The nature of a classic injury doesn’t require much explanation. Life has an all too obvious capacity to break bones, rupture tendons, tear muscle, dislocate joint tissues and rip ligaments. Less serious ‘true injuries’ cause the microscopic equivalents of these major injuries. Microtears to muscle fibre and ligament tissues and the like. 

Healthy, strong tissues are highly resilient to damage; if they weren’t, there would be no such thing as contact sports. So true injuries are, without exception, memorable physical events. If you experience a ‘sudden pain’ in your spine picking up a box of tissues, it is worth questioning how healthy your spine is; and whether it really qualifies as a true injury at all.

The most obvious feature of true injuries when they occur is how much they hurt. The purpose of this pain is protective. It is nature’s way of protecting you from the unthinkable horrors of running on a broken ankle bone or ACL tear. When you are injured, the body fires pain signals and releases a cascade of essential inflammatory chemistry. Under normal circumstances, you feel all that as temporary pain and swelling. This pain of injury is absolutely vital for the preservation of life. 

Yet, if an injury site hurts for too long or resolves temporarily, then comes back later, it stands to reason that there is something more complex going on. A persistent or recurrent pain after an injury is something that you should pay great care and attention to in the long term. The body is a very sophisticated system. One that seldom (if ever) generates persistent symptoms without a good reason to do so. 

The progression in how we manage significant injuries in the past 100 years is a match for the improvements we have made in telecommunications and transport in the same time period. 

At the beginning of World War I, as many as 90% of leg fractures were fatal. Most ultimately bled out after being thrown carelessly onto stretchers with no splints or casts. These days, however, almost no one dies of a broken leg, even in war zones. We have truly wondrous high-tech surgical means to preserve life and limbs after major injuries. Yet the longer-term rehabilitation of injury (which is supported by a mountain of scientific literature) still frequently remains an afterthought in today’s frontline healthcare setting. 

There is still a dark side to the way we tend to manage injuries in the 21st Century.

Louise was an apparently healthy 32-year-old American lady with lots of curly hair and the look of a world traveller. On first impressions, she seemed pretty normal, if a little stressed. 

Once you get talking to Louise, you gradually realise she isn’t living a normal life at all. You also notice after a few minutes that she isn’t able to sit in one position very long, and she constantly moves her body weight in the chair. The other thing you fail to notice right away is that she has some very dark blackish stripes across her face that she partially covers with makeup. These stripes are very distracting once you have noticed them because they are not the colour of any scar or birthmark you have ever seen. They are really, really black, like rubber.

When she was 23, Louise was driving home late one night in the small car her parents had purchased for her 21st birthday. For reasons she can’t explain, at an intersection, she accidentally ran a red light. As she crossed the intersection, her tiny little car was directly hit side-on at 90 mph by a very large commercial vehicle. 

The impact was so significant that it crushed her little car like an empty beer can. And in a bizarre, miraculous, incredible, one-in-a-million turn of fate, she seemingly wasn’t injured. She had no broken bones. She had no joint dislocations. She had no damage to her internal organs and no internal bleeding. And there was no brain damage or damage to her spine and central nervous system. She didn’t even have any concussion symptoms.

The only visible injury that Louise presented with at the hospital was two deep indented black marks which extended from her cheekbone across her eye into her forehead. These were caused when the frame of the car window drove itself into her face on impact. When I met her ten years later, she still had two long black stripes so deeply impregnated with rubber that they looked like strange black facial tattoos.

The night she was in the hospital, all her tests were done within less than 2 hours. Then the ED doctors report back to her on the miracle they had discovered. None of her scans or x-rays showed any major trauma whatsoever. The ED doctors confirmed that based on similar crashes, they would have expected her to have sustained multiple life-ending injuries. Yet she didn’t even so much as get a broken wrist for her troubles. All she had was the two black facial lesions.

All in all, after the most extreme car crash imaginable. Louise was congratulated and sent home with a few days worth of codeine and told she wouldn’t even need any follow-up physiotherapy. She was in the hospital for less than 3 hours.

It all seems like a pretty happy story until you hear the rest of it.

Louise went home the night of the crash with a pounding headache. Then when she woke up the next morning,  every muscle in her body felt like it had been torn apart. She also felt such an intense pain throughout her spine that she felt like it was literally on fire. The day after the crash, she also had a violently intense migraine that lasted about 3 hours.

Fast forward six months, and Louise was still in just as much pain as she had been the day after the crash. Her whole body ached and throbbed constantly. She also still had debilitating spinal pain and crippling daily headaches. She was unable to work, exercise or socialise. Her family doctor had diligently ordered a second set of scans several weeks after the crash, all of which also came back clear. He had prescribed her some strong painkillers and told her to wait it out in the hope that her body slowly recovered, which it was showing no sign of doing. 

A year or so after the injury, she got desperate and took matters into her own hands. She started seeing a chiropractor and a soft tissue therapist. Two years of weekly soft tissue sessions gradually got her muscle pain to a level where she found it manageable. While frequent gentle chiropractic sessions got her migraines down from 7 days a week to 3-4 days a week. Nothing touched the spinal pain, however.

Fast forward ten years, and Louise is sitting in my office on the other side of the world in New Zealand. Shifting around in her chair to take pressure off her back and telling me about the level of chronic pain she lives with.

When she met with me ten years on, Louise literally couldn’t remember a single waking moment without pain since the crash. She had never got rid of the headaches, and the spinal pain had simply never gone away, even for a moment. She estimated that her day-to-day quality of life was about a 4/10 due to the pain. She had long since given up on the career she had planned because she could only work about 20 hours per week, choosing to go on a long-term working holiday instead. She had not played sports or exercised with any intensity since the day of the crash. Her pain had not reduced in any appreciable way in the previous seven years.

It took two more years of intense weekly treatment and spinal rehabilitation to finally get Louise’s pain under control. At this point, she was able to resume a fairly normal life, aside from the ongoing work she requires to prevent the periodic relapses she is still prone to. 

All of Louise’s scans and x-rays were clear. Yet the reason for her headaches and spinal pain was clear as day if you know what you are looking for. Her functional spine tests and motion palpation tests (performed by me ten years later) revealed that she had sprained virtually every joint in her spine. These joints remained locked and inflamed a decade later, having never been mobilised. The fascia (connective tissue) around her spine had lost all its elasticity due to widespread scar-like adhesions. And ten years on, the muscles surrounding her spine were so tight it was as if the crash had occurred the previous day.

In other words, Louise’s entire spine had sustained an incredibly severe whiplash injury. And subsequently, they did not even make a partial recovery. Instead, it had transitioned into a chronic unhealed state which included the addition of extensive chronic inflammation and scar tissue. Perhaps none of which is  that surprising given the nature and severity of her accident.

Louise’s story contains many grim lessons about how badly our culture can still fail people with pain and injuries.

The obvious healthcare fumble presented by Louise was the complete lack of a diagnosis. It is still common practice to assume that the only injuries worthy of note are those that are identifiable with the limited medical scans and imaging we have. This is a corruption of the ‘disease model’ of healthcare which makes great use of ‘ lab tests’ to identify organic diseases in the body. And also works well for identifying fractures and the like.  

The ‘if it isn’t visible on the scan, it didn’t happen’ approach overlooks the elephantine fact that only a micro-fraction of our mechanical pain and injuries can actually be seen using medical scans and tests. The inflammation, joint stiffness and even scar tissue of a severe whiplash cannot be seen on MRI scans, x-rays, CAT Scans or ultrasounds. But that doesn’t mean they don’t exist.

Louis’s case also highlights the fact that we have yet to become a rehab culture in the sense that we are already a surgical and pharmacological culture. The notion that a human body could go through an impact of that magnitude and not need any follow-up physical therapy is outlandish. Admittedly Louise’s case is a particularly extreme example of ‘rehab oversight’. Yet it is a fair reflection of a widespread problem. We still routinely perform major surgeries and discharge major injuries (and pains) without meaningful rehab. 

Another grim observation posed by Louis’s terrible suffering is the fact that many injuries simply don’t heal unless they receive substantial encouragement. Many of them seemingly need a great deal of stimulation before the body is able to express its potential for healing. 

It is not known why so many of our injuries don’t ‘just heal’ fully.  

It’s worth noting that our bodies have a great capacity for strength and fitness, yet without the proper stimulation, they turn to jelly. The same is true of healing. Our bodies don’t need to move much these days,  compared with the outdoor life they are evolved for. This ‘sedentary factor’ may at least partially explain why so many injuries fail to heal on their own terms. It would also explain why all injury rehabilitation involves ‘supplementary movement’. To replace the natural movement we are starved of, perhaps?

There is one further thing that is fair to say about Louis’s catastrophic spinal whiplash. It was definitely a true injury – Unlike many of the ‘sudden pains triggered by movement‘ that we call injuries, but are, in fact, something far more complex and insidious.

There is a massive amount more to the topic we call injuries than meets the eye. The life cycle of a true injury is relatively simple. Yet, many of the musculoskeletal injuries we sustain unfold in a manner that is far more complex and concerning, often having far-reaching consequences for our health in the form of slow recovery,  relapses, reinjury, chronic pain and chronic disability.