Solving the Persistent Pain Puzzle PART 4: Why Pain is a Liar!


Why Pain is a Liar!

Pain really is a liar when you consider a few well established facts about pain:

  • The location of your pain cannot tell you exactly its source.
  • How your pain feels does not reliably tell you if it’s coming from a muscle, joint, bone or any other structure.
  • For chronic pain the causes are usually located well away from the painful area. This is in stark contrast to acute trauma where pain and injury are usually in the same spot.

Referred Pain and Referred Tenderness – The Ultimate Liars

  • Referred pain is common so for example you may feel pain in the shoulder but the cause is a neck problem.
  • Referred tenderness is a lesser known phenomenon. Patients often present to me with a sore spot which is tender to touch but the cause is actually from elsewhere. In the example above the shoulder muscles are often tender to touch which can confuse a practitioner and patient into thinking the cause is the shoulder, while it’s really the neck.
  • Seeing a practitioner who just rubs, manipulates or massages the sore spot and does not identify or treat the cause is highly unlikely to have any long term effect on your pain.

How Referred Pain, Referred Tenderness and Secondary Trigger Points can Trick You

If referred pain hangs around long enough, the muscles under the area of referred pain may not only exhibit referred tenderness but may also develop secondary trigger points.  These trigger points are painful “knots” in the muscle, and can generate pain by themselves even though the primary cause may lie elsewhere.  In some cases the secondary trigger point pain can become worse than primary pain.

The phenomena of referred tenderness and secondary trigger points in a region of referred pain are diagnostically challenging.  So if your practitioner keeps treating a trigger point and makes it worse or fails to improve it permanently, then chances are they are treating a secondary rather than the primary problem.  In this case treating the primary problem will make treatment of the secondary trigger point much easier and more effective.  The same concept applies to a joint problem – is the joint dysfunction secondary to something else, or the primary underlying cause of your pain?

How Your Neck Pain May be Lying to You

Some examples about how pain really is a liar might illustrate this concept better.  Let’s look at where lots of patients feel neck pain – in the back of their neck and top of the shoulders.  Look at the referred pain diagrams below.  They each show very similar areas of pain, but each one is the area of referred pain proven by research for a different structure (left sided pain shown only – obviously pain can occur on the right or on both sides simultaneously, and the pain areas are “typical”, meaning that as an individual you may experience a slightly different area of referred pain).  There are many other structures which refer pain into the neck / shoulder region, but here are 8 common ones:


Here’s a list of the structures from left to right.   Note how far away from the neck and area of pain some of them are, and how some very small structures (like the facet joints in the neck) can refer large areas of pain.

  1. Respiratory diaphragm
  2. C6/7 facet joint
  3. Cervical multifidus muscle trigger point
  4. Levator scapulae muscle trigger point
  5. C3/4 facet joint
  6. Splenius cervicis muscle trigger point
  7. Liver (organ, esp. liver capsule)
  8. C5/6 facet joint

So don’t believe pain – it’s a liar.  It can’t tell you:

  • What structure is generating the pain (ie the diagnosis);
  • Where the causes are (ie what needs treatment);
  • Whether the pain you feel is secondary or primary (it’s not uncommon for secondary trigger point pain to feel worse than the primary cause!).


So what DOES pain tell you? 

Pain is telling you to take action and see a professional about it.  Don’t leave it to fester away, as the earlier you seek the help the easier and more effectively your pain can be treated.