Can you have pain and have no injury or tissue damage?

More pain equals more damage, right? Well not always!


Today we will look at an editorial in the BMJ called, “There is more to pain than tissue damage: Eight principles to guide care of acute non-traumatic pain in sport.”

There is more to pain than tissue damage: Eight principles to guide care of acute non-traumatic pain in sport

So, can you have pain and have no injury or tissue damage? 8 principles of why pain doesn’t always equal damage.

So, usually, damage occurs when the load exceeds the tolerance of the tissue, such as ligament tear or muscle injury. This can be a one-off overload or a cumulative one but what about when you have pain but you haven’t actually done anything traumatic to cause it?

This article goes into 8 important things to focus on when you have pain in sport and have no trauma to cause it.


Number 1:

Don’t assume that, because you have pain, that there is actually any tissue damage.

This is very true and important to understand because this belief may cause fear and avoidance of loading the painful area. This will slow your return to your sport due to de-conditioning and nobody got fitter and stronger by resting, did they?

So, if you have no logical reason behind why you started with pain, then there is a high chance that you haven’t got damage or at least any structural issue that pre-exists in your body won’t have been made worse innocuously. In this case, you don’t need to be worried about any tissue damage being made worse, however, but you still need to be aware of your ‘injury tolerance‘.

Number 2:

Don’t just get a scan.

The only reason for imaging is if serious pathology is suspected or if the scan result may change your treatment approach. The second reason is commonly the reason not to scan. For example, somebody will say what if my knee pain, that hurts when I squat is not what we are thinking? The answer is simple! You treat the patient not the scan and you build into tolerance to the problem itself. In most cases, the scan results come back and you still rehab the injury exactly the same, so what is the point?

Now if your rehab is stalling and you can’t progress then maybe a scan may be useful as it may indicate a change in rehab direction but sometimes even then it doesn’t change things because again, pain is not always structural as you can see in the video below:

Number 3:

Look for wider issues called biopsychosocial factors.

These can be things such as lack of sleep, stress, depression, anxiety etc. Surprising to most people, these factors can be the reason that pain has initiated. Essentially pain can be part of the fight or flight response rather than damage. For example, in neck pain stress is a major reason behind why it exists. Check out this to see more on this:

What Is The Biggest Cause Of Neck Pain?

Number 4:

It is important for your physio, doctor, coach etc. to give positive messages to myth bust.

For example, somebody may believe that when they lift with a rounded back they may damage their back or they may believe that loading a painful tendon will make their injury worse. The reality is that these are not true and the fear of these myths will hinder the rehab process and slow the return to sport. We have so much evidence showing that injury and pain can resolve from progressively loading the painful area, as this will build tolerance, both mechanically and from the central nervous system, allowing you to return to sport faster and be less likely to re-injure in the future.

Number 5:

Gradually expose the “injured” area to load within tolerance and build up slowly as it allows.

This is the cornerstone of rehab. The body adapts to stimulus to better handle it and this is why avoiding load will create regression, not progression. I would advise reading the following video on how to rehab correctly to get your tolerance built back to sporting level again:

How Do You Progress Your Rehab Exercises Correctly?

Number 6:

Use passive treatment only alongside the active treatment/rehab.

Yes, if you only perform passive modalities such as massage, mobilisation, acupuncture etc. then you can’t get the injury built back up. However, these passive treatments can help in certain scenarios to enable the rehab by reducing sensitivity or improving range or motor unit activation and more. So if you see a physio who only does the hands-on treatment and there are no progressive rehab components then they are not helping you to get back to your sport. In this case, the treatments are making you feel better transiently but you aren’t building back to full tolerance with this. Some people don’t even need any hands-on treatments and the rehab alone is sufficient but there are plenty of people who need some degree of passive treatment to settle pain and enable good progressive rehab to full fitness.


Number 7:

Use shared decision making to promote self-efficacy.  

There are many ways to treat and rehabilitate a patient back to a full return to their sport, so it is important to understand the patient’s goals. For example, I could have 2 patients with the same issue and one has previously responded to acupuncture and one has responded better to massage. I would be a fool to treat them differently from what has worked for them in the past. I could attempt to rationalise what is best for them but this may be more problematic. Obviously, you have to do certain things but some are more debatable and individual, remember that everybody is different and their beliefs can make a huge difference to how effective the process will be.

Use shared decision making to promote self-efficacy.  

It is important to know their expectations to be able to meet them. For example, somebody may need much more close guidance in their exercises and another may be fine with very little guidance. This needs to be discussed with the patient and the best decision that you are both happy with will yield the greatest results.

Number 8:

Use a multi-disciplinary approach to the athletes care.

This is key because all aspects are relevant. For example, nutritionists, psychologists, coaching staff etc. have to be all on the same page and need to be working together. If the physio says one thing but this isn’t sitting well with the athlete then the psychologist needs to work on this otherwise it won’t work. Nobody is an expert in all areas that are relevant to the athlete and their recovery. So the most ideal approach is to use experts for all aspects of their recovery to ensure everything is optimised for 100% return to sport.



So these are 8 great pointers to help the return to sport with acute non-traumatic pain in sport. As you can see the reasons for pain in sport are not always what they seem and this is why it’s really important to follow this guide, otherwise the athlete may become chronic and become more likely to never return to full fitness.


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If you need any further information or would like to book an appointment then call Hawkes Physiotherapy on 01782 771861 or 07866 195914.

  • Caneiro, J. P., et al. “There is more to pain than tissue damage: eight principles to guide care of acute non-traumatic pain in sport.” (2021): 75-77.
  • Radanov, B. P., Di Stefano, G., Schnidrig, A., & Ballinari, P. (1991). Role of psychosocial stress in recovery from common whiplash. The Lancet, 338(8769), 712-715.
  • Smedley, J., Inskip, H., Trevelyan, F., Buckle, P., Cooper, C., & Coggon, D. (2003). Risk factors for incident neck and shoulder pain in hospital nurses. Occupational and environmental medicine, 60(11), 864-869.
  • van Tulder, Maurits W., et al. “Spinal radiographic findings and nonspecific low back pain: a systematic review of observational studies.” Spine 22.4 (1997): 427-434.

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Put simply this is Physio done via either telephone or video over the internet. Skype and facetime are examples of this.

Contrary to popular belief online physiotherapy can be very effective and it can help the same injuries that face to face physio can help. I have helped many people with injuries such as disc prolapses, tennis elbow, neck pain and much more).