Extremity Pain That Might Not Be Coming From Where You Think

Have you ever dealt with a nagging knee pain that seemed to come out of nowhere? Or a shoulder that just won’t settle down despite doing all the “right” exercises? Maybe your hip has been bothering you for months (or years), and no stretch seems to fix it. You’ve tried stretching it. Strengthening it. Resting it. And yet… it keeps coming back. What if the problem isn’t actually where you feel the pain?

A Different Way to Look at Pain

A study published in the Journal of Manual & Manipulative Therapy known as the EXPOSS study (Extremity Pain of Spinal Source) looked into this exact question. The goal was simple: How often is pain in the arms or legs actually coming from the spine?

How the Study Worked 

Researchers looked at 369 patients who had pain in areas like:

• Shoulder

• Elbow

• Wrist/hand

• Hip

• Knee

• Ankle/foot

  
  
  
  

The key detail: None of these patients had noticeable spine pain AND no one initially thought the spine was the cause. That includes the patient and the referring physician. 

Clinicians in the study then evaluated each patient using a system called Mechanical Diagnosis and Therapy (MDT). What this included was:

• Gathering baseline tests such as: what movements trigger symptoms, as well as range of motion and strength testing.

• Testing specific repeated movements of the spine (Think Press Ups, Chin Tucks, Neck Extensions etc…)

• Watching how baseline tests change in real time

  
  
  
  

If symptoms improved or changed with spinal movement, the pain was classified as likely coming from the spine.

What They Found

Here is the crazy part: Nearly 1 in 2 patients (43.5%) had pain that responded to spinal treatment even though their pain was felt elsewhere.

Here’s a breakdown of the findings:

Table 1. Prevalence of Extremity vs. Spinal Source Pain by Region

Adapted from Rosedale et al., 2020

Region: Extremity Source n (%), Spinal Source n (%), Total

Hip: 9 (29.0%), 22 (71.0%), 31

Thigh/Leg: 5 (27.8%), 13 (72.2%), 18

Knee: 58 (74.4%), 20 (25.6%), 78

Ankle/Foot: 34 (70.8%), 14 (29.2%), 48

Shoulder: 44 (52.4%), 40 (47.6%), 84

Arm/Forearm: 2 (16.7%), 10 (83.3%), 12

Elbow: 14 (56.0%), 11 (44.0%), 25

Wrist/Hand: 16 (61.5%), 10 (38.5%), 26

Total: 182 (56.5%), 140 (43.5%), 322

What This Actually Means

Some of the biggest takeaways:

• 71% of hip pain cases responded to spinal treatment

• 72% of thigh/leg pain may originate from the spine

• Nearly half of shoulder pain (47.6%) had a spinal component

• 83% of arm/forearm pain was linked to the spine

  
  
  
  

In other words: Pain doesn’t always equal the problem area.

Why This Matters for You

This study highlights something important: If you only treat where it hurts, you might miss the real driver of the problem. That’s why a thorough evaluation matters. Not just where it hurts, but, What changes the pain how your body responds to movement, whether the spine is involved even if it doesn’t hurt.

A Quick Reality Check (Important)

This doesn’t mean:

• Every knee pain is coming from your back

• Every shoulder issue is spinal

  
  
  
  

But it does mean the spine should always be considered as part of the full picture.

Final Thought

If you’ve been dealing with:

• Persistent, nagging pain

• Pain that doesn’t match imaging findings

• Symptoms that keep coming back despite treatment

  
  
  
  

…it might be time to look beyond the obvious. Because sometimes, the key to fixing the problem is finding where it actually starts, not just where you feel it.

📚 Reference

Rosedale, R., et al. (2020). A study exploring the prevalence of extremity pain of spinal source (EXPOSS). Journal of Manual & Manipulative Therapy, 28(5), 279–286. https://doi.org/10.1080/10669817.2019.1661706