When the Bone Has Healed but It Still Hurts

"They say the X-ray is clean. It healed well. So why does it still hurt?"

There are people who come to me several months after suffering a fracture or a major bruise. On the tests everything has healed. The bone has knitted, the cast is off, and the doctor said there's no problem.

But it hurts. It feels heavy, the swelling won't fully drain, the joint won't extend all the way, and on bad-weather days it's worse. It gives a jolt at the slightest brush, yet the sensation in that very area is dull.

To such a person I do not say "because the bone hasn't healed." The bone has healed; it's that the area around the bone hasn't finished recovering.

It's not only the bone that gets hurt

What broke is the bone. But what gets hurt at that moment is not only the bone.

The periosteum wrapping the bone, the capsule enclosing the joint, ligaments and tendons, muscle and the thin membranes running between them, the water channels beneath the skin, and the fine nerves and blood vessels running within — all of these are pressed, torn, and swollen together.

The X-ray looks at bone. It shows well whether the bone has knitted. But whether these tissues around the bone have regained their original material properties doesn't show up well in the image.

This is where I see the pain remaining.

What happens at a spot where recovery has stalled

After an injury, tissue swells. The swelling itself is part of the repair process. The problem arises when that swelling doesn't drain in time and lingers for a long while.

Here there is an important fact. Lymph is not pushed by the heart. Blood is driven out by a pump called the heart, but the lymph that clears away the fluid pooled between tissues has no such pump. For lymph to flow, the muscles must move, you must breathe, and the joints must bend and extend. The lymph vessels themselves squeeze a little on their own, but most of the force comes from when we use the body. This is established physiology.

But what about an injured area? Because it hurts, you don't move it.

Here a loop closes.

It hurts → you don't move it → the fluid doesn't drain → the tissue becomes heavy and stiff → it hurts more and you move it even less.

When this loop runs for a few months, the tissue loses its original soft, slippery nature. It hardens while holding water, and layer upon layer can no longer slide against one another and sticks together. Then the joint won't extend all the way, the muscle is always tensed as if defending, and the slightest touch makes the nerve respond excessively.

Up to here is how I understand this pain. That swelling, adhesion, and joint contracture obstruct recovery is something dealt with in rehabilitation medicine too, and to this I add the view that "the material properties of the tissue have changed."

So "just rest" is not enough

In the acute stage, you must rest. That's right.

But if you keep sparing it even after that period has passed, the loop above keeps running. The final stretch of recovery is made by movement. Draining the fluid, making the stuck-together layers slippery again, bringing back the sensation — all of it happens in the end by using that area again.

The problem is that it hurts, so you can't use it. So an order is needed.

I look at it in the direction of first making a state in which it can be used, and then having it used. Opening a path for the pooled fluid to drain, releasing the muscle hardened as if defending, letting the dulled sensation return, and on top of that bringing movement back little by little.

I think the same way when I use herbal medicine. Not forcefully pushing one thing hard, but composing it so that the pushing side, the receiving side, the draining side, and the holding side all move together. Once the tissue's environment returns to a state capable of recovery, the body does the work of knitting and mending. (What herbal medicine actually does)

The older you are, the longer this stretch becomes

Young people pass through this last stretch on their own. Even if it hurts, they use it within a few days, and using it works it loose.

But it's different with age. There is little muscle, circulation is slow, sensation is dull, and above all they don't use it for fear of falling. This, I believe, is why so many people have pain and swelling lingering long after a compression fracture or a hip fracture, with their strength dropping along with it. In people who have used steroids for a long time, and in those with osteoporosis, this stretch is especially long. (The body that stiffens with age)

When you should go to the hospital first

Treating all pain that won't heal as "recovery that isn't finished" is dangerous. For the following, receive orthopedic care first.

• Pain that is getting steadily worse (different from having improved and then stalled)
• The area being red, hot, and feverish — it could be an infection or osteomyelitis
• The injured area looking dislocated again or being unable to bear weight
• The skin changing color, hair or sweat becoming abnormal, and extreme pain at the slightest brush — complex regional pain syndrome must be checked
• With a history of fracture, losing height or the back becoming hunched — it could be a fracture of another vertebra

Finally

To the question "the bone has healed, so why does it hurt," I answer like this.

Because the knitting of the bone is the beginning of recovery, not the end.

Recovery is when the swelling drains, the hardened parts loosen, the sensation returns, and it becomes usable again. There are bodies stalled at that stretch, and my work is to get those bodies moving again.