Referred Pain

Article by Matthew Hewitt

Referred Pain

Referred Pain: Understanding and Managing This Phenomenon

 Managing Referred Pain: A Physiotherapist's Guide
Managing Referred Pain: A Physiotherapist’S Guide

What is Referred Pain?

Referred pain is a phenomenon where pain is felt at a location other than where the actual problem is. This can complicate diagnoses and treatment plans, as the source of the pain may be distant from the area experiencing discomfort. Understanding referred pain is crucial for healthcare professionals to diagnose and manage various medical conditions effectively.

Mechanisms of Referred Pain

Referred pain occurs due to the complex interaction between nerves, the spinal cord, and the brain. The primary mechanisms include:

Convergence-Projection Theory

This theory suggests that nerves from different parts of the body converge at the same levels in the spinal cord. When a painful stimulus occurs in one area, the brain may misinterpret the origin of the pain due to overlapping nerve signals, projecting it to another region. Think of this as interference between a stereo and its speakers.

Central Sensitisation

Central sensitisation happens when the central nervous system (brain and spinal cord) becomes sensitised, leading to an increased response to normal sensory inputs. Over time, this can cause pain to be perceived in areas other than where the actual damage or stimulus is located. This often occurs with repeated irritation over time.

Peripheral Nervous System Involvement

Irritation or inflammation in one part of the body can affect the nerves in another part due to shared pathways or close anatomical proximity. This can happen when tissue surrounding a nerve goes into spasm or becomes swollen, compressing the nerve. An example is piriformis syndrome.

Common Examples of Referred Pain

Several medical conditions manifest as referred pain, making it essential to recognise these patterns:


Sciatica is an example of referred pain, where an irritated nerve (often in the lower lumbar spine) causes pain to be felt down the back of the leg. One of the most common signs of sciatica is worsening leg pain with sitting or bending.

Double Crush Syndrome

Double crush syndrome involves referred pain where carpal tunnel symptoms are felt with movements of the head or neck. This occurs due to the nerves in your arm exiting from your lower cervical spine.

Heart Attack (Cardiac Ischemia)

During a heart attack, you may experience referred pain in the left shoulder, arm, neck, or jaw. This happens because of shared spinal segments (C3-T4) between the heart and these regions.

Diagnosis and Management

Diagnosing referred pain requires a thorough understanding of anatomy, nerve pathways, and common referred pain patterns. Healthcare professionals use various strategies to pinpoint the source of pain:

History and Examination

A detailed patient history and a comprehensive physical examination are critical. Understanding the characteristics, onset, duration, and location of pain helps in identifying its source.

Imaging Studies

Techniques such as X-rays, MRIs, CT scans, and ultrasound can visualise internal structures and identify potential pain sources not evident through physical examination alone.

Nerve Block Injections

In complicated cases, your doctor may recommend local anaesthetics to specific nerves to help diagnose referred pain. If the pain is relieved after the injection, it confirms the involvement of that nerve pathway.

Electrodiagnostic Studies

Special tests like electromyography (EMG) and nerve conduction studies (NCS) can assess nerve function and identify abnormalities causing referred pain.

Treatment Strategies

Managing referred pain involves addressing the underlying cause and providing symptomatic relief:

  • Manual Therapy: Techniques such as joint mobilisation, soft tissue mobilisation, and myofascial release can alleviate pain and improve function. Ask your physiotherapist for specific advice.
  • Therapeutic Exercises: Customised exercises targeting flexibility, strength, and endurance can address the underlying causes of referred pain. Your physiotherapist can assist you.
  • Postural Training: Improving ergonomics and posture can prevent the recurrence of referred pain. Ask your physio.
  • Neuromuscular Re-education: Retraining the nervous system can reduce central sensitisation and improve motor control. Seek the assistance of your physiotherapist.
  • Education and Self-Management: Strategies may include home exercises, lifestyle modifications, and pain management techniques. Specific advice is available from your physiotherapist.
  • Modalities: Treatments like ultrasound, electrical stimulation (TENS), and heat/cold therapy can provide symptomatic relief. Check with your physiotherapist first.
  • Medications: Analgesics, anti-inflammatory drugs, or nerve pain medications may be prescribed. Your doctor’s advice should be sought.
  • Surgery: In rare or severe cases, surgical procedures may be necessary.


Referred pain is a complex phenomenon that requires a multifaceted approach for accurate diagnosis and effective management. By understanding the underlying mechanisms and common patterns, healthcare professionals can better diagnose and treat patients, improving outcomes and alleviating suffering.

What to Do?

If you experience unexplained pain, consult a physiotherapist or doctor. They can help diagnose referred pain and provide tailored treatment plans to address your specific needs.

Referred Pain FAQs

  1. What is referred pain? Referred pain is pain felt in a different location from the source of the problem, due to nerve signal misinterpretation.
  2. What causes referred pain? Referred pain is caused by the convergence of nerve signals, central sensitisation, or peripheral nerve involvement.
  3. How is referred pain diagnosed? Diagnosis involves a detailed history, physical examination, imaging studies, nerve block injections, and electrodiagnostic tests. Book an appointment with your doctor or physiotherapist.
  4. Can referred pain be treated? Yes, treatments include manual therapy, therapeutic exercises, postural training, neuromuscular re-education, modalities, medications, and, in severe cases, surgery. Book an appointment with your trusted healthcare professional.
  5. What are common examples of referred pain? Common examples include sciatica, double crush syndrome, and pain from a heart attack referred to the shoulder, arm, neck, or jaw.
  6. When should I see a physiotherapist for referred pain? Consult a physiotherapist if you have unexplained pain, especially if it’s persistent or affects your daily activities.

Related Articles

  1. Sciatica Treatment
    • Discover effective treatments for sciatica and ways to manage symptoms.
  2. Neck Pain Treatment
    • Learn about various causes of neck pain and treatment options.
  3. Shoulder Pain Treatment
    • Explore the causes of shoulder pain and physiotherapy solutions.
  4. Heart Attack Symptoms
    • Understand the symptoms of a heart attack and the importance of timely intervention.
  5. Piriformis Syndrome
    • Find out more about piriformis syndrome and how to manage it.
  6. Carpal Tunnel Syndrome
    • Learn about the causes, symptoms, and treatments for carpal tunnel syndrome.
  7. Low Back Pain Treatment
    • Get insights into treating and managing low back pain.
  8. Postural Training
    • Discover how improving posture can prevent pain and improve overall health.
  9. Manual Therapy Techniques
    • Explore various manual therapy techniques used in physiotherapy.

John Miller Physiotherapist

Article by John Miller

What is Pain?


Pain acts as a crucial alert system in your body, signalling when something is amiss. As physiotherapists, we understand pain not just as a symptom, but as a complex experience influenced by various physiological factors. This article, written from a physiotherapist's perspective, aims to demystify pain and offer insights into its management.

what is pain
What Is Pain? Pain Explained

Understanding Pain Signal Transmission

The journey of a pain signal begins at the site of injury or discomfort. Here, receptor nerve cells, including nociceptors, detect harmful stimuli. These receptors are sensitive to various types of damage, such as thermal (heat), mechanical (pressure or impact), and chemical changes.

Once stimulated, these receptors transmit signals via nerve fibres to the spinal cord and brain. The types of nerve fibres involved are crucial in determining the nature of the pain:

  • A-beta fibres: These large, myelinated fibres rapidly transmit sharp, well-localised pain.
  • A-delta fibres: Smaller but still myelinated, they convey acute pain.
  • C fibres: These small, unmyelinated fibres are responsible for dull, throbbing, and chronic pain sensations.

Nociceptors and Their Role in Pain

Nociceptors are specialised nerve cells that play a key role in pain perception. They are adept at picking up potential damage and efficiently communicating this information to the brain. The brain then interprets these signals, leading to the experience of pain.

Chronic Pain: Understanding the Long-term Impact

Chronic pain, lasting beyond the usual course of acute injury or illness, poses a significant challenge. It often involves complex interactions between physical and psychological factors. Recent research highlights the role of the brain in maintaining chronic pain, even in the absence of an identifiable physical cause.

Related article: Chronic Pain

Myelin Sheath: Speeding Up Pain Signals

The presence of a myelin sheath around a nerve fibre is crucial in determining the speed of pain signal transmission. Myelinated fibres (A-beta and A-delta) allow for faster communication compared to unmyelinated C fibres. This difference in speed can influence the type of pain experienced.

Physiotherapy Techniques for Pain Relief

Physiotherapists employ various methods to manage pain:

  • Manual therapy: Techniques such as massage and joint mobilisation can provide immediate pain relief.
  • Exercise therapy: Tailored exercises help in managing chronic pain by improving muscle strength and flexibility.
  • Pain Education: Understanding the biological, psychological, and social aspects of pain can help individuals manage their pain more effectively.
  • Cognitive Behavioural Therapy (CBT) is a psychological intervention that has proven effective in managing chronic pain. It's based on the concept that our thoughts, feelings, and behaviors are interconnected, and changing negative thought patterns can lead to changes in feelings and behaviors.

What Causes Post-Exercise Muscular Pain?

Muscle soreness after exercise, often felt as a dull, aching pain, is commonly due to microscopic damage to muscle fibres and the surrounding tissues. This is a normal response and part of the muscle strengthening process.

The Brain's Role in Pain Perception

The brain plays a central role in interpreting pain signals. It integrates information from the body and can modulate the pain experience based on various factors, including emotional and psychological states.


Pain, a complex and subjective experience, involves intricate neurophysiological processes. Understanding these processes is crucial for effective pain management. Physiotherapy offers a range of techniques to alleviate pain, tailored to individual needs.

What to Do? Seeking Professional Advice

If you are experiencing persistent or unexplained pain, consulting a physiotherapist is a vital step. They can provide a comprehensive assessment, guidance, and a tailored treatment plan to manage your pain effectively.

For more detailed information and resources, visit our Pain Management section, a trusted source for physiotherapy insights and treatments.

Pain FAQs

You've just added this product to the cart: