'Sometimes I feel like the only physio in the whole wide world, so alone'.

Background: High-impact chronic pain (HICP) presents significant challenges within primary healthcare (PHC) settings, particularly in resource-constrained environments such as South Africa. Limited evidence exists regarding physiotherapists' lived experiences managing this condition in local contexts. Objectives: This study explored facilitators and barriers to providing adequate care for individuals with HICP, as experienced by physiotherapists working in Western Cape PHC facilities. It is envisaged that the findings may contribute to curriculum development, policy considerations, and clinical practice enhancement. Method: A descriptive qualitative approach was employed, and semi-structured virtual interviews were conducted with eight purposively selected physiotherapists from Western Cape PHC facilities. Inductive thematic analysis guided data interpretation. Results: Analysis revealed four interconnected themes: (1) High-impact chronic pain as a complex and disabling burden in PHC settings, (2) person-centred approaches as key facilitators, (3) systemic and personal barriers constraining effective management, and (4) specific needs for improved HICP care. While person-centred approaches were valued, participants struggled with implementation amid resource constraints. Conclusion: High-impact chronic pain management in South African PHC settings requires attention to interrelated factors of time, support, and knowledge. While physiotherapists recognise effective approaches, implementation challenges necessitate systemic adjustments. Clinical implications: These insights highlight the necessity for workforce planning reform, professional development in pain management, and enhanced interdisciplinary collaboration to better serve patients with HICP in resource-limited settings.