Understanding referred pain and root-cause physical therapy

If you’re struggling with persistent pain despite physical therapy, there’s a reason. It’s not always about where it hurts.

A few weeks ago, a new client reached out to me with shoulder pain that seemed typical—aching, painful overhead movements, and difficulty paddling. This client had already tried the usual remedies:

• Ice
• Rest
• Shoulder stretches
• Massage
• Rotator cuff strengthening exercises

But despite all their efforts, the pain lingered.

Here’s the key takeaway: the real issue wasn’t the shoulder at all.

Pain Isn’t Always Where the Problem Is

In pain physical therapy, one of the biggest misunderstandings is that pain always originates at the site of the symptom. In reality, referred pain is often to blame.

Referred pain occurs when pain is felt in one part of the body, but the actual problem is somewhere else.

Pain is your body’s alarm system, but like any alarm, it doesn’t always tell you exactly where the problem is. It simply signals that something is wrong.

When we only treat the painful area without identifying the root cause, we risk missing the full picture.

What Is Referred Pain in Physical Therapy?

Referred pain is the phenomenon where pain manifests in one location, but the dysfunction actually comes from somewhere else. Some common examples I see in pain physical therapy include:

• Shoulder pain originating from mid-back stiffness or core instability
• Knee pain caused by hip weakness or poor ankle mobility
• Foot pain resulting from a past ankle injury
• Low back pain triggered by poor rib mobility, shallow breathing, or core-pelvic coordination

The key here is that pain is often a symptom of something deeper in the body. When we treat only the symptom, we overlook the real cause.

The Shoulder Pain That Wasn’t a Shoulder Problem

Back to my client’s case. After a comprehensive pain physical therapy assessment, we discovered that the real cause of their pain wasn’t their shoulder. Instead, it was their thoracic spine (mid-back), which lacked mobility, combined with poor core activation and restricted breathing.

Every time they paddled or reached overhead, their shoulder had to overcompensate, doing the work that should’ve been shared with other parts of the body.

So, instead of focusing directly on the shoulder, we worked on:

• Increasing rib mobility and spinal rotation
• Improving core stability to support shoulder movement
• Strengthening the shoulder to heal the tissues and support the entire system

Within weeks, they were paddling again with no pain—and most importantly, sleeping better at night.

The Power of Root-Cause Physical Therapy

This is the heart of pain physical therapy. Real healing comes from understanding the body as a connected system, not just a collection of isolated parts.

Instead of chasing symptoms, we focus on finding out what’s not moving well, what’s compensating, and what’s truly causing the pain.

At Evolve Hawaii PT, we take a root-cause approach. That means we assess your entire movement pattern to get to the bottom of the problem, not just slap a band-aid over it.

How Do You Know If Your Pain Isn’t the Whole Story?

If you’ve been to physical therapy and you’re still dealing with persistent pain, it might be time to consider that the issue isn’t where you feel it.

Here are some signs that your pain might be referred from another part of the body:

• The pain moves around or changes location
• You’ve had a similar issue on the opposite side of the body
• You’ve experienced past injuries or surgeries, even years ago
• Certain movements feel off or asymmetrical
• You’ve treated the pain directly with minimal improvement

If any of these resonate with you, it might be time to dig deeper into your pain physical therapy journey.

Want to Get to the Root of Your Pain?

You deserve more than just temporary relief. If you’re tired of treating symptoms and want to understand what’s truly causing your pain, I’m here to help.

🌀 Book your free consult here to explore how we can finally get to the root cause of your pain. No pressure—just a chance to discuss your story and find out what’s possible.