Finding the Primary Driver: Stop Treating the Victim and Find the First Domino

Clinical reasoning, meaningful tasks, and the art of figuring out what’s actually driving the problem

We all know that what hurts isn’t necessarily what’s causing the problem. Yet identifying the primary driver, rather than simply treating the area that’s complaining, remains one of the most challenging and important things we do as physical therapists.

Your patient comes in with knee pain. You find a collapsing foot, a femur moving medially, and a pelvis doing something interesting. You treat the foot, the knee improves, and everybody’s happy.

Except maybe the foot wasn’t the primary driver. Maybe the hip was driving the knee, or perhaps a restricted rib cage was influencing the entire lower extremity.

If we don’t figure out who’s driving and who’s compensating, we can spend an awful lot of time treating the victim.

Over the years, I’ve collected strategies from incredible mentors, including Peter Edgelow, Greg, Vicky, Dianne and LJ, Gary Gray, and others. Conversations with colleagues practicing Stecco Fascial Manipulation and visceral approaches have added further perspectives.

Most of these strategies aren’t new. Many of you already use them. What’s valuable is putting them together into a deliberate clinical reasoning process.

I don’t have a magical formula for finding the primary driver. If I did, I’d probably be retired on a beach somewhere.

But here are several strategies that help me develop, test, and continually refine my hypotheses.

1. History, History, History: Old Is Gold

If I had to choose just one strategy, it would be taking a really good history.

Shirley Sahrmann has emphasized how trauma, surgery, and repetitive movement influence tissues and movement patterns. I’d add sustained positions, immobility, and significant internal medical events.

Trauma, Surgery, and Scars

An old ankle sprain, a childhood fall on the coccyx, or a fracture 30 years ago may still be relevant.

I’m not suggesting every old injury causes today’s problem. But we should investigate whether it changed how the person moves, loads, or compensates.

Two favorite questions:

• “What injuries caused you to limp or change how you moved for a couple of weeks?”
• “Where are your scars?”

Patients frequently forget injuries but remember scars.

They’ll tell me they’ve never had a significant injury, then describe scars from a bicycle crash, abdominal surgery, and a childhood fracture.

Suddenly we have three events worth investigating.

Explore all surgeries, not just orthopedic procedures. Abdominal surgery, appendectomies, and other procedures may affect tissue mobility or movement strategies even when the surgical site isn’t painful.

Repetitive Motion and Sustained Positions

I spent years rowing competitively, frequently on the same side of the boat, and I’ve spent thousands of hours cycling. I’d be surprised if those activities hadn’t influenced my movement patterns.

The same applies to tennis players, runners, musicians, and people performing repetitive work.

Ask:

“What have you done a lot of in your life?”

Not just recently, but over decades.

Consider someone who spent 20 years holding a telephone between their shoulder and ear, or sitting at a computer eight hours daily.

Sustained positioning and periods of immobilization may also influence tissue mobility and movement strategies.

What Makes It Worse? And What Hurt First?

Aggravating activities provide clues.

Does sitting increase symptoms? Does walking help? What happens with sustained flexion, extension, rotation, or loading?

These patterns help narrow our hypotheses without establishing a diagnosis by themselves.

Another favorite question:

“What was the first pain you remember that significantly limited you?”

Perhaps the patient injured an ankle at 15, developed knee pain at 25, hip pain at 35, and back pain at 45.

Is that progression meaningful? Maybe.

But it’s a hypothesis worth investigating.

I’m listening for patterns across their lifetime, not simply collecting diagnoses.

2. Look for the Most Off-Axis Segments

One strategy I’ve learned from Greg is identifying structures that are significantly off-axis.

In the spine, he often looks for the most anterior or posterior segments.

Maybe T6 is remarkably posterior or C4 is significantly anterior.

Outside the spine, we might find a laterally translated talus, a sheared cuneiform, or a femur moving substantially away from its optimal axis.

These findings don’t automatically establish causation, but they deserve attention, particularly when they correspond to a significant trauma.

Suppose someone has an old ankle injury, an unusually translated talus, and movement dysfunction that appears to originate around the foot.

Now several findings point toward the same region.

That’s more compelling than simply discovering that the talus doesn’t move well.

3. General Listening: Where Is the System Drawing You?

Jean-Pierre Barral’s general listening offers another way to direct our attention.

I’m not always able to identify the exact tissue involved. Frankly, most of the time I can’t.

But I may identify a region.

Is the restriction drawing me anteriorly or posteriorly? Above or below the diaphragm? Right or left?

Suppose general listening draws me toward the right lower abdomen. The patient has a history of abdominal surgery there, and I find substantial tissue restriction in that region.

Now I have several findings suggesting where to investigate.

I like having multiple findings converge on a hypothesis.

They’re not necessarily independent, and agreement doesn’t prove causation. But convergence helps prioritize the next assessment.

4. Meaningful Tasks: First and Furthest Off-Axis

Dianne and LJ have greatly influenced how I identify primary drivers through meaningful tasks and areas of non-optimal load transfer.

Choose a task relevant to the patient’s symptoms or goals: walking, squatting, stepping down, reaching overhead, or shifting weight onto one leg.

Then look for two things:

What goes off-axis first, and what goes furthest off-axis?

Imagine someone shifting onto their right leg.

The femur translates medially, the foot collapses, and the thoracic spine shears and rotates.

Which structure becomes dysfunctional first? Which moves furthest?

These observations help identify potential drivers.

But the next step is even more important.

Correct the Suspected Driver—and Look for What Gets Worse

Suppose I manually improve the position of the femur while the patient repeats the task.

The knee tracks better, the foot improves, and the patient feels stronger.

Excellent.

But here’s the question I consider even more important:

What got worse?

For years, I was really good at noticing everything that improved when I made a correction.

I’d correct the foot, see the knee improve, and think, “Beautiful! I’ve found it.”

Meanwhile, the lumbar spine had gone into extension or the rib cage had sheared dramatically.

I was so pleased with what I’d improved that I missed what I’d made worse.

Now I deliberately search for deterioration elsewhere.

My eyes naturally find the improvements. I have to make myself look for the problems.

The Compensation You Just Exposed

Suppose I correct the hip.

The knee and foot improve, but now the rib cage shears left and rotates right.

Rather than dismissing the hip, I wonder whether it was compensating for something happening in the thorax.

So I maintain the hip correction and add a correction to the rib cage.

Now the hip, knee, foot, and thorax all improve.

Perhaps the thorax is more primary. Perhaps both regions contribute.

Either way, I’ve learned something important about their relationship.

A correction that makes something worse isn’t necessarily a failed test. Sometimes it’s the most useful information you’ve collected all day.

5. What If the Primary Driver Doesn’t Have Any Wiggle Room?

During a recent discussion, Brent raised an important limitation.

What happens when the suspected driver is so restricted that you can’t meaningfully correct it?

Imagine a profoundly stiff foot or a cranial structure restricted following trauma or surgery.

You attempt a correction, but the structure barely moves. Instead, the rest of the system moves around it.

Does that mean it isn’t a primary driver?

Not necessarily.

Brent called this a “bossy” driver.

I like that description.

Sometimes a structure is so restricted that the rest of the body has organized itself around accommodating it.

My approach is to work within whatever mechanical capacity remains.

Can I improve its position or mobility by 10%, 20%, or 30%?

Sometimes even a small change is enough to alter the neuromuscular response and reveal a meaningful relationship.

And sometimes it isn’t.

Failure to improve a meaningful task through manual correction doesn’t automatically eliminate that structure as a potential driver.

If positional correction isn’t possible, a brief trial treatment may provide more information.

6. Trial Treatment: Let the Treatment Become the Correction

Sometimes the history, palpation, and movement assessment suggest a particular structure is important, but I can’t adequately correct it during the meaningful task.

Rather than abandoning the hypothesis, I’ll perform a brief trial treatment.

Perhaps I spend 10–15 minutes improving mobility in the foot, thorax, or another suspected region.

Then I return to the original meaningful task.

Did the patient’s experience improve? Did other areas of non-optimal load transfer improve? Did anything get worse?

Most importantly, what changed in the relationships between the regions?

The treatment becomes a way of testing the hypothesis.

A positive response doesn’t prove that the treated structure was the original cause. Pain modulation, motor control, and other factors may contribute.

But a meaningful change gives us useful clinical information.

If nothing changes, perhaps our hypothesis needs revisiting.

7. Stecco Fascial Manipulation: Another Way to Follow the Compensation

Colleagues trained in Stecco Fascial Manipulation have added another perspective.

Many of us approach primary drivers through joint biomechanics, alignment, and load transfer.

The Stecco approach emphasizes tissue adaptation, patterns of compensation, and palpatory findings associated with fascial densification.

History remains essential: old fractures, surgeries, repetitive activities, sustained postures, and immobility help identify possible starting points.

The clinician then uses palpation to investigate tissue mobility and density along relevant fascial sequences and spirals.

Rather than focusing primarily on which joint is furthest off-axis, the emphasis is on identifying potentially influential tissue restrictions.

Develop a hypothesis, treat the suspected region, and reassess.

If the expected changes occur, continue investigating that relationship. If not, reconsider.

Different assessment emphasis, but a familiar process:

History → Hypothesis → Assessment → Intervention → Reassessment.

Multiple frameworks can be useful, provided we don’t mistake every palpatory finding for a proven causal relationship.

8. Don’t Forget What’s Happening Inside the Body

What about infections, significant inflammatory episodes, internal bleeding, or prolonged illness?

These events may alter physical capacity, pain experience, activity tolerance, and movement behavior.

Manual therapy frameworks sometimes consider changes in visceral or fascial mobility following surgery or inflammation, although the specific mechanical explanations require careful evaluation.

Importantly, a patient who develops widespread symptoms and exercise intolerance after a significant infection may have ongoing medical issues rather than a primarily biomechanical problem.

Not every primary driver is a joint, fascia, nerve, or visceral restriction.

Sometimes the most important decision is recognizing the need for additional medical evaluation or interdisciplinary care.

Early Development and the Whole Person

For patients with longstanding or unexplained movement patterns, childhood injuries, developmental history, and structural changes during growth may provide additional clues.

Psychosocial factors, including adverse childhood experiences and chronic stress, can also influence pain, recovery, and movement behavior.

That doesn’t mean persistent pain is simply psychological.

It means we’re treating a whole person.

Sensitive questions should be asked with permission and without assuming that a particular life experience explains the patient’s symptoms.

9. The Rolling Hypothesis: Relationships Matter More Than Isolated Findings

If there’s one concept that’s become increasingly important to me over the years, it’s relationships.

It’s not enough to know that the foot is restricted, the hip is off-axis, and the thoracic spine doesn’t rotate well.

I want to know how those findings relate to one another.

What happens to the hip when I correct the foot?

What happens to the thorax when I improve the hip?

What happens to the patient’s meaningful task when I treat the thorax?

And what happens to everything else along the way?

These relationships form the basis of what I call my rolling hypothesis.

At any given moment, I have an idea about which structure is most important, and hopefully a second and third possibility.

Maybe the foot accounts for 70% of the problem and the thorax for 30%. Or perhaps the hip and rib cage are co-drivers.

Those percentages aren’t measurements. They’re simply a way of organizing my thinking.

I test one hypothesis, observe the response, and update my understanding.

The goal isn’t to prove my original hypothesis correct. It’s to get closer to understanding what’s actually happening.

This can be harder than it sounds.

We become attached to our clinical explanations, particularly after investing time and energy in them.

But if treatment doesn’t produce the expected response, we need to reconsider.

Perhaps we chose the wrong structure, the wrong intervention, or missed another driver.

Or perhaps the problem isn’t primarily mechanical.

Primary Drivers Change Over Time

It’s relatively uncommon to find one primary driver, treat it, and watch everything else resolve.

Usually several factors contribute.

An old injury may initiate a compensation that eventually develops its own restrictions and altered motor control.

Now both regions need attention.

As one improves, another may become more clinically relevant.

It’s like peeling an onion.

Sometimes without the tears.

The most important driver today may not be the same one three visits from now.

Sometimes the structure that looks worst isn’t the most important. Sometimes a compensation has become a significant problem in its own right.

Sometimes two or three regions are working together, in cahoots, to create the dysfunction we’re seeing.

And sometimes our original explanation is simply wrong.

That’s why I keep returning to the relationships between structures rather than getting attached to any one isolated finding.

Putting It All Together

When searching for primary drivers, I organize my reasoning around six questions:

1. What does the history suggest? Look for injuries, surgeries, scars, repetitive activities, sustained positions, medical events, and symptom progression.
2. Where are the significant dysfunctions? Use movement assessment, palpation, off-axis findings, general listening, and other examination strategies.
3. What happens during a meaningful task? Look for the first and furthest areas of non-optimal load transfer.
4. What happens when I make a correction? What improves, and especially, what gets worse?
5. What happens after a trial treatment? Reassess the meaningful task and the relationships between regions.
6. Does my hypothesis still make sense? If the findings don’t support it, change it.

The more we understand these relationships, the less likely we are to keep treating the victim while the real driver continues doing its thing.

Keep asking questions. Keep testing hypotheses. Look for what improves, and deliberately search for what gets worse.

And don’t get too attached to being right.

Our job isn’t to defend our favorite theory. It’s to help the patient get better.

I’d love to hear what strategies you’ve found most useful for identifying primary drivers, particularly those I’ve missed.

Most of what I’ve learned has come from generous mentors and thoughtful conversations with other physical therapists.

And I’m still learning.

Curtis Cramblett, PT, CFMT, CSCS, CAFS

Revolutions in Fitness