What causes pain may not be what maintains it.

When someone experiences pain—whether it’s acute, nagging, or persistent—the natural question is, “What’s causing this?” For both patients and clinicians, this often leads to a hunt for a specific tissue or structure to blame. A muscle, a joint, a disc. But pinpointing a source of pain isn’t always the same as identifying the cause. Just because we can see something on a scan or feel tenderness in a particular area doesn’t necessarily explain why it hurts, or more importantly, why it’s still hurting.

Pain is complex. And it evolves. That means the factors involved in the beginning might not be the ones keeping it going. This is where it helps to expand our view of causation. We can break it down into a few different areas: risk factors (like previous injuries or general health), the initial triggering event (such as a fall, strain, or accident), and then the maintaining factors—the ones that can keep pain around long after the original issue has healed.

Maintaining factors are sneaky. They may not have anything to do with how the pain started, but they can play a big role in how long it lasts. Nervous system changes are a big one—the system can become more sensitive, more reactive, more “on alert.” In fact, one of the most reliable predictors of future pain or injury is having had it in the past. The body remembers and sometimes it doesn’t let go easily.

So is pain in the brain? Yes and no. The reason we have moved away from saying this is because pain at the lies on multiple systems working together. Perception is only one part of that and the brain could well be an even lesser part than we originally thought.

All pain is real and true, but when we say it is in the brain we are in very close territory to suggesting it is in that persons head which is one of the key and important factors in us moving away from the language and catchphrases of pain being in the brain.

The biopsychosocial model of pain itself may well be more responsive than causative which could also be considered causation It can all seem so tricky because regardless of what the bro podcasts, bio hackers and ‘fix it in three steps’ influencers would have us believe – it’s just not that black and white. When you make the decision to follow facts and evidence and prioritise the person not the problem, you have to be prepared to change your opinion and deal with fluctuations in this field of interest amidst the cacophonous and overwhelming absolutism of click bait culture.

There are also psychological changes to consider. Fear of pain or re-injury can alter the way we move and behave, leading to avoidance of certain movements, positions, or activities. That can snowball into motor adaptations—compensations that may not be helpful in the long run. Add to that potential lifestyle changes—like reduced activity, poor sleep, increased stress—and suddenly our whole internal ecosystem may shift toward a more inflammatory, less resilient state.

So when we talk about treating the “cause” of pain, it’s worth asking: are we focusing on the right thing? Do we even know? The thing that started it all may no longer be the thing driving it. Modern pain research is increasingly showing that pain is not just about what was injured, but how our systems respond and adjust to that injury over time.

What causes pain may not be what maintains pain—and some systems may be simply being responsive, not causative.