Why Does Pain Continue After a Slip and Fall?
Persistent pain after a slip and fall is one of the most common and difficult issues in medical-legal evaluations. A claimant may have no documented prior neck or back pain, sustain a fall, treat with chiropractic care for months, undergo MRI six months later showing multilevel degenerative changes, and continue reporting pain for two years.
The causation question is straightforward but clinically complex:
If acute inflammatory pain from a sprain or strain should have improved within weeks to months, what is causing the ongoing pain years later?
The answer is rarely found in a single phrase. Ongoing pain may reflect pre-existing degenerative disease that became symptomatic, chronic nonspecific spinal pain, central sensitization, fear avoidance, deconditioning, mood or anxiety symptoms, somatic symptom features, prolonged passive care, litigation-related reinforcement, or some combination of these. Less commonly, persistent pain may reflect a missed structural injury, inflammatory disorder, neurologic condition, or other pathology.
The physician expert’s task is not to dismiss pain simply because MRI shows degeneration. The task is to determine whether the fall caused a temporary injury, permanently aggravated an underlying condition, or merely preceded a chronic pain presentation no longer explained by acute tissue injury.
Acute Soft Tissue Injury Should Usually Improve
A slip and fall can cause real injury. Depending on the mechanics, it may cause contusion, sprain, strain, fracture, disc injury, ligament injury, concussion, or other trauma. If the injury is limited to uncomplicated cervical or lumbar sprain/strain, the expected course is usually improvement over time.
Soft tissue pain may persist for weeks or months, especially if the fall was significant, the patient is older, or there are comorbidities. But when pain continues for two years without objective evidence of ongoing tissue injury, the physician expert should ask whether the original injury remains the primary cause.
Important questions include:
- Was there immediate neck or back pain?
- Was there focal tenderness, spasm, neurologic deficit, or functional loss?
- Were there red flags such as fracture, infection, tumor, inflammatory disease, or cauda equina symptoms?
- Did imaging show acute injury?
- Did the claimant improve with time?
- Was treatment active and restorative or passive and prolonged?
- Are current symptoms anatomically consistent?
- Are current objective findings different from expected age-related findings?
If the answer is that there was an acute strain with no structural injury, persistent pain two years later requires a broader explanation.
Degenerative MRI Findings Are Common
A major pitfall is assuming that MRI findings explain pain simply because they appear after an injury. Multilevel degenerative changes on cervical or lumbar MRI are common, especially with age, and may exist in people without pain.
Brinjikji and colleagues performed a systematic review of imaging findings in asymptomatic individuals and found that degenerative spine findings are common in people without back pain. The authors concluded that many imaging-based degenerative features are likely part of normal aging and must be interpreted in clinical context.
This does not mean degenerative changes are never painful. Degenerative disc disease, facet arthropathy, stenosis, and foraminal narrowing can be symptomatic. But MRI alone usually cannot establish that a slip and fall caused those changes, especially when the imaging is performed months later and does not show acute findings such as fracture, marrow edema, ligament disruption, traumatic herniation, or instability.
A defensible report might state:
“The MRI performed six months after the fall demonstrates multilevel degenerative changes. These findings may contribute to symptoms but are not, by themselves, evidence of acute traumatic injury. In the absence of acute imaging findings or objective neurologic deficit, the MRI supports chronic degenerative spinal disease rather than ongoing traumatic tissue injury.”
No Prior Pain Does Not Automatically Prove Causation
The absence of prior documented neck or back pain is relevant, but it is not conclusive.
There are several possibilities:
- The claimant truly had no prior symptoms.
- Degenerative disease was present but asymptomatic.
- Symptoms existed but were not treated or documented.
- The fall temporarily made a pre-existing condition symptomatic.
- The fall caused a sprain/strain that resolved, while chronic pain persisted through other mechanisms.
- The fall permanently aggravated a pre-existing condition, if objective evidence supports that conclusion.
In medicolegal work, “no prior complaints” should not be treated as equivalent to “no prior condition.” Degenerative spinal changes can predate symptoms by years.
The causation analysis should distinguish:
- Pre-existing condition: degenerative changes present before the fall, even if asymptomatic.
- Symptomatic activation: the fall made a previously asymptomatic condition painful.
- Temporary exacerbation: symptoms worsened for a limited period and then should have returned to baseline.
- Permanent aggravation: the fall permanently worsened the underlying condition beyond natural history.
- Chronic pain syndrome: persistent pain maintained by non-structural mechanisms after tissue healing.
Central Sensitization and Pain Chronification
When pain persists beyond expected tissue healing and appears disproportionate to objective findings, central sensitization may be relevant. Central sensitization refers to amplified pain processing within the nervous system. Pain may become more intense, widespread, persistent, or easily triggered even when ongoing tissue injury is not evident.
A recent scoping review of central sensitization after orthopedic trauma notes that persistent pain can occur despite satisfactory structural healing and may present with disproportionate symptom intensity, sensory amplification, and widespread hypersensitivity. The Lancet Rheumatology has similarly described central sensitization as a diagnostic challenge when pain and disability exceed the degree of tissue damage.
Central sensitization is not malingering. It is also not a diagnosis that should be casually applied whenever the MRI is unimpressive. It should be considered when the clinical pattern includes:
- Pain disproportionate to objective findings
- Widespread pain beyond the original injury site
- Allodynia or hyperalgesia
- Sleep disturbance
- Fatigue
- Cognitive complaints
- Multiple somatic symptoms
- Heightened sensitivity to touch, movement, light, sound, or stress
- Poor response to passive structural treatments
- Significant mood, anxiety, or trauma-related symptoms
In an IME report, central sensitization is best described as a possible pain-maintaining mechanism rather than as proof of structural injury from the fall.
Biopsychosocial Risk Factors and Delayed Recovery
Chronic pain after injury is not purely biomedical. Psychological and social factors may influence pain intensity, function, treatment response, and recovery.
An umbrella review of biopsychosocial factors associated with chronic musculoskeletal pain found numerous biological, psychological, and social factors linked to the development of chronic pain, drawing from systematic reviews involving a large number of participants. The International Association for the Study of Pain also emphasizes that chronic musculoskeletal pain should be understood using a biopsychosocial model that includes biological, psychological, and social variables.
Relevant risk factors may include:
- Depression
- Anxiety
- Catastrophizing
- Fear avoidance
- Low recovery expectations
- Sleep disturbance
- Prior pain history
- High initial pain intensity
- Passive coping style
- Deconditioning
- Work dissatisfaction
- Litigation or compensation context
- Social stressors
- Prolonged passive treatment
- Opioid exposure
- Belief that pain always means damage
These factors do not prove the pain is fabricated. They help explain why pain may persist after the expected healing period.
Delayed and Failed Recovery
The AMA Guides Newsletter has specifically addressed psychological factors in delayed and failed recovery and unnecessary disability. The 2019 article by Caruso and Kertay discusses psychological influences in delayed or failed recovery and work disability, while the second part discusses evaluation and intervention approaches.
This concept is highly relevant to a claimant with two years of pain after an injury that should have biologically healed. The key issue is whether ongoing disability reflects:
- Persistent structural pathology, or
- Delayed recovery driven by psychological, behavioral, social, or system-level factors.
In an IME, delayed recovery may be suggested by:
- Pain escalation despite time and treatment
- Increasing disability despite lack of objective deterioration
- Continued passive care without functional gains
- Fear of movement
- Reliance on repeated chiropractic, massage, injections, or medications without durable improvement
- No return to normal activity
- Increasing identity as injured or disabled
- Discrepancy between physical findings and reported limitations
- Absence of a restorative treatment plan
The physician expert should document these patterns without using pejorative language.
Litigation Context and the “Plaintiff” Problem
One response in the discussion suggested that the claimant may no longer be a patient but a plaintiff. That concept should be handled carefully.
Litigation can influence symptom reporting, treatment duration, disability behavior, expectations, and recovery. Compensation context is a recognized social factor in chronic pain and disability claims. However, it is usually inappropriate to conclude that pain persists solely because of litigation unless the record strongly supports that conclusion.
A more defensible formulation is:
“The litigation context may be one of several psychosocial factors that can reinforce symptom focus and disability behavior, but it does not by itself prove symptom fabrication.”
Physician experts should avoid inflammatory language such as “secondary gain explains everything” unless there is clear evidence. The better analysis is to identify objective inconsistencies, functional patterns, treatment response, and recovery barriers.
Chiropractic Care Beyond the Acute Phase
Six months of chiropractic treatment after a slip and fall may or may not be reasonable depending on the documented injury, treatment response, and functional gains. In uncomplicated sprain/strain cases, prolonged passive care should be scrutinized.
Important questions include:
- Was there objective improvement?
- Did range of motion improve?
- Did function improve?
- Did work status improve?
- Did medication use decrease?
- Did home exercise progress?
- Were treatment intervals extended?
- Was the claimant discharged to self-management?
- Did treatment continue only because pain temporarily decreased after sessions?
Passive treatment that provides short-term relief but no durable functional improvement may be palliative rather than medically necessary restorative care.
A report can state:
“Ongoing chiropractic treatment beyond the expected recovery period would require documentation of sustained functional improvement. The records provided do not demonstrate progressive objective or functional gains sufficient to attribute two years of ongoing symptoms to the original soft tissue injury.”
Somatic Symptom Disorder: Use Carefully
Somatic symptom disorder may be relevant when a claimant has excessive thoughts, feelings, or behaviors related to somatic symptoms. The diagnosis does not mean symptoms are fake, and it does not require that symptoms be medically unexplained. It requires disproportionate and persistent symptom-related distress or behavior.
However, this diagnosis should be made carefully, usually by a qualified mental health professional. A non-psychiatric physician expert may identify features suggesting the need for psychological evaluation, such as:
- Disproportionate symptom focus
- Excessive fear of movement or reinjury
- Severe disability without objective explanation
- Repeated healthcare use despite reassuring findings
- Persistent belief that benign degenerative findings prove severe injury
- Poor participation in active recovery
- High distress related to bodily symptoms
A careful opinion might state:
“The claimant’s persistent symptoms appear disproportionate to the objective structural findings and expected recovery from uncomplicated soft tissue injury. Psychological evaluation may be useful to assess for somatic symptom features, pain catastrophizing, fear avoidance, mood symptoms, or other factors contributing to delayed recovery.”
That is more defensible than declaring “this is somatic symptom disorder” without adequate foundation.
A Structured Differential for Ongoing Pain
When asked, “What is causing the ongoing pain?” the best answer is often a differential, followed by the most probable explanation.
Potential causes include:
- Residual Traumatic Injury
Supported by objective findings such as fracture, ligament injury, traumatic herniation, neurologic deficit, instability, or persistent documented tissue abnormality.
- Degenerative Spine Disease
MRI may show chronic multilevel degeneration that may be symptomatic but not necessarily caused by the fall.
- Temporary Injury With Persistent Pain Behavior
The fall may have caused a sprain/strain that healed, while pain behavior, fear avoidance, and deconditioning persisted.
- Central Sensitization or Nociplastic Pain
Pain processing may remain amplified after tissue healing.
- Mood, Anxiety, Sleep, or Trauma-Related Factors
These may worsen pain perception and disability.
- Somatic Symptom Features
Excessive symptom focus and disproportionate health anxiety may maintain disability.
- Litigation or Compensation Reinforcement
May contribute to symptom persistence, treatment continuation, or delayed return to activity.
- Missed Medical Condition
Inflammatory disease, malignancy, infection, neurologic disease, or other non-traumatic pathology should be considered if red flags exist.
A physician expert should not force a single cause if the evidence supports a multifactorial explanation.
Example Causation Opinion
A balanced report might read:
“The slip and fall likely caused an acute cervical and lumbar soft tissue injury based on the onset of symptoms after the event. However, the MRI performed six months later demonstrates multilevel degenerative changes without objective evidence of acute traumatic structural injury. In an uncomplicated sprain/strain, inflammatory tissue pain would generally be expected to improve within weeks to months. The persistence of pain for two years is not adequately explained by ongoing traumatic tissue injury. The ongoing symptoms are more likely multifactorial, including chronic nonspecific spinal pain, pre-existing degenerative spinal disease that became symptomatic, deconditioning, prolonged passive treatment, and possible biopsychosocial factors contributing to delayed recovery.”
If the record supports central sensitization:
“The clinical pattern may also include pain amplification or central sensitization, particularly if pain is disproportionate, widespread, and associated with sleep disturbance, mood symptoms, fear avoidance, or heightened sensitivity.”
If the question is permanent aggravation:
“The available records do not demonstrate that the fall permanently aggravated the underlying degenerative spinal condition beyond natural history. The evidence supports, at most, a temporary exacerbation of symptoms.”
How This Applies in Medicolegal Reporting
For physician experts, the key is to avoid two common errors.
The first error is to say:
“The claimant had no prior pain, so the fall caused all pain for the next two years.”
That ignores degenerative disease, natural history, and pain chronification.
The second error is to say:
“The MRI shows degeneration, so the fall caused nothing.”
That ignores the possibility of a real acute soft tissue injury or temporary symptomatic exacerbation.
A more defensible analysis separates time periods:
- Acute period: fall-related sprain/strain or contusion may be causally related.
- Subacute period: symptoms should improve; treatment should show functional gains.
- Chronic period: persistent pain requires evidence of ongoing pathology or a non-structural chronic pain explanation.
- Two-year period: absent objective traumatic pathology, ongoing pain is unlikely to be explained by acute inflammatory injury.
Practical Implications for Attorneys, Adjusters, and Physician Experts
For attorneys and claims professionals, important questions include:
- Were symptoms immediate and anatomically consistent?
- Was there objective evidence of acute injury?
- Did MRI show trauma or only degenerative changes?
- Was there prior imaging?
- Did the claimant improve with treatment?
- Did chiropractic care produce functional gains?
- Were symptoms localized or widespread?
- Was there fear avoidance or deconditioning?
- Were mood, anxiety, sleep, or psychosocial factors evaluated?
- Was there a return-to-work or activity plan?
- Did treatment remain passive for months?
- Is ongoing pain being attributed to the fall based only on timing?
For physician experts, the strongest reports explain why pain can persist even when tissue injury has healed, while still distinguishing pain from structural causation.
Conclusion
Ongoing neck or back pain two years after a slip and fall is not automatically explained by the original injury, especially when MRI shows only multilevel degenerative changes and there is no objective evidence of acute traumatic pathology. The fall may have caused an acute sprain, strain, or temporary exacerbation, but persistent pain beyond expected healing requires a broader analysis.
Possible explanations include symptomatic degenerative disease, chronic nonspecific spinal pain, central sensitization, fear avoidance, deconditioning, mood or anxiety symptoms, somatic symptom features, prolonged passive care, and litigation-related reinforcement. These factors do not mean the pain is fabricated. They mean the pain may no longer be explained by ongoing acute tissue injury.
The central principle is clear: persistent pain is real, but persistent pain is not always persistent injury. Medical-legal causation requires objective pathology, expected healing analysis, and careful consideration of biopsychosocial contributors to delayed recovery.
References
- Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology. 2015;36(4):811-816.
- Caruso GM, Kertay L. Psychological factors in delayed and failed recovery and unnecessary disability, Part I. AMA Guides Newsletter. 2019;24(3).
- Caruso GM, Kertay L. Psychological factors in delayed and failed recovery and unnecessary disability, Part II. AMA Guides Newsletter. 2019;24(4).
- Mistry J, Soundy A, Heneghan NR, et al. The biopsychosocial factors associated with development of chronic musculoskeletal pain: an umbrella review. PLOS One. 2024.
- International Association for the Study of Pain. Evidence-based biopsychosocial treatment of chronic musculoskeletal pain.
- Central sensitisation after orthopaedic trauma: an overlooked mechanism in chronic post-traumatic pain. Journal of Clinical Medicine. 2026.
- Central sensitisation in chronic pain conditions: latest discoveries and their potential for precision medicine. The Lancet Rheumatology. 2021.