why does pain not always show up immediately after injury?

WHY CAN PAIN TAKE TIME TO
SHOW UP AFTER AN INJURY?

Sometimes I get emails that beg to be answered via a posted article so that everyone can learn something (HERE’S ANOTHER ONE).  The question below was sent to me by an individual who will remain anonymous.  Understand that what she is going through is happening all over the country, all day, every day.  In fact, I see similar scenarios so often, I would almost call this the norm.

Dear Dr. Schierling,

I am a female with no history of back or pelvic injury.  About eight months ago, while transporting a patient in the Emergency Department, something happened to the gurney, causing my body to be forcibly twisted.  As I strained to correct the situation (the whole thing lasted just a couple of seconds) I felt a tearing sensation in the upper portion of both buttocks that sort of felt like old elastic giving way. 

After the initial pain during the twist I did not feel any more pain for about 4-5 days. Then I started having shooting pains in my left buttocks and then the right buttock three different times over a two week period. The third time I felt the pain I almost went to the ground it was so severe. It was at this time that I sought medical attention.

After months of tests, injections, and PT I was diagnosed with Myofascial Pain Syndrome (MPS). My question is, can myofascial tissue be torn and there not be pain?  In other words, does the pain have to show up immediately, or can there be a delay in the onset of pain if the injured area is not being stressed by my work?

The Workman’s Compensation doctor is saying that the MPS is not from the injury because of the delay time for the pain. The physiatrist that I am seeing only wants to treat the symptoms without finding out the cause.  Since I am an RN, I find this both frustrating and hard to swallow.

Sincerely,
Jane Doe

Hello Jane,

There are several points here that need to be addressed, and I will attempt to tackle them one by one. Also bear in mind that while this is being written in regard to your question, not everything here is going to pertain specifically to you. The first thing I want my readers to understand is that when it comes to Workman’s Comp, they are never your friend.  Not sure what state you live in, but it’s important to be aware that some are much worse than others.  By the way, the same phenomenon you are going through occurs thousands upon thousands of times a day with INJURIES CAUSED BY MVA’S

Because of the way our insurance system is set up, in order to treat people, there has to be a working diagnosis.  Unfortunately, these diagnosis are frequently wrong (MUPS).  Why?  Because so many health problems don’t show up on tests the way we have always been taught (HERE).  For instance, you can imagine how big a deal it is that the single most pain-sensitive tissue in the body (FASCIA — which also happens to be the most abundant connective tissue) does not image well with standard advanced imaging techniques such as MRI (HERE).  On top of this, the NSAIDS and CORTICOSTEROID INJECTIONS so frequently used for treating the sort of injury you received, are not therapeutic (i.e. — they do not aid the healing process, but actually inhibit it — HERE). 

Another thing I would like to briefly address is your diagnosis of MPS.  MPS is a diagnosis that is almost always given to those struggling with TRIGGER POINTS.  Understand, however, that when it comes to the sort of injury that it sounds to me like you are dealing with, FASCIAL ADHESIONS are a much more likely choice.  This point might be splitting hairs, as the vast majority of the medical community is going to attack them the same way (HERE), but the reality is that while potentially related, they are two very different problems.  But we still have not answered the main question……

WHY DOES THE PAIN NOT SHOW UP IMMEDIATELY AFTER INJURY?

“Nearly 1.7 million traumatic brain injuries (TBI) occur every year in the US, and they have a significant impact on the lives of patients and their families. Headache is the most common complaint, and it can occur after mild, moderate or severe injury.  The International Classification of Headache Disorders (ICHD) includes diagnostic criteria for post-traumatic headache. According to ICHD, post-traumatic headaches must occur within seven days of injury.  The rule that headaches must occur within one week of injury may not reflect reality. Some individuals appear to develop post-traumatic headache in a delayed manner. In the study by Walker about one quarter of the patients without headaches immediately after TBI had ‘delayed onset’ headaches at six months.”  From the American Migraine Foundation’s website (Post-Traumatic Headaches)

“Is there really such a big difference between the three day delayed onset so commonly discussed in the literature, and the four day delayed onset being claimed by Jane but being rebutted by Workman’s Comp?  To claim that this 24 hour or so difference is somehow a deal-breaker for Jane’s claim is absurd.”   Dr. Russell S. Schierling

And now for the answer to the question Jane is really looking for — why does pain sometimes not show up immediately after injury?  Let me start out by saying that delayed onset of pain is, in many instances, more common than the instant onset of pain.  Following a quick Google search for “delayed onset pain” I came up with many many attorneys advertising for injured persons.  They all basically said something like this quote taken from Nolo dot com.  “Soft tissue injuries typically result in pain, swelling, and reduced mobility, but these symptoms may not show up immediately. They can take days, even weeks, to manifest. In addition, soft tissue injuries are not visible on an X-ray. This makes them more challenging to diagnose and document.”  None of these attorneys, however, seemed to have good articles on why this is the case. 

The most common reason given for delayed onset of pain was “excitement“.  Because there was a good deal of adrenaline surrounding the accident / injury, you didn’t realize you were hurt immediately. Sorry, but except for rare exceptions, I am not buying this.  Not to mention, the web is loaded with all sorts of evidence proving Jane’s side of things (HERE is a great example, although it really has nothing to do with her specific problem).  The thing is, it’s not like this concept of delayed onset of pain after a physical trauma is anything new, or that it’s solely related to litigation. 

Back in 1941 (the year Pearl Harbor was attacked by the Japanese), Martin Brazelay graduated from Harvard with a masters degree in engineering.  After working on aircraft design throughout the SECOND WORLD WAR, Brazelay became a Professor of Mechanical and Aerospace Engineering at Syracuse University in 1947.  Upon retirement from teaching and research he became one of the world’s foremost experts on accident reconstruction.  In chapter 46 of his 1984 treatise Scientific Automobile Accident Reconstruction (BTW, this thing will cost you over $4,300), Brazelay revealed that, “Whiplash injuries may be present as a result of automobile accidents, even though no physical, radiological or other objective evidence of injury can be found. Sometimes there may be as much as weeks or even months delay between the automobile accident and the experience of symptoms.”  He wrote these words as I was graduating from HIGH SCHOOL — almost 33 years ago.

Let’s shift gears for a moment and talk about something known as Delayed Onset Muscle Soreness. According to that pinnacle of truth and veracity, Wikipedia (you can double check their definition by looking at any of dozens of studies on PubMed), “Delayed onset muscle soreness (DOMS) is the pain and stiffness felt in muscles several hours to days after unaccustomed or strenuous exercise.  The soreness is felt most strongly 24 to 72 hours after the exercise and is thought to be caused by microtrauma to the muscle fibers.  Delayed onset muscle soreness is one symptom of exercise-induced muscle damage. The other is acute muscle soreness, which appears during and immediately after exercise.”   Now, listen to what Paul Ingram has to say on the subject in this completely cherry-picked quote (as are many quotes I use) from the November 20, 2016 article on his PainScience site (The Biological Mysteries of “Muscle Fever,” Nature’s Little Tax on Exercise)

“Medical science can barely even explain DOMS, let alone treat it.  [It is caused by] exercise or other physical stresses outside your normal range of intensity — anything you aren’t used to. Even extremely well-conditioned athletes can get DOMS, if they train harder than usual. Eccentric contractions — controlled elongation — cause DOMS far more readily than concentric contractions.  Maybe the worst DOMS I ever had was after a night of dancing and, yes, a little ‘head banging.’ (I grew up in a Canadian logging town; AC/DC and Metallica were like gods to us.) Even a little head banging can be hard on neck muscles. I could barely lift my head off my pillow for 3 days.

Neurology never comes up when professionals talk DOMS. It’s really not on anyone’s radar, but it should be.  We’ve established that DOMS is obviously more complicated than it seems on the surface, and nothing demonstrates that more clearly than an 2011 study, which showed that it can actually spread — probably via a neurological mechanism — to adjacent muscles groups that were not exercised at all.  Thus DOMS may well often feel much worse and more extensive to some patients than it ‘should’ feel … and with an explanation that isn’t really on anyone’s radar.  The biology of pain is never really straightforward, even when it appears to be.” 

DOMS, however, is not an “injury” as we think of the term; it is due to overworking untrained muscles or really overworking well-trained muscles.  If working out too hard has the ability to cause this sort of pain and stiffness — pain and stiffness that peer-review commonly describes as showing up 24 to 72 hours after the initial injury, do you think that a real injury — an injury that physically and mechanically compromises connective tissues — could manifest somewhat differently and potentially worse?  In light of what we’ve seen so far, it certainly appears so.  A side note that was doubly interesting about Ingraham’s article is that one of two things he mentioned as actually being potentially beneficial for DOMS was CURCUMIN — the highly anti-inflammatory yellow component of the spice Tumeric — that just just happened to be the topic of my last blog post (see link).  Let’s now move out of DOMS and back into the realm of real injuries.

Medical doctor, surgeon, and medico-legal expert, Dr. Colin Tidy of Oxfordshire, England, writing for Patient dot info (Whiplash and Cervical Spine Injury) states that, “Most cases of whiplash injury occur as the result of rear-end vehicle collisions at speeds of less than 14 miles per hour. Patients present with neck pain and stiffness, occipital headache, thoracic back pain and/or lumbar back pain and upper-limb pain and paraesthesia.  The clinical symptoms of whiplash injury may not develop until 6-12 hours after the injury, or even after a few days.”  Dr. Tidy also mentions that the top risk factor for indicating a potentially serious injury is, “immediate onset of neck pain following the event.”  He goes on to say that, “studies have shown that the strongest prognostic indicators are factors that are present before impact. Lankester et al found that the factors that showed significant association with poor outcome on both physical and psychological outcome scales were pre-injury back pain, high frequency of GP attendance, evidence of pre-injury depression or anxiety symptoms, front position in the vehicle and pain radiating away from the neck after injury.”   Not sure whether or not Jane had DEPRESSION, but as per what little history she sent me, she did not seem to have pre-existing back issues.  Let me show you another area where delayed onset of pain is considered the norm.

Problems with the jaw (TMJ / TMD) don’t always show up immediately after injury as shown by a 2007 study (Delayed Temporomandibular Joint Pain and Dysfunction Induced by Whiplash Trauma: A Controlled Prospective Study) from the Journal of the American Dental Association.  “The authors studied 60 consecutive patients who had neck symptoms after whiplash trauma and were seen at a hospital emergency department. They followed up 59 subjects one full year later.  The incidence of new symptoms of TMJ pain, dysfunction or both between the initial examination and follow-up was five times higher in subjects than in control subjects.  Our results suggest that one in three people who are exposed to whiplash trauma is at risk of developing delayed TMJ symptoms that may require clinical management.”  And in similar fashion….

The jaw problems might be partially explained by a HEADACHE study published five years earlier in the journal Pain (Antinociceptive Reflex Alteration in Acute Posttraumatic Headache Following Whiplash Injury) due simply to the fact that the temporalis is one of four muscles that allow you to chew (one of the four muscles of mastication).  According to the authors, whiplash injuries lead to, “Brainstem-mediated antinociceptive inhibitory reflexes of the temporalis muscle….”  In English, this means that anti-pain inhibitory reflexes (reflexes from the brainstem that could best be described as anti anti-pain responses) frequently led to — well, pain, via “reflex abnormalities [which] are considered a neurophysiological correlate of the posttraumatic (cervico)-cephalic pain syndrome [headache]. The authors point to an altered central pain control in acute post-traumatic… following whiplash injury but without neurological deficits, bone injury of the cervical spine, or a combined direct head trauma on average 5 days after the acceleration trauma.”  In other words, it took five days for aberrant reflexes from the neck / brainstem to raise their ugly heads and cause headaches after injuries that many doctors would write off as “WHIPLASH” simply because there was no blood, guts, broken bones, or overtly objective physical findings.

A 2001 study from the journal Brain (Delayed Onset and Resolution of Pain: Some Observations and Implications) took things a bit further, opening the door for (delayed) development of more serious complications like possible CENTRAL SENSITIZATION OR CRPS.  “Late-onset pains may develop gradually or suddenly, and may be brief or long standing. Pains which develop after an innocuous insult may be associated with slowly evolving sensory changes. However, even long-standing pains, particularly those of nociceptive origin, may resolve sometimes after many years. Resolution, which again can occur gradually or suddenly, may be spontaneous or follow development of another disorder or after therapeutic intervention. The duration of this pain relief can range from minutes to an indefinite period.  It is postulated that mechanisms implicated in acute pain may not be the same as those that subserve pain that develops after a long interval. Those late-onset pains which develop slowly after innocuous lesions may be associated with a variety of slow anatomical, physiological and biochemical changes.”  There is, however, a significant difference between an injury to the NECK / brainstem and / or BRAIN, and an injury to the PELVIS or GLUTEAL MUSCLES.  However, because of Fascia’s connection to both scar tissue / fibrosis and chronic pain (HERE), the later can sometimes prove problematic and even debilitating.

This leads to to wonder if the delay of days or weeks might be due to the INFLAMMATORY / FIBROTIC aspect of the healing process itself hypersensitizing nerves and leading to Allodynia or Hyperalgia?  If you scroll down my COLLAGEN SUPER-PAGE, you come to the section titled The Phases / Stages of Tissue Repair & Healing, in which I deal with its four distinct phases.  Remember that SCAR TISSUE was just beginning to be laid down when Jane felt her second buttock pain. 

So, what can I definitively say about delayed onset of pain after an injury?  Nothing really except that it is poorly understood, yet extremely common. Unfortunately, this always works in the favor of the insurance company (and also unfortunately, there seem to be increasing numbers of people being attracted to attorney’s TV advertisements).  Ultimately, what all this means that everything under the sun will be used against you — the injured person.  Previous injuries or pain (none in this case, but if you’ve ever visited a chiro for any reason, prepare to be accused). Degenerative changes in the spine or joints (almost guaranteed by age 50, but virtually impossible to correlate to present symptoms — HERE).  Drug seeking (don’t be surprised if you are accused of being a closet addict on the prowl for your next fix — HERE).  Greed (you will be accused of malingering for the sake of collecting a monetary settlement).  Laziness (don’t be surprised if you are accused of faking the injury so that you can stay at home collecting Disability).

Because pain — especially CHRONIC PAIN — is so poorly understood (and all but impossible to quantify), it is extremely difficult to defend people whose pain started weeks or months after the accident, mostly because these individuals usually have nothing in the way of objective findings (things other than pain) to show for it that can be directly tied back to the original accident / injury (HERE). Jane’s situation, however, is different.  Because her severe symptoms happened four to five days after the initial injury, a good attorney should be able to make the case that her problem is legitimate (see my quote from the top of this section).   I also think that Jane’s might be the perfect example of ripped out pants.  Ripped out pants… huh?

Let me take you back in time to something that happened to me when I was ten or eleven years old. Back in the day, my “dress clothes” (clothes only worn to church, or for weddings and funerals) consisted of a pair of polyester pants, a polyester button-up shirt, and some doubly cool platform shoes (Jackson Five, eat your heart out!).   One day when I bent over, I felt / heard my pants rip out.  But when I looked in the mirror and tried to figure out what had happened, there was nothing to be seen — everything looked normal.  But the next time I wore them and bent forward, I had the same experience.  Only this time there was a hole in the seam of the butt about four or five inches long (interestingly enough, Jane described her injury as “old elastic giving way“).  I think that sometimes this is sort of what happens with connective tissue injuries.  For example……

Uncle Roger calls up and asks you to help him move his antique upright piano.  You go over and do your part, grunting and straining while in awkward positions.  After it’s all over, your back feels a bit “catchy” for a couple minutes and you are relieved the job is finished.  No real pain, and not even anything that could be characterized as soreness; just a catchiness that lasted all of 2 or 3 minutes before you walked it off.  But the next day you bend over to pick up a quarter off the parking lot of your local Mal Wart and bam — your back grips you so hard that you can barely breathe, let alone stand up. You have all the CLASSIC SIGNS of a disc injury (even though they can prove extremely DIFFICULT TO DIAGNOSE). Just remember it’s not that pesky quarter that caused the problem, the quarter was just the final straw after moving the piano.  Best guess is that Jane experienced something similar.  She felt tearing and pain after the initial injury that went away almost immediately.  But the damage from her initial injury was likely hiding just below the surface.

What do I recommend people do to solve their chronic pain issues?  Although there is no such thing as a one-size-fits-all solution, fortunately for my readers there is a one-size-fits most.  The secret is to solve the mechanical issues at hand, deal with the underlying Scar Tissue, and then make good and sure that any and all sources of excess INFLAMMATION are mopped up so as not to be driving FIBROTIC CHANGES and potential hyper-sensitization of the nervous system (HERE).  Although weeks and weeks of visits to a chiropractor or therapist are the norm, these visits are all too often not addressing the underlying cause of said problems — Scar Tissue (HERE and HERE respectively). That’s why I have provided my readers with THIS PROTOCOL.  No; it’s not going to fix everything that ails you. What it will do, however, in even the most difficult of cases, is to provide a firm foundation that you can ‘scaffold’ off of if needed.

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