Why Isn’t the Place That Hurts Always Where the Problem Is Coming From?

Have you ever had pain in one area, only to have your osteopath start assessing somewhere else?

If your shoulder hurts, it makes sense to assume the problem must be your shoulder. And sometimes it is. But not always.

Where you feel pain gives us useful information, but it doesn’t necessarily tell us exactly which structure is contributing to it.

How can pain come from somewhere else?

One reason is something called referred pain.

Referred pain is pain felt in a different area from the tissue or structure thought to be contributing to it. For example, some problems involving the neck can produce pain around the shoulder, shoulder blade or arm (Katsuura et al., 2020).

Part of the explanation lies in how our nervous system processes information. Signals from different tissues can converge along shared pathways within the nervous system. This can make it difficult for the brain to identify exactly where a signal originated, so pain may be perceived somewhere other than its source (Jin et al., 2023).

So, the place that hurts still matters... it just isn't always the whole story.

Does that mean the painful area isn’t actually the problem?

No.

If your knee hurts, I’m still going to assess your knee.

Sometimes the painful area is the main area we need to focus on. Sometimes another region may be contributing. And sometimes there are several things worth considering at the same time.

This is why I’m cautious about statements like “your back pain is actually coming from your hips” without properly assessing someone first.

Pain location gives us one piece of information. Your history, symptoms and examination give us the rest.

What about pain that travels down the arm or leg?

This is where I want to know exactly what you mean when you say your pain “travels”.

Pain extending into an arm or leg can sometimes be referred pain, but it can also involve irritation or sensitivity of a nerve.

These aren't necessarily the same thing.

For example, pain associated with a lumbar nerve root can extend from the lower back into the leg. Depending on the presentation, there may also be symptoms such as tingling, numbness, changes in strength or altered reflexes (Knezevic et al., 2021).

That distinction matters because it changes what I assess and, potentially, how we manage it.

Can other areas of the body contribute to pain?

Yes, but I prefer the word contribute rather than automatically saying another area has caused the pain.

Let’s use hip pain as an example.

If your hip hurts when you run, I’ll assess the hip itself. But I’ll probably also want to know what happens when you squat, how strong the area is, what your running currently looks like and whether your training has recently changed.

I might assess other areas as well if there’s a reason to.

That doesn’t mean I’m searching for a hidden dysfunction or something that needs to be “put back into place”. I’m looking for findings that are relevant to your presentation and, importantly, things we can actually do something about.

Current recommendations for musculoskeletal pain support looking beyond a single painful structure. A good assessment considers the person’s symptoms, physical findings, general health, activity, goals and other factors that may be relevant to their recovery (Lin et al., 2020).

Why does an osteopath assess more than the painful area?

Because I want to understand how the pieces fit together.

If you come in with shoulder pain, I’ll look at your shoulder movement and strength. Depending on what you tell me, I may also assess your neck, upper back or neurological function. There can be considerable overlap between symptoms arising from the shoulder and cervical spine, which is one reason differentiating between them is important (Katsuura et al., 2020).

If you come in with knee pain, I might want to see what happens at your hip and ankle, or watch you perform the movement that actually bothers you.

I’m not looking for a perfectly aligned body.

I’m trying to answer more useful questions:

What reproduces your symptoms?

What makes them feel better?

What are you finding difficult to do?

Is there anything in the assessment that helps explain that?

And what can we work on that might actually help?

That information is much more useful to me than treating one sore spot in isolation.

What does this mean for treatment?

Treatment depends on what we find.

Sometimes I may treat the painful area directly. Sometimes another area is relevant as well. Your plan might also involve working on strength or mobility, modifying something temporarily, or gradually building your tolerance back up to an activity.

And sometimes the assessment tells me that your symptoms need further investigation or input from another health professional.

There isn’t a rule that says the “real problem” must be somewhere other than where you hurt.

The aim is simply to understand your presentation well enough to make a sensible plan.

Pain somewhere that doesn’t quite make sense?

If you’ve had pain that keeps returning, seems to move around, travels into another area or just hasn’t responded the way you expected, it may be worth having it assessed.

You’re welcome to book an osteopathy appointment with me in Burleigh Waters.

References

Jin, Q., Chang, Y., Lu, C., & Chen, L. (2023). Referred pain: characteristics, possible mechanisms, and clinical management. Frontiers in Neurology, 14, 1104817. https://doi.org/10.3389/fneur.2023.1104817

Katsuura, Y., Bruce, J., Taylor, S., Gullota, L., & Kim, H. J. (2020). Overlapping, masquerading, and causative cervical spine and shoulder pathology: A systematic review. Global Spine Journal, 10(2), 195–208. https://doi.org/10.1177/2192568218822536

Knezevic, N. N., Candido, K. D., Vlaeyen, J. W. S., Van Zundert, J., & Cohen, S. P. (2021). Low back pain. The Lancet, 398(10294), 78–92. https://doi.org/10.1016/S0140-6736(21)00733-9

Lin, I., Wiles, L., Waller, R., et al. (2020). What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: Systematic review. British Journal of Sports Medicine, 54(2), 79–86. https://doi.org/10.1136/bjsports-2018-099878