Why Your Pain Keeps Coming Back: When Pain Is Collateral Damage – Not the Core Problem

Pain is usually the reason someone seeks treatment—but pain does not always tell us precisely what is wrong. Pain is usually Collateral Damage: why pain keeps coming back? You need to fix the Core Problem!

Pain can indicate the general region of your body that feels threatened or irritated. However, it does not necessarily identify:

• The structure producing the symptoms
• The factor that originally overloaded that structure
• Why the problem developed
• Why it keeps returning
• Whether the painful area is the primary problem or collateral damage

This is one reason people can repeatedly treat a sore neck, knee, shoulder, or lower back, feel temporarily better, and then experience the same problem again.

The treatment may have reduced the symptom without adequately addressing the dysfunctional body parts that made the area vulnerable and are the real problem.

Pain Is Real—but It Is Not a Perfect Damage Detector

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It is produced by the nervous system as a protective response—not measured directly inside a muscle, joint, or disc.

This distinction matters.

Severe pain does not always mean severe structural damage. Conversely, meaningful tissue or physiological changes can exist without producing pain.

A systematic review of spinal imaging found that disc degeneration, bulging discs, and other findings become increasingly common with age—even among people without back pain. Disc degeneration was reported in 37% of asymptomatic 20-year-olds and 96% of asymptomatic 80-year-olds. These findings must therefore be interpreted alongside the examination and the patient’s symptoms, rather than automatically being labelled the cause of pain. Brinjikji et al., 2015

The opposite is also possible: a person may have significant pain without a dramatic structural abnormality on an MRI. Pain can be influenced by inflammation, nerve sensitivity, previous injury, sleep, stress, activity tolerance, general health, and how the nervous system processes information.

Pain is therefore valuable information—but it is only one part of the clinical picture. This is why your pain keeps coming back!

The Place You Feel Pain May Not Be the Source | Core Problem vs Collateral Damage

One of the most important principles in musculoskeletal care is that symptoms can be referred from another part of the body.

The nervous system receives an enormous amount of information from muscles, joints, nerves, skin, and internal organs. Signals from different tissues can converge along shared neurological pathways. As a result, the brain may sometimes perceive pain in an area away from the irritated structure.

This is known as referred pain.

Common examples include:

A Neck Problem Felt in the Shoulder or Arm

A problem involving the cervical spine or a cervical nerve root may produce pain around the shoulder blade, shoulder, upper arm, elbow, forearm, or hand.

In fact, a recent review found that scapular pain was commonly described in cervical radiculopathy and could precede arm pain by several weeks. Someone may initially believe that they have strained a shoulder-blade muscle when the symptoms are related to irritation closer to the neck. Carmichael et al., 2025

This does not mean every painful shoulder originates in the neck. Shoulder and cervical conditions frequently overlap, which is exactly why testing the neck, shoulder, strength, reflexes, sensation, and symptom-provoking movements is important. Katsuura et al., 2020

A Hip Problem Felt at the Knee

Hip-joint problems can sometimes present as thigh or knee pain. A person may focus on the knee because that is where the symptom is felt, even though the knee itself is not the primary source.

In one study of patients with confirmed symptomatic hip-joint pain, symptoms were reported not only in the groin and thigh but also in the buttock and, in some cases, below the knee. Lesher et al., 2008

This is why a proper knee assessment should not stop at the knee. The hip, ankle, lower back, neurological system, walking mechanics, strength, and training demands may all need to be considered.

A Lower-Back Problem Felt in the Leg

Irritation involving a lumbar nerve root can produce pain, numbness, tingling, or weakness in the buttock, thigh, lower leg, or foot.

In some cases, leg pain is more prominent than back pain. Treating only the tight or painful leg muscles may offer temporary relief while overlooking a possible neurological contribution.

A Shoulder Problem Felt in the Upper Arm

Rotator-cuff and other shoulder conditions are frequently felt over the outside of the upper arm rather than directly over the injured tendon.

This is another reminder that the location of pain is not an anatomical map. The examination must determine whether the symptoms behave like a shoulder problem, a cervical problem, a peripheral nerve problem, or a combination.

Internal-Organ Problems Felt Elsewhere

Referred symptoms are not limited to muscles and joints.

Cardiac ischemia can produce symptoms in the chest, arm, shoulder, neck, jaw, or upper back. Diaphragm or abdominal irritation may be perceived around the shoulder. Certain gallbladder, kidney, and gastrointestinal problems can also produce back or shoulder-region pain.

These examples are important because new, unexplained, severe, or unusual pain should not automatically be assumed to be musculoskeletal.

Chest pressure, unexplained shortness of breath, fainting, sweating, sudden neurological changes, fever, unexplained weight loss, progressive weakness, or changes in bowel or bladder control require appropriate medical assessment.

Changes Can Develop Before Symptoms Begin: Why Your Pain Keeps Coming Back

The body can often adapt to gradual change for a surprisingly long time.

A tendon can become structurally abnormal before it becomes painful. A joint can show age-related changes without producing symptoms. Movement and strength can gradually decline before a person notices a limitation in daily life.

Research examining asymptomatic tendons supports this point. A systematic review found that abnormalities seen on ultrasound in pain-free tendons were associated with an increased likelihood of developing future tendinopathy. However, not every abnormal-looking tendon became painful. McAuliffe et al., 2016

The same complexity appears in other areas:

• MRI abnormalities were found in 97% of knees in one study of asymptomatic adults, including cartilage, meniscal, tendon, and bone-marrow findings. Horga et al., 2020
• Rotator-cuff abnormalities become increasingly common with age, including in shoulders without symptoms. Teunis et al., 2014
• Imaging findings associated with femoroacetabular impingement are common in asymptomatic hips, particularly among athletes. Frank et al., 2015

These findings do not mean that every pain-free person needs treatment. They also do not mean that imaging findings are irrelevant.

They demonstrate that structure, function, and symptoms do not always change at the same time. Imaging findings must be interpreted in context, and treatment decisions should be based on the person—not simply on the scan.

Symptoms Can Be Late in Non-Musculoskeletal Conditions Too

The delay between biological change and obvious symptoms is not unique to musculoskeletal health.

Atherosclerosis can develop gradually before it produces angina or another cardiovascular event. Parkinson’s disease may have a prodromal phase involving non-motor changes—such as altered smell, constipation, mood, or sleep—before its characteristic movement symptoms become apparent. Many infections also have an incubation period during which a person has been infected but has not yet developed recognizable symptoms.

The point is not that these unrelated conditions can be screened for or treated through chiropractic care. They simply illustrate a broader biological principle:

The beginning of a process and the beginning of noticeable symptoms are not necessarily the same event.

In musculoskeletal care, pain may seem to start after one ordinary run, workout, workday, or night of sleep. Sometimes there truly is a distinct acute injury. In other cases, that final event is simply when the accumulated demands exceeded the body’s current capacity.

Why Does Pain Keep Returning?

Recurring pain usually deserves a broader question than, “How do we calm this area down?”

We should also ask, “Why is this area repeatedly becoming irritated?”

Several factors may contribute:

• Incomplete recovery from a previous injury
• A rapid increase in training or workload
• Reduced strength or physical capacity
• Loss of movement in a nearby region
• Repetitive occupational positions
• Poor sleep or inadequate recovery
• Technique or equipment that exceeds current tolerance
• Nerve irritation or neurological weakness
• Fear-driven avoidance and deconditioning
• A mismatch between tissue capacity and daily demands
• A medical condition that requires assessment outside musculoskeletal care

These are not universal explanations, and finding one postural fault or tight muscle does not automatically reveal the “root cause.” Recurring symptoms are often multifactorial.

The are often multifactorial goal is to identify the most relevant and modifiable contributors for the individual patient.

Knee Pain: A Practical Example

Consider someone whose pain appears at the front of the knee while running.

The knee is unquestionably painful, and local structures may be sensitive. But a comprehensive assessment may also examine:

• Hip and ankle mobility
• Quadriceps and hip strength
• Running volume and recent workload changes
• Previous injuries
• Footwear
• Running mechanics
• Recovery between sessions
• Lower-back or nerve involvement
• The movements that reproduce or relieve the pain

Treatment may still include the knee. The mistake is assuming that the assessment should end wherever the pain begins.

This is the difference between treating the painful area in isolation and treating the person who developed the pain.

Pain Relief and Correcting Contributing Factors Are Both Important

There is nothing wrong with wanting pain relief. Pain can interfere with sleep, work, exercise, concentration, and quality of life. Reducing it is a meaningful clinical objective.

But lasting improvement may require more than temporarily changing the pain signal.

Depending on the diagnosis, care may include:

• Manual therapy or spinal manipulation when appropriate
• Acupuncture or electroacupuncture
• Progressive strengthening
• Mobility or movement exercises
• Modification of aggravating activities
• Gradual return to work or sport
• Ergonomic or bike-fit changes
• Education about pain and recovery
• Referral for medical assessment, imaging, or specialist care when indicated

The correct combination depends on what the examination finds. No single treatment is appropriate for every person or every pain problem.

What a Comprehensive Assessment Should Determine

A thorough assessment should attempt to answer four questions:

1. What is the most likely source of the symptoms?
2. Are the symptoms local, referred, neurological, or potentially non-musculoskeletal?
3. What factors may be contributing to the problem or delaying recovery?
4. What can reasonably be changed to improve function and reduce recurrence?

This may involve assessing movement, strength, neurological function, symptom behaviour, previous injuries, daily demands, exercise habits, and relevant health history.

When appropriate, it should also include recognizing when the problem requires medical investigation rather than—or in addition to—conservative musculoskeletal care.

The Bottom Line

Pain is real, important, and deserving of care. But pain is not always a precise explanation of what is happening.

The place you feel pain may not be its source. Tissue or functional changes may exist before symptoms become noticeable. Imaging abnormalities may also exist without causing any symptoms at all.

That is why recurring pain should not be reduced to one sore muscle, one “bad” joint, or one MRI finding.

If your neck, back, shoulder, knee, or repetitive-strain symptoms keep returning, the next step may be a more comprehensive assessment of the painful area, the surrounding regions, your neurological function, and the demands you place on your body.

At Toronto Corrective Chiropractic, our goal is not simply to ask, “Where does it hurt?” We work to understand what is producing the symptoms, what may be contributing to them, and what needs to change to help you move and function more confidently.

Request an appointment with Dr. Alex Ritza at Toronto Corrective Chiropractic near Yorkville and Yonge–Bloor in Toronto.

Frequently Asked Questions

Why does my pain keep coming back?

Recurring pain may be related to incomplete recovery, repeated overload, reduced strength, activity changes, nerve irritation, or other contributing factors. A comprehensive assessment can help identify which factors are relevant are to you.

Can pain come from somewhere other than where I feel it?

Yes. Neck problems can produce shoulder or arm symptoms, hip problems can be perceived near the knee, and lower-back or nerve problems can create symptoms in the leg. This is called referred or radiating pain.

Does an abnormal MRI identify the cause of my pain?

Not necessarily. Disc changes, meniscal abnormalities, rotator-cuff tears, and other findings can occur in people without symptoms. Imaging should be interpreted alongside your history, examination, and symptom pattern.

Does severe pain mean that I have severe damage?

Not always. Pain intensity is influenced by tissue irritation, inflammation, nerve sensitivity, sleep, stress, previous experiences, and other factors. Severe or unusual pain should still be properly assessed.

Should I receive treatment if I have no pain?

Not simply because an imaging test shows an abnormality. Treatment should be based on your health history, function, risks, goals, and examination—not on an incidental finding alone.

When should recurring pain be assessed?

Consider an assessment when pain repeatedly returns, limits your work or activities, is accompanied by numbness or weakness, is worsening, or is not improving as expected. Sudden neurological symptoms, chest pressure, shortness of breath, fever, significant trauma, or bowel or bladder changes require prompt medical attention.

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