26/06/2025
Understanding Pain: An Introductory Overview
Estimated read time: 12–14 minutes
Disclaimer:
Modern pain science often confuses—and can even discomfort folks, because it challenges deeply held beliefs.
Beliefs about the body and pain are not just personal; they’re cultural, which makes tackling these complex issues that much harder.
As a note, I post about pain on my pages as a reference for my clients. Since pain is one of our most complex systems, it's not an easy task explaining the complexity of pain, let alone working through belief systems while working out.
Last disclaimer: Complex issues should always come with caveats and nuance. Rarely should anything be taken in black and white.
So let's go..
We All Just... Assumed
Most people—including those working in rehab, training, and surgery—have operated on an assumption. Myself included:
If something hurts, it must be injured.
We assumed physios, chiros, osteos, and surgeons must’ve learned about pain during their studies.
They must have been taught how pain actually works.
Turns out... not really.
Why does this matter? Because without the signal of pain, you’ve got no reason to change anything, right?
Most of what we seek help for starts with some alert from pain right?
But many professionals weren’t taught how pain functions as a protective, predictive system.
Instead, most were trained in structural models: diagnose the damaged part, fix the damaged part.
The problem?
That’s not how pain works.
🚗 If Pain Worked Like a Car Sensor...
Imagine reversing your car, hitting a pole—and only then the sensor beeps.
Pretty useless, right?
That’s how most of us still think pain works: damage first, pain second.
Simple cause and effect.
But pain isn’t an injury report—it’s a warning system. A predictive one.
It kicks in before actual harm.
It’s trying to protect you before you hit the pole.
This system isn’t perfect. It can get it wrong.
It can become overly sensitive and stay turned on—even after tissues have healed.
As Lorimer Moseley—arguably the most influential pain scientist alive—says:
“Most of the time, pain has nothing to do with damage.”
Pain is real. But it’s not always a sign that something is broken.
1. What We’ve Been Taught About Pain (And Why It’s Flawed)
We were raised to believe: pain = damage.
And professionals kept that belief alive.
“I have pain because my posture is bad.”
“My core is weak.”
“I’ve got a slipped disc.”
“It’s wear and tear.”
But then explain this:
People with horrific scans and zero pain
People in severe pain and clear scans
Phantom limb pain—when the limb isn’t even there
Usain Bolt breaking world records with scoliosis
If pain = damage, none of those make sense.
2. The Myth of “Perfect Structure”
You’ve been told to fix your scapula, neutralise your spine, align your pelvis.
If structure caused pain, we’d see clear patterns in the data.
We don’t.
People chase things like:
Anterior pelvic tilt
Leg length discrepancy
Winged scapulae
…an endless list, to be honest.
(20 years in gyms—it’s truly endless how much nocebo is out there.)
Myself included—I was part of that movement for a long time.
But there’s no reliable evidence linking these to pain.
You’re not a machine that needs alignment. You’re human. Humans adapt.
So the better question becomes:
What load—physical, mental, emotional—are you placing on the system?
Is it too much? Too little?
🧠 Cheat code → It’s usually not what you’re doing, but how much.
The dosage, the stimulus. And of course, this can be derailed by thoughts, beliefs, and expectations.
Yep—that’s how intertwined the mind, brain, and body are.
And here’s the thing… just because the science shows pain isn’t what we thought, doesn’t mean you should ignore it or push through it.
We still need to respect the system’s complexity.
If your brain is creating pain, even when the boxes are ticked, then pushing harder might just make the system grumpier.
Neurons that fire together, wire together.
The more you experience pain, the more efficient your brain becomes at creating it—
even if that’s the opposite of what you want.
3. The Nocebo Effect and the Danger of Misinformation
Negative beliefs create or amplify pain. That’s the nocebo effect.
Believe your back is fragile?
You’ll move like it is—and your system will protect accordingly.
That ramps up sensitivity. Drops your tolerance.
Many professionals unknowingly feed this:
“Your spine’s out.”
“You’ve got a tear—we better operate.”
“Your posture’s broken.”
All of which is fear-mongering crap, and truly just worsens the situation.
Take meniscus tears.
Study after study—even from the New England Journal of Medicine—shows most don’t need surgery.
Sham surgeries work just as well. Yet people still line up for the real thing.
Are clinicians malicious? No.
Are they up to date with pain science? Also no.
We’ve kept treating pain like a structural issue because the system and or individuals profits when damage = pain.
That model is outdated. And it’s failing people.
4. Pain Is an Output
Pain doesn’t just come from the body.
It’s created by the brain in response to perceived threat.
The question isn’t:
“Is something broken?”
It’s:
“Do I need to protect this?”
And that answer depends on:
Nerve and tissue input
Emotional state
Environment
Memories
Attention
Beliefs
Context
Pain isn’t a signal. It’s a decision.
5. Why People React Differently
Same injury. Two different outcomes.
One walks it off. The other spirals.
Why?
For the same reasons as "do I need to protect this?"
6. Scans and Machines: Why They Often Mislead
Scans can help—when used well.
But with pain, they often do more harm than good.
Why? Because pain doesn’t show up on a scan.
Brinjikji et al. (2015):
88% of pain-free 60-year-olds had disc degeneration
30% of 20-year-olds had disc bulges—with no symptoms
Those scary labels—“degeneration,” “tear,” “arthritis”—are often just normal ageing.
But hearing them creates fear. And that fear becomes a driver of pain.
Your scan doesn’t know your story.
7. When Pain Lasts Beyond 3 Months
If your pain’s been around for more than 3 months, it’s probably not about tissue anymore.
The original injury may have healed and maybe even safer than before.
But your nervous system stayed "on."
That’s central sensitisation:
Your system becomes better at creating pain.
Even without threat.
It can:
Spread
Linger
Be triggered by just about anything highly dependent on your individualisation.
8. Pain Can Shift
Back pain becomes shoulder pain.
Then hip pain. Then neck pain.
Not because you’re falling apart.
But because your brain is casting a wider net—trying to protect more territory.
Real pain. But not new damage.
9. Bioplasticity: You Can Retrain the Pain System
Pain systems can change. That’s bioplasticity—your brain and nervous system adapting to new input.
You retrain it with:
Gradual movement
Building safe experiences
Shifting focus
Reducing fear
Rewriting your narrative
Truth is—just like pain can show up for a hundred reasons,
It can fade for a hundred more.
It’s not linear.
Trillions of inputs feed the brain every moment—no wonder it’s hard to pin pain down.
Remember: the system is all about protection.
10. “So It’s All In My Head?”—No.
This is a common (and frustrating) misread.
Yes, your brain produces pain.
But that doesn’t mean it’s imaginary.
Pain is a deeply complex experience—one that the brain generates based not just on physical input, but also on how safe it feels. This is why two people with the same injury can report wildly different levels of pain. It's not just about tissue damage; it’s about context, emotion, memory, and perceived threat.
Pain is not a simple signal. It’s a decision the brain makes after weighing all kinds of information—biological, psychological, and social. That’s why arguments that try to reduce it to “just in your head” or “purely physical” fall short.
Pain is a human experience—and it refuses to be pigeonholed.
11. What the Science Actually Shows 📊
🦴 Structure ≠ Pain
Brinjikji et al., 2015 – 3,000+ asymptomatic people:
88% of pain-free 60-year-olds had disc degeneration
68% had disc bulges
50% had disc protrusions
With no pain.
🎭 Sham Surgeries Work
NEJM, 2013 – Moseley et al.:
Fake knee surgeries relieved pain just as well as real ones.
Lancet, 2017 – Shoulder impingement trial:
Fake surgery = real relief.
Pain is neuroimmune, emotional, contextual.
🧠 Sensitisation Is Real
QST and fMRI studies show:
Lower pain thresholds
Brain activation in unrelated areas
Pain without new injury
That’s central sensitisation.
📸 Imaging Can Make It Worse
JAMA, 2014:
Early MRIs → More opioids, referrals, surgeries
Worse outcomes
🧪 Placebo Can Outperform Surgery
BMJ 2020 – Review of placebo-controlled surgeries:
Little to no benefit from real surgery vs placebo, especially in orthopaedics.
🛠️ Fusion Surgery Doesn’t Outperform Rehab
Spine, 2005 (Brox et al.):
Spinal fusion vs education/movement?
No difference in outcome.
🏃♂️ Movement + Education = Best Outcomes
Cochrane Review, 2021:
Movement and pain education outperform passive treatments.
Massage, needles, gadgets? Nice.
But movement and knowledge change lives.
😨 Fear = More Pain
FABQ and cohort studies confirm:
More fear → Worse outcomes
Fear rewires your system to be more sensitive and less tolerant
Education reduces fear, which reduces pain
🇦🇺 Australia’s Leading the Way
Pain Revolution: Prof. Lorimer Moseley’s outreach—less pain through better understanding
Explain Pain (Butler & Moseley): Changing how we think and treat pain globally
It’s not about thinking positive.
It’s about learning the system—and regaining control.
Menezes Costa et al., 2017 – Pathoanatomical explanations for pain lack consistent evidence.
O’Sullivan et al., 2018 – Persistent low back pain is more related to psychosocial than biomechanical factors.
Traeger et al., 2019 – Information alone can change pain trajectories.
The research is clear.
Most pain isn’t about damage.
It's about protection.
Adaptable, not fragile.
