Hip Pain Secondary to Knee Pain

If your knee is service connected and your hip has started to hurt, you can claim the hip as secondary to the knee. The theory is compensation: a painful or stiff knee changes how you walk and how your weight falls, and over years another joint carries the difference. VA rates the hip only for a diagnosed hip condition, such as osteoarthritis or greater trochanteric pain syndrome, so the claim needs a hip diagnosis and a medical opinion that explains the link. This page covers what the research shows, how VA decides and rates the claim, and what that opinion has to say.

Can knee pain cause hip pain?

The research supports the idea that arthritis in one leg joint changes the load on the others. The replacement and gait data point mostly to the hip on the opposite leg, and the evidence rests on small gait studies and observational cohorts.

• In a referral center's records of 900 patients with osteoarthritis who had a first hip or knee replacement (Shakoor and colleagues, Arthritis and Rheumatism, 2002), when the next joint replaced was not the matching joint, it was more than twice as likely to be on the opposite leg as on the same leg, including from knee to hip. Patients with rheumatoid arthritis showed no such pattern, which the authors read as a sign that the spread of osteoarthritis may be driven by factors such as altered joint loading.
• A gait study of 20 patients with arthritis in one knee and 20 people without (Metcalfe and colleagues, Gait and Posture, 2013) found higher loading at both knees and at the opposite hip. A year after knee replacement, the abnormal loading of the other leg had recovered only partly or not at all in most of the 14 patients followed up.
• In 3,026 adults aged 50 to 79 in the Multicenter Osteoarthritis Study (Segal and colleagues, Archives of Physical Medicine and Rehabilitation, 2007), knee osteoarthritis went with higher odds of greater trochanteric pain syndrome, pain over the outer hip: odds ratio 3.47 for the same side and 1.74 for the opposite side. The authors said altered lower-limb mechanics may be involved and that a longitudinal study is needed to identify causes.
• A 2019 review of 32 studies (Iijima and colleagues, Journal of Biomechanics) found that people with knee osteoarthritis lean the trunk toward the side of the affected knee and change the forces at the hip when they walk. The authors suggested this might weaken the hip abductor muscles, called for studies to test it, and graded the evidence very low.
• Amputation, the most extreme form of uneven loading, goes with more hip arthritis in the other leg. Among 78 people who had lost one leg in an accident at least 5 years earlier (Struyf and colleagues, Archives of Physical Medicine and Rehabilitation, 2009), 14% had osteoarthritis in the hip of the intact leg, far above general population rates. An amputation is a much larger change than a bad knee, so this shows the principle, not the size of the risk.
• Leg length can matter, but the evidence is mixed. In two large cohorts (Kim and colleagues, Arthritis and Rheumatology, 2018), a leg at least 2 cm shorter than the other had higher odds of new hip osteoarthritis (odds ratio 4.20), but only 1% of participants had that much difference. In a community cohort (Golightly and colleagues, Journal of Rheumatology, 2010), the higher risk of hip arthritis with a leg length difference was not statistically significant.

In my read, the research points to the hip on either side, with the replacement and gait data leaning toward the opposite leg, so an opinion should say which hip and why. None of these studies proves that one veteran's knee caused one hip condition. A doctor has to connect the research to your history.

How VA decides hip pain secondary to knee pain

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

• Caused by. Your service-connected knee condition caused the hip condition, at least as likely as not.
• Aggravated by. Your hip condition is aggravated by your service-connected knee condition, meaning it would be less severe but for the knee condition (M21-1 V.ii.2.D). VA rates only the part above the baseline, so the opinion should describe the baseline, from the earliest medical evidence of the hip's severity before the worsening. 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 knee condition, and a medical opinion linking the two with reasoning. Hip pain on its own is not enough. If your back is also service connected, pain felt in the hip may come from the spine; hip pain secondary to back pain explains how VA tells the two apart.

VA rating for hip pain secondary to knee pain

The hip is rated under 38 CFR § 4.71a on measured motion, separately from the knee. 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: rated on limitation of motion, and when that limitation is noncompensable, 10% for the hip as a major joint if it is "objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion"

Ankylosis, a flail joint, femur impairment and hip replacement (DC 5054) are covered on the hip VA rating page. Painful motion counts: § 4.59 treats "actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint," § 4.40 says "a part which becomes painful on use must be regarded as seriously disabled," and § 4.45 counts pain on movement, excess fatigability and "disturbance of locomotion."

The hip and knee ratings combine under 38 CFR § 4.25, larger rating first. On the same leg, a 10% knee and a 10% hip combine to 19, which rounds to 20%. On opposite legs, the bilateral factor in § 4.26 applies, because it covers compensable disabilities of both legs "regardless of location or specified type of impairment." A 30% right knee and a 20% left hip combine to 44; adding 10% of 44 gives 48.4, and if those are your only ratings, VA rounds to 50%. Without the bilateral factor, 44 would round to 40%.

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

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

A careful examiner looks at these things.

• A hip diagnosis from a hip exam and hip imaging
• Which hip is affected, and how that fits the way you favor your knee
• How long you have limped or used a brace, cane or crutches, and any measured leg length difference
• Hip motion tested as § 4.59 directs: "on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint"
• Other causes, such as age, weight, an old hip injury and heavy work

Watch for a VA opinion that says the knee and hip are separate systems, or that a knee condition does not put more strain on the hip. In Board decision A25051587 (June 2025), the Board relied on an opinion like that, nothing in the file answered it, and the Board denied both hips. The gait studies above are the kind of evidence a private opinion can use to answer it. C&P exam prep can help you describe how the knee changes the way you walk.

Why hip pain secondary to knee pain claims get denied

The gaps that lead to a denial are predictable.

• There is no hip diagnosis, only hip pain.
• The only medical opinion is a negative VA opinion, and nothing in the file answers it.
• A private opinion says the knee altered your gait but does not explain how, for how long, or why that would damage the hip.
• The opinion does not say which hip, or the side does not fit the theory.
• No opinion addresses aggravation, or the opinion skips weight, age or an old hip injury in your file.

Nexus letter for hip pain secondary to knee pain

A strong nexus letter for this claim does six things.

1. States that the doctor reviewed your records, including the knee history, hip imaging, and notes on gait, braces or canes.
2. Names the hip diagnosis and which hip, and explains why the side fits the way you favor your knee.
3. Gives an opinion on causation: your hip condition is at least as likely as not caused by your service-connected knee condition.
4. Gives a separate opinion on aggravation: your hip condition is aggravated by your service-connected knee condition, meaning it would be less severe but for the knee condition, and describes the baseline.
5. Explains the mechanism, such as a limp, shifted weight or a shorter leg, with the time course, and cites the research, including its limits.
6. Deals with the other causes in your file directly.

Board decision A25031203 (April 2025) shows what works. The Board granted both hips secondary to a service-connected right knee on a private opinion that reviewed the whole file, explained how the knee pain produced a limp and an altered center of gravity that put more force through the other joints, tied specific medical literature to the veteran's case, and addressed both causation and aggravation. The file also held two negative VA opinions; the Board found the private opinion persuasive and resolved reasonable doubt in the veteran's favor. Board decisions are not precedential, but they show what the Board accepts. Raven Nexus can organize your records and the research into a draft for your doctor to review. If the knee also affects your back, see back pain secondary to knee pain, and for every condition claimed secondary to the knee, see secondary conditions to knee pain.

Questions veterans ask about hip pain secondary to knee pain

Can I get VA disability for hip pain secondary to my knee?

Yes, if you have a diagnosed hip condition and a medical opinion that links it to your service-connected knee. VA grants it under 38 CFR § 3.310 when the knee caused the hip condition or made it worse.

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

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

Can my right knee cause problems in my left hip?

It can. Joint replacement records and gait studies point to extra load on the opposite leg, and the opinion should explain the side in your case.

Does the bilateral factor apply to a knee and a hip?

Yes, when they are on opposite legs and both are compensable. Section 4.26 applies to compensable disabilities of both legs regardless of which joint is involved.

Do I need a hip diagnosis, or is hip pain enough?

You need a diagnosis. VA rates the hip for a hip condition shown on exam and imaging, not for pain alone.

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, DCs 5003, 5054 and 5250 to 5255; 38 CFR §§ 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.
• Shakoor N, Block JA, Shott S, Case JP. Nonrandom evolution of end-stage osteoarthritis of the lower limbs. Arthritis and Rheumatism. 2002;46(12):3185-3189. PMID 12483722.
• Metcalfe A, Stewart C, Postans N, et al. Abnormal loading of the major joints in knee osteoarthritis and the response to knee replacement. Gait and Posture. 2013;37(1):32-36. PMID 22841587.
• 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.
• Iijima H, Shimoura K, Ono T, et al. Proximal gait adaptations in individuals with knee osteoarthritis: A systematic review and meta-analysis. Journal of Biomechanics. 2019;87:127-141. PMID 30904334.
• Struyf PA, van Heugten CM, Hitters MW, Smeets RJ. The prevalence of osteoarthritis of the intact hip and knee among traumatic leg amputees. Archives of Physical Medicine and Rehabilitation. 2009;90(3):440-446. PMID 19254609.
• Kim C, Nevitt M, Guermazi A, et al. Brief Report: Leg Length Inequality and Hip Osteoarthritis in the Multicenter Osteoarthritis Study and the Osteoarthritis Initiative. Arthritis and Rheumatology. 2018;70(10):1572-1576. PMID 29700988.
• Golightly YM, Allen KD, Helmick CG, et al. Hazard of incident and progressive knee and hip radiographic osteoarthritis and chronic joint symptoms in individuals with and without limb length inequality. Journal of Rheumatology. 2010;37(10):2133-2140. PMID 20634243.
• Board of Veterans' Appeals citations A25031203 (April 4, 2025, granted) and A25051587 (June 11, 2025, denied). 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.