Why pain can continue even after an injury has healed

There is a strange stage of recovery that can be difficult to make sense of. The “injury” has healed. The fracture has joined. The wound has closed, if that’s the case. The inflammation has settled. Perhaps the scan looks reassuring and yet, the pain remains.

For the person experiencing it, this can be deeply confusing. It can also create a particularly unhelpful assumption: if the pain is still there, something must still be damaged.

Pain, however, is not a direct measurement of tissue damage.

It is an experience produced by the nervous system, drawing on information from the body alongside previous experience, expectations and the context in which those signals are being interpreted. That distinction is at the heart of modern pain science, and it helps explain why pain and tissue damage do not always move together.

Think about what happens immediately after an injury.

Your nervous system has a very good reason to become protective. Movement changes, muscles tighten. You become more aware of the injured area. You may avoid certain positions because they hurt. You learn which movements feel threatening and which feel safe.

This is useful information while the body is vulnerable.

The interesting part is what happens later.

The nervous system does not have a simple switch that says injury healed now return to normal. It is continually trying to work out what is happening and what level of protection might be appropriate. Research into predictive processing suggests that the brain uses previous experience and expectations alongside incoming sensory information when constructing our experience of the body.

That means recovery is not simply a matter of waiting for damaged tissue to repair itself.

The nervous system also has to update its understanding of what is safe.

When protection outlives the original threat is where something particularly interesting happens.

Protective behaviour can sometimes make it harder for the nervous system to learn that circumstances have changed.

Imagine someone who injured their back lifting a heavy box. For several weeks, avoiding bending makes perfect sense. As recovery progresses, however, they may continue to bend cautiously (or stop bending altogether) because the movement has become associated with danger.

Every time the back feels uncomfortable, the old prediction can be reinforced.

This reminds me of a TED Talk I watched recently, given back in 2011 by an Australian pain scientist, Professor Lorimer Moseley. With more than 30 years of experience researching chronic pain, over 300 scientific papers and several books to his name, he certainly knows a thing or two about pain.

In the talk, Moseley shares a remarkable story from his own experience. While walking through the Australian bush one day, he felt something brush against the outside of his left leg. It felt like a twig, so he barely gave it a second thought and carried on walking. What he didn't know was that he had just been bitten by an eastern brown snake. The sensation hadn't been interpreted by his nervous system as an immediate threat, so no significant pain response followed. Months later, while walking in the bush again, he felt an almost identical sensation in exactly the same place. This time, he dropped to the ground in agony. His nervous system had learned something from the first experience: a sensation like that could mean danger. The culprit was another twig. The tissue was perfectly safe, but his brain had a very good reason to sound the alarm. It's a fascinating example of how previous experience can influence the way the nervous system interprets incoming sensations and, ultimately, whether we experience them as pain.

I recommend watching it, it’s also funny!

Now, that does not mean the pain is imaginary. The sensation is real. It means the sensation cannot automatically tell us how much damage is currently present.

A recent control-theory account of post-injury pain describes this problem particularly well: the brain is continually estimating the state of the injured body, while protective behaviours can sometimes obscure the information that would allow it to update that estimate. Avoiding movement, for example, may reduce the opportunity to discover that a previously threatening movement is now tolerable.

This is one reason recovery can become complicated.

The behaviour that was sensible at one stage can become unhelpful at another.

Pain science has another important caution here. Terms such as central sensitisation are sometimes used as if they provide a complete explanation for persistent pain after an injury has healed. The evidence is considerably more nuanced. A comprehensive review found no strong evidence that central sensitisation following an injury can simply persist as an autonomous pain generator after the original injury has healed.

That matters because people deserve explanations that are both reassuring and scientifically honest.

Persistent pain is real. It can be influenced by changes in how the nervous system processes information. But that does not mean there is one hidden mechanism responsible for every person's pain.

The nervous system can learn safety too

Perhaps the most useful implication of this science is that the story does not have to end with this is how your nervous system is now.

The nervous system is capable of learning and adapting.

That is one of the reasons carefully graded activity can be so important in persistent pain. It gives the system new information. A movement that was once associated with danger can, over time and under the right conditions, become less threatening.

This is very different from forcing yourself through pain or adopting a “push harder” mentality. The aim is never to prove that pain does not exist, it is to create experiences from which the nervous system can learn something new.

This is where pain recovery becomes much more interesting than a simple story about damaged tissue. A person may need to rebuild confidence in movement, change the way they interpret sensations, gradually expand what they do, sleep better, manage stress and understand their own patterns of flare-ups and recovery. These factors do not mean that pain is psychological. They are part of the biological context in which pain is experienced.

The brain is constantly updating its predictions from experience so sometimes recovery involves giving it better information.

A different way of thinking about persistent pain

There is something quite powerful about understanding pain this way.

It moves the conversation away from the idea that every painful sensation must represent new damage, without dismissing the sensation itself.

It also gives people something practical to work with. Instead of treating pain as a perfect gauge of what is happening inside the body, we can begin to see it as one piece of information within a much larger system.

That distinction can change behaviour.

Someone who believes pain means I am damaging myself is likely to protect themselves from movement.

Someone who understands that pain can persist after tissue healing may be able to approach movement differently—with appropriate clinical guidance, curiosity and patience.

That shift in understanding does not make pain disappear overnight. It can, however, change the relationship a person has with it.

That is where meaningful progress begins.

The Ciao Change perspective

At Ciao Change, this is an important part of how I approach persistent pain. I don't want people to be frightened by their symptoms, nor do I want to tell them that their pain is “all in their head”. Pain deserves to be taken seriously while also being understood in the context of the whole nervous system and the person's life.

The aim is to help people understand what their body may be communicating, build confidence in what they can do, and gradually create the experiences that support a different relationship with pain.

Because the body can heal before we feel recovered.

And sometimes, the next part of recovery is helping the nervous system catch up.

Sources and further reading

Kube, T., Rozenkrantz, L., Rief, W. & Barsky, A. (2020). Understanding persistent physical symptoms: Conceptual integration of psychological expectation models and predictive processing accounts. Clinical Psychology Review, 76, 101829. DOI: 10.1016/j.cpr.2020.101829.

Ted Talk Professor Lorimer Moseley 2011 - TEDxAdelaide - Lorimer Moseley - Why Things Hurt - https://www.youtube.com/watch?v=gwd-wLdIHjs&t=11s

Post-injury pain and behaviour: a control theory perspective (2023). PMID: 37165018.

Brazenor, G.A., Malham, G.M. & Teddy, P.J. (2022). Can Central Sensitization After Injury Persist as an Autonomous Pain Generator? A Comprehensive Search for Evidence. Pain Medicine, 23(7), 1283–1298. DOI: 10.1093/pm/pnab319.

Castejón, J. et al. (2024). Chronic pain – A maladaptive compensation to unbalanced hierarchical predictive processing. NeuroImage, 297, 120711. DOI: 10.1016/j.neuroimage.2024.120711.

Disclaimer: This article is for informational purposes only, even if and regardless of whether it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of Ciao Change Ltd unless specified under “The Ciao Change perspective” section.