One-Sided Low Back Pain Isn’t Always a “Low Back Problem”

(Why looking upstream changes everything)

If you’ve ever had one-sided low back pain—especially when it’s teamed up with a tight hip, a cranky knee, or even one-sided plantar fasciitis—you’ve probably been told some version of:

“Your low back is tight. Let’s loosen it up.”

And sure… that can help.

But what I’ve noticed after practicing for 24 years is this: we often aren’t looking upstream. We follow the same old template—“low back protocol,” regardless of technique—and then prescribe generic, non-targeted exercise. Meanwhile, the body keeps replaying the same mechanics.

To be fair, physical therapy often does address upstream contributors—especially hip strength, gait mechanics, ankle mobility, and core control. The challenge is that many healthcare systems still default to region-based protocols (a “low back program for low back pain”), which can miss the specific torsion driver in your chain.

When that happens, care can reduce symptoms without fully changing the pattern that keeps recreating the same one-sided overload.

The pattern I see again and again

For many people, the foundation looks like this:

• An overcontracted hip flexor group (front-of-hip + lower abdominal chain)

• One weaker glute because those hip flexors are doing too much of the stabilizing

• Uneven load-sharing through the pelvis

• The low back, hip, and knee take extra stress as a result

This is why some people feel great right after care… and then the same side flares again a day or two later. It’s not that anything “failed.” It’s that the body is still running the same compensation pattern.

The hip flexor group is rarely “just one muscle”

When I say “hip flexors,” I’m not talking about one simple tight spot.

Often, it’s a whole front-of-hip contraction pattern, including:

• psoas major (and psoas minor when present)

• iliacus

• rectus femoris (the quad that crosses the hip)

• TFL (tensor fascia lata)

• sartorius

• pectineus

• and often adductors, especially when they start acting like hip flexor helpers

When this group is chronically tight, it changes how the pelvis sits and rotates—and that changes how the glute on one side can activate.

A glute that can’t turn on doesn’t stabilize well.

A hip that doesn’t stabilize well forces the low back to compensate.

And the knee ends up receiving load it was never designed to handle.

Why the knee is often “in the story,” but not the author

Patients often point to the knee because the knee is loud. But in many cases, the knee is reacting to what’s happening above it (or below it).

If hip stabilization and pelvic mechanics are off, the knee becomes the stress collector. Treating the knee directly can help symptoms, but it’s often not the whole fix if the driver lives higher in the chain.

A sneaky trigger most people forget: mild ankle injuries

One of the most overlooked upstream triggers is an ankle injury.

People rarely think a “barely rolled ankle” counts as a real injury—especially if they didn’t break anything or it's been decades since they injured it.

But even mild sprains can subtly change gait timing and weight-bearing patterns. The body adapts… and months or years later you’ve got one-sided low back pain, a hip that never feels right, and a knee that gets irritated with stairs—without anyone connecting it back to the ankle.

The pelvis is not a brick. It’s a dynamic ring.

The pelvis isn’t just bones. It’s a ring influenced by joints, muscles, and fascia (connective tissue). And sometimes pelvic imbalance isn’t just about “tight muscles.”

The pelvis can twist due to:

• abdominal surgeries (scar tension and fascial drag)

• old trauma

• chronic stress patterns in the pelvic/abdominal region

• metabolic hyperdrive of organs within the pelvic cavity

Organs and structures such as the bladder, prostate, uterus, ovaries, colon, appendix, and the peritoneal cavity can contribute to tension patterns that pull on fascia and alter pelvic mechanics.

And here’s a key point:

You can’t correct a traction pattern with posterior spinal work alone.

If the driver is pulling from the front and deep within the pelvic bowl, simply working the posterior spine may calm symptoms—but it may not remove the underlying torsion.

A common clinical clue: the “other side” often feels tighter

One of the most consistent findings I see:

The SI joint on the opposite side of the pain tends to feel tighter.

That surprises people—until it clicks: when one side can’t function well, the other side works harder and takes more weight. The painful side may be the side doing overtime, not the side that’s “most stuck.”

The bigger idea: this is a torsion pattern in a connected chain

These symptoms often live on one connected chain. The issue isn’t just where it hurts—it’s where the torsion pattern starts.

When we correct the origin of that torsion—often involving hip flexor overcontraction, pelvic imbalance, and glute inhibition—the downstream tissues (including fascial tension patterns) stop needing to compensate as aggressively.

That’s when results start to hold.