs 5003, 5054 and 5250 to 5255; 38 CFR §§ 4.14, 4.25, 4.26, 4.40, 4.45 and 4.59 (eCFR text as of October 1, 2026).
• El-Amin v. Shinseki, 26 Vet. App. 136 (2013), an opinion must address aggravation.
• Offierski CM, MacNab I. Hip-spine syndrome. Spine. 1983;8(3):316-321. PMID 6623198.
• Segal NA, Felson DT, Torner JC, et al. Greater trochanteric pain syndrome: epidemiology and associated factors. Archives of Physical Medicine and Rehabilitation. 2007;88(8):988-992. PMID 17678660.
• Tortolani PJ, Carbone JJ, Quartararo LG. Greater trochanteric pain syndrome in patients referred to orthopedic spine specialists. Spine Journal. 2002;2(4):251-254. PMID 14589475.
• Morimoto T, Kitajima M, Tsukamoto M, et al. Sagittal spino-pelvic alignment in rapidly destructive coxarthrosis. European Spine Journal. 2018;27(2):475-481. PMID 28840349.
• Smith JA, Stabbert H, Bagwell JJ, et al. Do people with low back pain walk differently? A systematic review and meta-analysis. Journal of Sport and Health Science. 2022;11(4):450-465. PMID 35151908.
• Pirkle S, Bhattacharjee S, Reddy S, et al. Does lumbar spine fusion predispose patients to future total hip replacement? Journal of Neurosurgery: Spine. 2021;35(5):564-570. PMID 34359035.
• Yukawa Y, Kato F, Kajino G, et al. Groin pain associated with lower lumbar disc herniation. Spine. 1997;22(15):1736-1739. PMID 9259784.
• Oikawa Y, Ohtori S, Koshi T, et al. Lumbar disc degeneration induces persistent groin pain. Spine. 2012;37(2):114-118. PMID 21270682.
• Brown MD, Gomez-Marin O, Brookfield KF, Li PS. Differential diagnosis of hip disease versus spine disease. Clinical Orthopaedics and Related Research. 2004;(419):280-284. PMID 15021166.
• Maldonado DR, Mu BH, Ornelas J, et al. Hip-Spine Syndrome: The Diagnostic Utility of Guided Intra-articular Hip Injections. Orthopedics. 2020;43(2):e65-e71. PMID 31881085.
• Board of Veterans' Appeals citations A25055221 (June 25, 2025, hips denied, radiculopathy granted) and A25050135 (June 6, 2025, granted). Board decisions are not precedential.
• Board figures on this page: Claim Raven's read of every Board decision from 2021 to 2026 that it holds, and of every decision since 1992 for the longer view.