Unlocking the Mystery of Pain: Why Your Symptoms Might Not Be What They Seem

KEY TAKEAWAYS

• Pain you feel in one place is often driven by a problem somewhere else in the body. This is a well-described idea in physiotherapy called regional interdependence.
• A scan that shows something at the painful spot does not always mean that spot is the source. Imaging findings are common in people with no pain at all.
• Old surgeries, even small ones, can change how you move for years. The scar itself, the muscles that learned to compensate, and the joints that took the extra load all matter.
• Treating only the painful spot is one of the most common reasons chronic pain comes back. A real plan looks above and below the symptom.
• At Unpain Clinic in Edmonton, we use a full-body assessment, focused shockwave for the tissues that need it, and a real exercise plan for the chain around them. We tell you honestly if we are not the right fit.

When something hurts, the instinct is to treat the spot. The neck aches, so you rub the neck. The ankle is sore, so you ice the ankle. For acute injuries that often works. For chronic pain that keeps coming back, it often does not. The reason is that the spot where you feel the pain is frequently not where the problem started. Here is how that actually works, why it matters for treatment, and what we do about it at Unpain Clinic in Edmonton.

WHY DOES PAIN SHOW UP IN ONE PLACE WHEN THE PROBLEM IS SOMEWHERE ELSE?

Bodies are connected. Muscles, joints, fascia, and nerves do not operate in isolation. When one region of the body cannot do its job, other regions step in. That stepping in is called compensation, and it is normal. Over weeks and months, the regions doing the extra work get overloaded. Eventually one of them starts to hurt. That hurting region is rarely where the original problem started.

A clean example: a stiff thoracic spine forces the shoulder and neck to do extra work for overhead motion, which can show up as rotator cuff pain or headaches months later. A weak gluteal muscle on one side can let the pelvis drop with every step, which loads the opposite low back and shows up as a chronic lumbar ache. A surgical scar on the abdomen can change how the deep core engages, which changes how the hip works, which changes how the knee tracks, which can show up as knee pain that orthopedics cannot find a structural cause for.

This pattern is not new. It is one of the more useful concepts in modern physiotherapy. The 2007 editorial in the Journal of Orthopaedic and Sports Physical Therapy by Wainner and colleagues that formalised the idea of regional interdependence put it this way: seemingly unrelated impairments in remote anatomical regions of the body may contribute to, and be associated with, the patient's primary complaint. In plain English, the problem is often not where the pain is.

That principle changes what a good assessment looks like. If you only examine the painful spot, you can miss the actual driver. If you examine the chain around the painful spot, the driver usually becomes visible within a few movement tests.

WHAT IS REGIONAL INTERDEPENDENCE, IN PRACTICE?

Regional interdependence is the formal name for the clinical reality that joints and tissues affect each other up and down the chain. It is the reason a good shoulder assessment includes the thoracic spine and the neck. It is the reason a good low back assessment includes the hips and the ankles. It is the reason a good headache assessment includes the upper neck and the jaw.

In practice, three patterns show up over and over.

• The painful joint is the loudest, but a stiff joint nearby is the loader. Stiff ankles after an old sprain often produce knee pain. A stiff thoracic spine often produces neck and shoulder pain. The painful joint is doing the extra work the stiff joint refuses to do.
• The painful muscle is the overworked one, but a weak muscle is the cause. Hamstring strains often come back when the gluteals are weak. Calf strains often come back when the foot and hip are not pulling their weight. Rotator cuff problems often persist when the scapular and core stabilisers are underactive.
• The painful tissue is the symptom, but the nervous system is part of the story. Chronic pain is not just a tissue problem. It is also a nervous system that has become more sensitive to inputs that used to be quiet. That is why two people with the same imaging findings can have completely different pain. The 2022 review of tendon pain mechanisms in the Scandinavian Journal of Pain lays out how chronic tendon sites end up with abnormal nerve ingrowth into tissue that should not have nerves growing into it. That changes how the area responds, and how it needs to be treated.

HOW DO SURGERIES AND SCAR TISSUE CAUSE PAIN ELSEWHERE IN THE BODY?

This is one of the most overlooked drivers of chronic pain that we see in clinic. A scar from any abdominal or pelvic surgery, even one that healed decades ago, can change how the muscles around it work. A C-section scar, an appendectomy scar, a hernia repair, a laparoscopic site, a gallbladder scar; each of these can leave the deep core slightly less able to fire in coordination than it was before.

The mechanism is not mysterious. Surgery interrupts skin, fascia, and sometimes muscle. The body lays down scar tissue to heal those interruptions. Scar tissue is structurally and mechanically different from the tissue it replaced. It is denser, less elastic, and often less well connected to its neighbours. The brain learns to slightly avoid loading through the area. The deep abdominal muscles fire a fraction of a second late or with less force than they did before. The pelvic floor, the diaphragm, and the low back muscles all subtly recalibrate to make up the difference.

Most of the time this passes without symptoms. Sometimes the recalibration is the start of a chain that produces problems years later. The hip that worked a little harder eventually gets cranky. The low back muscle that took up the slack eventually flares. The neck that started doing more of the breathing eventually feels tight.

The honest framing is this: not every chronic pain is caused by an old scar. But for some patients with chronic pain that has resisted treatment, an old surgical site is part of the picture, and addressing it changes the trajectory. That is something we look at during an assessment, not assume.

WHY DOES THE USUAL APPROACH (REST, MEDICATION, SPOT TREATMENT) OFTEN NOT WORK?

Most of the time, an acute injury heals well with rest, gentle movement, and time. The body is built for that. Chronic pain, by definition, is what is left when the usual healing has not worked. Treating chronic pain like an acute injury is one of the more common reasons it does not resolve.

Three patterns plateau most often.

• Rest without restoration. Resting a painful area calms it down. It does not restore strength, coordination, or load tolerance. If you go back to your normal demands after resting, you are loading a region that is now weaker than when it first got hurt. The pain comes back, often within days.
• Spot treatment without context. Targeting only the painful area can give short-term relief. If the rest of the chain is still loading that area the same way, the relief does not last. The painful spot keeps getting overloaded by the same pattern that caused the problem in the first place.
• Medication as the only intervention. Pain medication can be valuable for short-term use, and it has clear roles in care. As the only intervention for chronic pain, it tends to manage symptoms while the underlying drivers progress. That is not a moral judgement on medication; it is what the natural history of chronic pain shows.

A real plan for chronic pain has to look at the area that hurts and the chain around it. It has to restore strength and coordination, not just dial down sensitivity. And it usually has to address the nervous system component, not only the tissue.

HOW DOES UNPAIN CLINIC FIND THE ACTUAL SOURCE OF PAIN?

A first visit at Unpain Clinic is a 60-minute one-on-one assessment. That length is deliberate. A 15-minute assessment can identify the painful spot. It cannot find the chain driving it.

The assessment usually includes the following.

• A detailed history. What hurts, when it started, what makes it better and worse, what you have tried, what your work and daily life look like, and what surgeries or injuries you have had in the past. Old scars, old fractures, and old injuries are part of the picture even when they feel unrelated.
• A full-body movement screen. We look at how you move, not just where it hurts. Squatting, reaching, bending, single-leg balance, breathing, and a few specific provocations tell us which regions are stiff, which are unstable, and which are compensating.
• A focused exam of the painful region. Range of motion, strength, joint tests, palpation, and any specific orthopedic tests that fit the picture.
• A look at imaging if you have it. We go through any MRI, ultrasound, or X-ray with you and explain what is relevant, what is incidental, and what is not. A finding on a scan is one piece of the puzzle, not the whole answer.

What we put together at the end is not just a diagnosis; it is a model of what is driving your pain and what we think will move it. If our approach is a fit, we explain the plan in plain language: how many visits, what each visit involves, what we expect to see and when, and what you need to do between visits.

HOW CAN SHOCKWAVE THERAPY HELP WITH SCAR TISSUE AND REFERRED PAIN?

Focused shockwave therapy uses acoustic waves, not electricity, delivered through a handheld applicator. The waves transfer mechanical energy through the skin into the targeted tissue, including scars, tendons, and the connective tissue around joints.

For a chronic site, shockwave does several things at once. It improves blood flow to areas that often have low vascularity. It restarts a stalled inflammatory phase that the body needs to remodel tissue. It influences the abnormal nerve and tissue changes that develop in chronic sites. A 2024 systematic review and meta-analysis in BMC Sports Science, Medicine and Rehabilitation covers this across multiple tendinopathies and finds consistent pain improvement compared with sham. A systematic review of shockwave across orthopedic conditions in the British Medical Bulletin concluded that shockwave is a safe modality when applied by trained clinicians.

For an old surgical scar, shockwave can help by mechanically loading the scar and the tissues underneath it. That input changes how the tissue responds and, over time, how the surrounding muscles fire. We do not promise that every old scar produces dramatic results. We do see scars that have been quietly contributing to a chain of compensation respond meaningfully when they are addressed as part of a wider plan.

What shockwave is not is a stand-alone fix. It is one tool in a layered plan that almost always includes manual therapy, exercise, and education. The article on how focused shockwave therapy works goes through the technology in more depth if you want the mechanics.

For some patients with widespread, long-standing pain that has clearly sensitised the nervous system, we add other layers. EMTT uses pulsed electromagnetic fields delivered through a loop applicator over the painful region. NESA neuromodulation targets autonomic regulation more directly through low-intensity stimulation. Both have a place when the picture warrants them, and neither replaces the assessment, the manual work, or the exercise.

“Dr lacina . I have been seeing this wonderful human for the last 12 years . I'm a nurse plus a little clumsy. Initially seen her for a lower back injury from a patient falling on me.. she has helped me on more than one occasion. And I will continue to go back for her expertise... Chiro . Shockwave and IMS”- Miranda Hamilton

WHAT WE DO NOT OFFER

• We do not perform injections of any kind, including cortisone or platelet-rich plasma.
• We do not prescribe oral or topical pain medications. We are physiotherapists and registered massage therapists, not physicians.
• We do not perform surgery. If your situation requires a surgical opinion, we will tell you and refer you to the right specialist.
• We do not promise cures. Most chronic pain improves with the right combination of treatments, but not every case resolves completely. What we offer is an honest assessment, a clear plan, and a team that will tell you if we are not the right fit.

FREQUENTLY ASKED QUESTIONS

Is referred pain the same as regional interdependence?

They are related but not identical. Referred pain usually means pain that is felt in one location but generated by a structure in another (for example, gallbladder pain felt in the shoulder, or hip arthritis felt in the knee). Regional interdependence is broader; it covers the way one region's function affects another's, with or without classical referred pain pathways. Both concepts point to the same practical lesson: examining only the painful spot misses too much.

How long does a full-body assessment take?

A first visit at Unpain Clinic is 60 minutes one-on-one. That includes history, a movement screen, a focused exam of the painful area, a review of any imaging you bring, and a discussion of the plan. Follow-up visits are usually 30 to 45 minutes depending on what they include.

Can an old surgical scar really cause pain years later?

Sometimes, yes. Not every chronic pain is caused by an old scar, and we do not assume one is involved without evidence. When the assessment shows that a scar has changed how the deep core or pelvic floor fires, addressing it is part of the plan. When it has not, we leave it alone.

How do I know if my chronic pain has a root cause somewhere else?

The strongest signal is that the painful area has been treated repeatedly with no lasting improvement. Other signals include pain that moves between regions, pain that flares with seemingly unrelated activities, and imaging that shows findings the medical team has called "not surgical" while the pain continues. A full-body assessment is the way to find out.

Does shockwave therapy work on old scar tissue?

It can help. Focused shockwave applied to a surgical scar provides mechanical input that influences how the scar and surrounding tissue load. The general evidence base for shockwave on tendons and soft tissue is strong; the specific evidence for shockwave on surgical scars is more limited and is part of a broader plan rather than the only intervention.

Do I need a doctor's referral to come to Unpain Clinic?

No referral is needed. Physiotherapists and registered massage therapists in Alberta are primary contact providers, so you can book directly. Some extended health plans require a doctor's referral for reimbursement, so it is worth checking your benefits.

What if my pain turns out to be something you cannot treat?

We tell you. If your assessment points to a problem outside our scope (a structural issue that needs surgery, a medical condition that needs investigation, a pain pattern that is not what we treat), we say so and refer you to the right professional. We would rather lose a visit than treat something that is not ours to treat.

ABOUT THE AUTHOR

Written by Uran Berisha, PT, RMT, Founder of Unpain Clinic and Medical Shockwave Institute. Uran is a physiotherapist based in Edmonton, Alberta, and an International Educator in Shockwave Therapy. Medically reviewed by Uran Berisha, PT, RMT.

READY TO STOP CHASING THE PAIN AND START TREATING THE CAUSE?

If you have been dealing with chronic pain and the usual treatments have not moved the needle, the next step is a 60-minute one-on-one assessment in Edmonton where we look at the painful area and the chain around it, go through any imaging you have, and build you a clear, written plan. No referral needed. No pressure. We will tell you honestly whether our approach is the right call, and we will refer you on if it is not. You can book a one-on-one assessment when you are ready.

REFERENCES

The following sources are linked inline in the body above. The full citations are listed here for completeness.

1. Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: a musculoskeletal examination model whose time has come. Journal of Orthopaedic and Sports Physical Therapy. 2007;37(11):658-660. doi:10.2519/jospt.2007.0110. PMID: 18057674. https://pubmed.ncbi.nlm.nih.gov/18057674/
2. Ackermann PW, Alim MA, Pejler G, Peterson M. Tendon pain: what are the mechanisms behind it? Scandinavian Journal of Pain. 2023;23(1):14-24. doi:10.1515/sjpain-2022-0018. PMID: 35850720. https://pubmed.ncbi.nlm.nih.gov/35850720/
3. Majidi L, Khateri S, Nikbakht N, Moradi Y, Nikoo MR. The effect of extracorporeal shock-wave therapy on pain in patients with various tendinopathies: a systematic review and meta-analysis of randomized controlled trials. BMC Sports Science, Medicine and Rehabilitation. 2024;16(1):93. doi:10.1186/s13102-024-00884-8. PMID: 38659004. https://pubmed.ncbi.nlm.nih.gov/38659004/
4. Schmitz C, Császár NB, Milz S, Schieker M, Maffulli N, Rompe JD, Furia JP. Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database. British Medical Bulletin. 2015;116(1):115-138. doi:10.1093/bmb/ldv047. PMID: 26585999. https://pubmed.ncbi.nlm.nih.gov/26585999/