When pain shows up in one part of the body, it’s tempting to assume the answer must be sitting in that same spot. In practice, the human body is far more connected and adaptable than that. This article explores why an osteopathic assessment may look beyond the painful area, including old injuries, movement patterns and other regions that may be influencing how the body is working. The goal isn’t to make things more complicated, but to ask a better question: why is this happening? From there, the assessment can begin to build a clearer picture and a more focused plan.
You booked because your shoulder hurts.
It wakes you when you roll onto it. Reaching into the back seat has become an oddly complicated manoeuvre, and putting a jumper on now requires a strategy. So we start looking at the shoulder.
Fair enough.
Then, a few minutes later, I’m watching you walk. Now I’m asking about the ankle you rolled two years ago.
At which point there is a perfectly reasonable question forming in your head:
What on earth has my ankle got to do with my shoulder?
Sometimes? Nothing.
And that’s actually the important bit.
After more than 20 years working clinically with people, one of the things I still find fascinating is how adaptable the human body is. We change the way we move, find another route around a problem and carry on, usually without giving it much thought.
A broader osteopathic assessment isn’t about hunting for a secret body part that “caused” your pain. It’s about stepping back far enough to understand the bigger pattern and asking a better question:
Why is this happening?
In Brief
- Your shoulder might be the part complaining, but it doesn’t operate on its own.
- The human body is connected through muscles, fascia, joints, nerves and the way movement and load travel from one region to another. That’s why an osteopathic assessment may wander beyond the sore spot.
- Not because I’m trying to make the problem more complicated than it needs to be.
- I’m trying to understand why this problem is happening, in this person, at this point in time.
The sore spot still matters
Let’s get this one out of the way first. If your shoulder hurts, I’m assessing your shoulder.
Pain location gives us useful information. So does the history: what started it, what aggravates it, whether it wakes you at night, what movements have changed and what you can no longer do comfortably.
But after years of doing this work, I’ve learnt not to assume that the postcode of the pain tells me everything I need to know. Sometimes the story is wonderfully straightforward. The shoulder hurts, the shoulder is irritated and the assessment stays largely around the shoulder.
Other times, something doesn’t quite add up.
The neck and shoulder are a good example because symptoms arising from these regions can overlap considerably, which is one reason examining both can be clinically useful when the presentation isn’t clear [1].
Maybe the neck changes the movement. Maybe the upper back isn’t contributing particularly well. Maybe the way someone rotates through their trunk looks completely different from one side to the other.
And every now and then, the history takes you farther away.
That’s when curiosity becomes useful.
Everything is connected. The question is why this is happening.
This is probably the part of the human body that still amazes me most.
It is connected. Quite literally.
Muscles blend into fascia. Fascia continues between anatomical regions. Joints influence the movement available above and below them, while forces generated through one part of the body are transferred elsewhere as we walk, reach, lift, twist and throw.
Human anatomical dissection studies have demonstrated structural continuity between a number of muscle and fascial regions, including identifiable myofascial continuities through the shoulder and upper limb [2,3].
Movement research tells a similar story from another angle. The shoulder complex functions as part of a wider kinetic chain, with trunk and lower-limb movement capable of changing muscle recruitment patterns around the shoulder during functional movement and exercise [4].
Knowing the body is connected, however, doesn’t answer the clinical question.
Why is this happening?
Why this shoulder? Why now? Why does one movement hurt while another doesn’t? Why did the problem settle six months ago and return? Why does changing movement somewhere else alter what happens here?
That’s where assessment becomes interesting.
Your body is remarkably good at finding another way
Lose a little movement somewhere and the body often finds another option. An old injury changes how you walk for a while, so you develop another strategy. A stiff upper back may change the way you reach overhead. A sore hip changes your stride. A shoulder that doesn’t particularly enjoy one movement starts borrowing movement somewhere else.
None of this automatically means something has gone wrong. Adaptation is one of the things human beings do brilliantly.
Research gives us plenty of examples. Thoracic position can change available shoulder range of motion, although that does not mean thoracic posture itself neatly explains shoulder pain [5]. People with chronic ankle instability can also demonstrate altered movement patterns not only at the ankle, but at the knee and hip during walking [6].
That doesn’t prove an old ankle injury caused someone’s shoulder pain.
Nor does it need to.
The interesting question is what happens when an adaptation becomes part of the way you move long after the original reason for it has disappeared. Sometimes absolutely nothing happens. Other times, it becomes another clue in a much bigger picture.
Connection is the starting point. “Why?” is the assessment.
I already know the ankle and shoulder are connected.
The interesting part is understanding whether the way those regions are functioning helps explain why this shoulder problem is happening in this person, at this point in time.
That broader idea isn’t particularly radical. Musculoskeletal literature has used the term regional interdependence to describe the observation that impairments or changes in one anatomical region may sometimes be associated with symptoms or function elsewhere [7].
In the clinic, though, I’m less interested in giving it a fancy name than I am in asking useful questions.
Maybe we change something through your upper back and your shoulder immediately moves differently. Interesting.
Maybe we assess the neck and a movement that reproduced your shoulder symptoms behaves differently. Also interesting.
Maybe I look at that ankle you injured years ago, test it, watch you move again and discover another piece of a much broader movement pattern. Or perhaps I find absolutely nothing useful there.
That’s fine too.
A finding still has to earn its place in the story.
The aim isn’t to collect twelve abnormalities and construct an elaborate theory around them. It’s to keep asking why.
Why has the body chosen this strategy? Why is this area carrying load this way? Why has something that worked perfectly well for years suddenly become uncomfortable? Why does one change alter the picture while another does nothing?
Those questions gradually turn a collection of findings into something far more useful: a coherent clinical picture.
Old injuries are clues, not convictions
This is why you’ll sometimes hear me ask about injuries you stopped thinking about years ago.
Not because I believe every rolled ankle is secretly waiting to ruin your shoulder. It’s because an old injury occasionally changes something that never completely changes back.
Perhaps a movement never fully returned. Maybe you avoided loading something for long enough that the alternative became your normal. Maybe your body found an excellent workaround and you’ve been happily using it ever since.
Or perhaps the injury healed beautifully and has absolutely nothing to do with why you’re sitting in front of me today.
All of those possibilities exist.
That uncertainty doesn’t bother me. It’s what assessment is for.
After all these years, I’m probably more impressed by the complexity and adaptability of the human body than I was when I started. There is usually more than one way to move, more than one way to adapt and very rarely one neat little culprit sitting there waiting to confess.
A wider assessment should eventually make the plan smaller
This is probably the bit that matters most.
The goal of looking wider isn’t to collect twelve things that are “wrong with you.” It’s to narrow the field until we have a better idea of why the problem is behaving the way it is.
At Barefoot Osteo, I tend to organise that thinking around:
Mobility → Stability → Balance
First, what movement options are available? Then, where does control or capacity need work? Finally, how well are those pieces working together when you actually move?
For someone with shoulder pain, that might mean assessing the shoulder itself, checking relevant neck and upper-back movement, looking at strength or loading tolerance and occasionally exploring something farther away if the history gives me a reason.
It isn’t complexity for complexity’s sake.
Quite the opposite.
A wider look should help decide what belongs in the plan and, just as importantly, what we can leave alone.
Three questions worth asking during an assessment
If you’re ever wondering why I’m apparently wandering off into another body region, ask.
Three questions cut through a remarkable amount of clinical fog:
- What did you find?
- Why do you think it’s happening?
- How does that change the plan?
There should be a sensible answer.
You don’t need a twelve-minute anatomy lecture involving three Latin words, a whiteboard and an increasingly desperate-looking skeleton. But you should understand the reasoning behind what is being assessed.
If something deserves a place in your management plan, I should be able to explain why.
The plan should be less mysterious, not more complicated
So, why am I checking your ankle when your shoulder hurts?
Because your shoulder doesn’t operate in isolation. Neither does your ankle. The human body is one connected, endlessly adaptable system, and watching the different ways people move, compensate, recover and find another way around a problem is still one of the things I find most fascinating about clinical practice.
But knowing the body is connected is only the beginning.
The better question is:
Why is this happening?
Why here? Why now? Why this particular movement? Why this particular pattern? And what does the rest of the body tell us about it?
That’s what the wider assessment is trying to understand. Not to find one magical culprit, and not to turn an old ankle sprain into the villain of your shoulder story, but to keep following the clues until the picture makes more sense.
Because a good assessment should leave you with a clearer explanation of what we think is happening, why we think it is happening and what we’re going to do about it.
Less mystery.
Better questions.
A clearer plan.
If you’re dealing with a problem that keeps returning, or the sore spot no longer seems to explain the whole picture, book a consultation and we can explore what’s happening.
Points to Remember
- The painful area still matters and should be properly assessed.
- The body is anatomically and functionally connected, and movement in one region can influence another.
- Your body constantly adapts to changes in movement, injury and load.
- An old injury may contribute to the wider pattern, or it may have very little relevance to the current problem.
- Looking beyond the sore spot is about understanding why the problem is happening, not searching for an elaborate remote cause.
- A wider assessment should ultimately lead to a clearer, more focused plan.
Frequently asked questions
Why does an osteopath check areas that don’t hurt?
Because the painful area doesn’t operate in isolation. Looking at nearby or occasionally more distant areas can provide useful information about how you move, how load is being shared and why the current problem may be behaving the way it is.
Does pain always come from the area that hurts?
Not necessarily. Pain location is useful information, but symptoms can sometimes overlap between regions. The neck and shoulder are a good example, which is why an assessment may include both when the presentation suggests it is useful [1].
Can an old ankle injury cause shoulder pain?
I wouldn’t reduce the relationship to a simple cause-and-effect statement. An old ankle injury can change the way someone moves, and persistent ankle instability has been associated with changes farther up the lower limb during walking [6]. Whether any of that contributes meaningfully to a particular shoulder problem has to be considered in the context of the individual assessment.
Why would you watch me walk if my shoulder hurts?
Sometimes walking gives useful information about how someone moves through the whole body. It won’t be necessary for every shoulder problem, but if something in the history or assessment points toward a broader movement pattern, it can be worth looking at.
How do you decide whether another area belongs in the assessment?
By following the history, assessing the person in front of me and continuing to ask why the problem is behaving the way it is. A finding should help make the clinical picture clearer rather than simply adding another item to a list of things supposedly “wrong.”
References
- Katsuura Y, Bruce J, Taylor S, Gulotta L, Kim HJ. Overlapping, masquerading, and causative cervical spine and shoulder pathology: a systematic review. Global Spine J. 2020;10(2):195-208. https://doi.org/10.1177/2192568218822536
- Wilke J, Krause F, Vogt L, Banzer W. What is evidence-based about myofascial chains: a systematic review. Arch Phys Med Rehabil. 2016;97(3):454-461. https://doi.org/10.1016/j.apmr.2015.07.023
- Wilke J, Krause F. Myofascial chains of the upper limb: a systematic review of anatomical studies. Clin Anat. 2019;32(7):934-940. https://doi.org/10.1002/ca.23424
- Richardson E, Lewis JS, Gibson J, Morgan C, Halaki M, Ginn K, et al. Role of the kinetic chain in shoulder rehabilitation: does incorporating the trunk and lower limb into shoulder exercise regimes influence shoulder muscle recruitment patterns? Systematic review of electromyography studies. BMJ Open Sport Exerc Med. 2020;6(1):e000683. https://doi.org/10.1136/bmjsem-2019-000683
- Barrett E, O’Keeffe M, O’Sullivan K, Lewis J, McCreesh K. Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Man Ther. 2016;26:38-46. https://doi.org/10.1016/j.math.2016.07.008
- Luan L, Orth D, Newman P, Adams R, El-Ansary D, Han J. Do individuals with ankle instability show altered lower extremity kinematics and kinetics during walking? A systematic review and meta-analysis. Physiotherapy. 2024;125:101420. https://doi.org/10.1016/j.physio.2024.101420
- Sueki DG, Cleland JA, Wainner RS. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. J Man Manip Ther. 2013;21(2):90-102. https://doi.org/10.1179/2042618612Y.0000000027
