Remember the song “Dem Bones” from when we were kids? It goes something like, “the backbone’s connected to the hip bone, the hip bone’s connected to the thigh bone, the thigh bone’s connected to the knee bone, the knee bone’s connected to the shin bone…”

While we may associate this song with primary school, there is actually some truth to it (even with the questionable bone-naming).

From our spine all the way down to our ankles, our bones and muscles work together to propel our movements each day. That’s why, if we are experiencing knee pain, it could be associated with an ankle injury or even a tight hip flexor muscle: They’re all interconnected.

When we think about how our body works, especially our lower extremities, we often overlook how interconnected our feet, ankles, knees, hips, and lower back are. But, if your ankle is damaged, it almost always leads to knee and hip pain down the line.

Having ongoing lower back and hip pain can be a symptom or cause of other complications, and can even lead to additional surgeries if left untreated. Understanding how joints and muscles interact as a unit can help you manage your pain following lower back, knee, or foot surgery.

Why do I have pain after surgery?

Surgery is seen as a threat to the body, no matter what kind of surgery. Undergoing surgery takes a significant toll on your overall health, and your muscle-joint interactions as well.

Threats like surgery or injury often cause your muscles to tighten, as an instinctive protective mechanism. During your recovery, your body is likely more stationary than usual as you heal. Your normal walking movements will be altered or assisted, and your muscles won’t engage as readily or in the same fashion as usual, especially if you are experiencing pain. Add-in sleep challenges and increased pain, and it’s natural for your body to want to tighten the iliopsoas muscle and protect the pelvis.

You may have heard of the iliopsoas muscles under a different name: your hip flexors. The iliopsoas muscle is made up of two muscles, the iliacus and the psoas, which work together to perform important movements like walking, sitting, and standing.

The iliacus crosses over your hip joint and attaches to the pelvis, whereas the psoas crosses both the hip joint and pelvis to the spine. If these muscles tighten, they can pull the region off balance by creating a tilt or twist, which can affect your whole lower body and cause lower back and hip pain.

With all the stress your body is going through after surgery, your iliopsoas muscles may tighten to try to support and protect the injured area. Unfortunately, the lower back and hip pain that often accompanies this protective act can be confusing and frustrating when it adds extra pain to your recovery.

But if you had a knee or foot surgery…why are you experiencing lower back and hip pain instead of knee or foot pain? Let’s take a look at how it all connects.

The connection between the lower back and hip pain

Your body is an intricately connected, well-oiled machine. When one piece stops working properly, it affects just about everything. You need your bones for support, your joints to connect them, and all your muscles, tendons, and ligaments to move in the wonderful ways you do.

When one part of the body is injured, weak, loose, or too tight, it impacts how the rest of your body works. That’s why even when you have knee surgery, it can create lower back and hip pain.

The lower back and your hip pain are especially interconnected because of the iliopsoas muscle and the piriformis muscle. If one is too tight, it will add tension to the other, and if one part of your low back or hip is weak, both muscle groups will overcompensate and tighten to protect it.

Since the psoas connects to the spine and works hard to stabilize the back, and the iliacus connects to the pelvis to help stabilize the hip and sacroiliac joint, they’re a primary foundation for both your back and hips.

After surgery, especially hip or knee surgery, your iliopsoas is at a very high risk of tightening and causing an anterior pull. That tug on your pelvic bone strains the connection between your pelvis and tailbone, particularly where the two bones meet.

That junction is known as the sacroiliac or SI joint, and when added tension is put in that area, it gets twisted and irritated, causing lower back and hip pain. If you’re not feeling pain in the SI joint area, then the next most commonly affected joint junction is the hip joint.

The hip socket (acetabulum) cradles your femur (thigh bone) to allow a perfect fit and comfortable movements. When an anterior rotation begins with your pelvis, the thigh bone no longer sits well into the hip socket, and can cause friction or even pull the hip joint out of place.

With or without anterior or internal pelvic rotation, your psoas could also be tightening along with your iliacus. Since the psoas muscle attaches to the front of the thigh bone and the spine at the lower back, it has a similar chain reaction effect as the iliacus muscle as it tightens.

If you have a tight psoas, you are likely to feel a reaction down the leg and up to the spine, but the majority of the tension and pain will be on the spine itself.

A tight psoas muscle pulls your spine into an arched position. This compresses and bends the spine to the side that is being pulled by the psoas. All of the tension and tugging of that part of your spine can easily cause lower back and hip pain.

Leg pain after lower body surgery

Just as with the lower back and hip pain connection, pain from hip to knee is a common issue. An unhealthy iliopsoas, and more specifically an unhealthy iliacus, has a profound effect on pain from hip to knee – as well as the rest of the body overall.

Because a tight iliacus muscle twists the hip and thigh bone, it anatomically changes how your leg connects to your upper body. When the tension in your iliacus muscle is released, your leg and hip alignment will work as designed, but you are far more susceptible to pain when it is tight.

Although the direct connection between pain from hip to knee appears to be with a tight iliacus, that doesn’t mean that the psoas muscle should be ignored completely. After all, together, they form the iliopsoas, so if one is tight, the other is directly affected.

When strain is put on your iliopsoas, it can create a pelvic rotation as the muscle pulls and tightens. This can be either an anterior or internal rotation. Your pelvis’s internal rotation is what could potentially connect hip to knee pain and knee to foot pain.

You can also experience an internal rotation that puts a strain on your knee. An internal rotation of your pelvis affects the way your leg works from the hip down and doesn’t allow the kneecap to track correctly. This internal rotation can also cause the foot to flatten (or pronate), which changes how your foot and toes are aligned.

As you can see, when one area of your body is affected, it can cause a chain reaction of negative effects throughout your body. And, in the case of your lower body, the culprit for lower back and hip pain and imbalance is often an overactive iliopsoas.

So now that we have found the likely culprit for your lower back and hip pain, or your pain from hip to knee, what is there to do about it?

Addressing lower back and hip pain from tight hip flexors

Because of the likelihood of a chain reaction of lower back and hip pain from tight iliopsoas muscles, it is important to address and release them. There are multiple ways you can do this, including gentle strengthening exercises and stretches, and targeted physical therapy.

Strength training for lower back and hip pain

A big part of targeted physical therapy is balancing and strengthening your muscles to recover from – or prevent – future injury. Something you must remember when you exercise in any capacity is that you need equal strength in all of your muscles.

For instance, if you only exercise your front abdominal muscles and neglect your back core muscles, you are far more likely to injure your back or start to develop back pain from a consistent pull from the front of your abdomen.

The same is true for your legs and hips. Finding ways to work all of your muscles to build strength equally can help your body maintain alignment and balance and prevent lower back and hip pain.

Stretching

Stretching and yoga can be a wonderful way to relieve stress, but it can also help as you recover from surgery. After any type of surgery, you will be slightly more stationary than usual, and that can cause your muscles to tense and tighten more than normal.

When it comes to your iliopsoas muscles in particular, stretching can be beneficial. However, you can have too much of a good thing, and if you stretch too much or too deeply, it can cause more harm than good to your iliopsoas.

If you are stretching too much, your muscles will lengthen during the stretching period. Then, once you’re finished stretching, your muscles will begin to tighten again. Additionally, too much stretching can make your muscles too loose, and your muscles will not fully support your joints.

You may wish to consult a physical therapist or other medical practitioner to help decide which stretches will be most beneficial to your lower back and hip pain.

Muscle relaxation for lower back and hip pain

Taking time to relax is imperative to muscle health. Many of us often only find time to relax at night as we are falling asleep, but if our muscles are engaged throughout the entire day and only have one instance of relaxation, it’s not going to be enough to prevent tension from building.

One of the best ways to relax your iliopsoas is to elevate your legs on a couch or ottoman while laying on the floor. This is a traditional restorative yoga practice and can be done for 15-20 minutes at a time.

Consult your doctor about this exercise if you’ve just had hip surgery, as (depending on the entry angle for your surgery) having your hip at a 90-degree angle is not advised for about 6 months.

Another very accessible way to achieve muscle relaxation is to get a professional therapeutic massage. Deep tissue massages can be great for relieving muscle tightness, but they tend to be more invasive and too intense immediately post-surgery. Opt for a soothing Swedish instead!

Muscle release for lower back and hip pain

Releasing muscle tension can help you resolve your lower back and hip pain, and if you are aware of it before you go into surgery, you could even prevent it altogether.

If you visit a physical therapist, they will likely be aware of the complications associated with a tight iliopsoas muscle. A physical therapist can release some muscle tension during physical therapy appointments by putting pressure on specific muscle connection areas with their hands.

However, that is only helpful if you can attend appointments on a regular basis.

Because I don’t want you to have to wait for a physical therapist to help you every single time, I invented the Hip Hook and Hip Release Ball. These tools allow you to release the iliacus and psoas muscle tension you’re experiencing any time you need from the comfort of home.

The Hip Hook’s unique design gives you the ability to apply precise and angular pressure on the hard-to-reach iliacus muscle. The Hip Flexor Release Ball is the perfect size and density to target and help release the psoas muscle.

You can even learn more about realigning your body and treating unresolved pain in my book, Tight Hip Twisted Core.

As you expand your knowledge of how interconnected your joints and muscles truly are, you can easily prevent and treat lower back and hip pain – as well as unresolved pain throughout your body.

FAQs about lower back and hip pain after surgery:

Why do I have lower back or hip pain after surgery?

Along with periods of immobility following surgery, and changes in movement, your body is protecting itself from the trauma of surgery by tightening your core muscles.

But I had hip surgery; why does my knee hurt?

Your core muscles affect the alignment of your entire lower body. If the psoas and iliacus muscles are tight, they will tug on the entire interconnected line from your back, through your legs, and down to your toes. But you can often trace the source back to tension in those core muscles, even though you’re feeling it in your toe.

Why do my hip flexors hurt?

Your iliopsoas muscles may have tightened to try to support and protect the injured area. They work in opposition to the piriformis muscle (deep in your glutes), and when one muscle is tight they begin tugging on each other.