Objective: To highlight the necessity for on-going vigilance of serious pathology when assessing and managing people with spinal pain. Methods: A case report of a young male patient who sought physiotherapy treatment for his acute thoracic pain. Following physiotherapy assessment, it seemed unlikely that the pain was related to a musculoskeletal problem. Besides pain-induced vomiting, there were no overt signs of serious pathology. However, he had a family history of cardiac issues. The patient was referred back to his general practitioner (GP) for further assessment. Results: The patient was subsequently diagnosed with perimyocarditis following investigations and was treated accordingly. At 6, 12 and 24 months follow-up, he reported good health. Conclusions and impact statement: Physiotherapists must remain vigilant of serious pathology even if patients have been examined by other healthcare professionals. This case also raises the issue of whether `vascular profiling¿ should be part of routine practice protocols.