Persistent Pain: Why Does It Hurt When Nothing Seems to Be Wrong?
- Ben Proctor
- 3 days ago
- 14 min read
Understanding persistent pain and how you can take back control
Living with pain for weeks, months or even years can be exhausting. It can affect your sleep, work, relationships, hobbies, confidence and ability to do the things you enjoy.
You may have had X-rays, scans, injections, medication or physiotherapy. Perhaps you have been told that you have arthritis, a disc problem, "wear and tear" or an old injury. Sometimes there is a clear physical reason for pain, while at other times there isn't an obvious explanation for why it continues.
One of the most frustrating things about persistent pain is that the amount of pain you experience doesn't always accurately reflect the amount of damage or injury in your tissues. If something hurts badly, it is completely understandable to think that something must be badly damaged. However, pain is much more complicated than a simple measurement of tissue damage.
This doesn't mean your pain isn't real. Persistent pain is very real. It means that understanding how pain works can give you more options for managing it.
What is pain?
Pain is one of your body's most important protective systems. If you touch something extremely hot, your nervous system detects a potential threat and your brain produces pain, encouraging you to move your hand away and protect yourself.
Pain is therefore extremely useful. Without it, we would be much more vulnerable to injury.
However, pain isn't simply a direct message travelling from an injured body part to your brain. Your nervous system gathers information from your body and combines it with everything else it knows about the situation before producing a pain response.
This is why the same physical stimulus can feel very different depending on the circumstances. Previous experiences, expectations, stress, sleep, mood and how threatening something feels can all influence the pain experience. Live Well with Pain describes understanding the relationship between persistent pain and the brain as an important step towards moving away from a constant "find and fix" approach and towards learning to live well with pain. (Live Well with Pain)
Pain is real, but pain is not always a reliable measure of tissue damage.
Why can pain continue after an injury has healed?
When you injure yourself, pain is usually helpful. It encourages you to protect the injured area while your body repairs itself. As tissues heal, the pain usually settles. Persistent pain can be different. If pain continues for months, the nervous system can become more sensitive and more efficient at producing a pain response. Tame the Beast describes this as the pain system "learning" pain. The nervous system adapts to repeated experiences, rather like it adapts when we learn any other skill. (Tame the Beast)
Imagine turning up the sensitivity on a microphone. A sound that previously wouldn't have been noticed can suddenly become very loud. Something similar can happen with persistent pain. Activities that once caused only a small amount of discomfort may begin to hurt considerably more. Movements that were previously comfortable may become painful, and areas of pain may sometimes spread or change. This can be frightening. You may naturally think:
"My pain is getting worse, so my injury must be getting worse."
But if the original injury has healed and serious causes have been ruled out, an increase in pain does not necessarily mean an increase in damage. The pain system itself may have become more sensitive. (Tame the Beast)
Pain can be affected by much more than your tissues
Persistent pain is influenced by the whole person, not just the painful body part.
For example, imagine you have had a poor night's sleep, you are stressed about work, you are worried about your pain and you have a busy day ahead. You may find your pain is considerably worse than it was on a relaxed day when you slept well.
This doesn't mean that stress or emotions are "causing your pain".
It means that your nervous system is influenced by what is happening throughout your body and your life. Retrain Pain highlights the importance of understanding the wider context of pain, including attention, meaning, goals and what is happening in our lives. (Retrain Pain)
This is also why persistent pain can sometimes seem unpredictable. You might perform the same activity on two different days and experience very different levels of pain.
That inconsistency can actually be useful information. It reminds us that pain isn't simply a direct read-out of what is happening inside a joint, muscle or disc.
Does pain mean that I am damaging myself?
Not necessarily.
When something hurts, it is natural to protect it. If bending forwards hurts your back, you may stop bending. If walking hurts your knee, you may walk less. If using your shoulder hurts, you may avoid using it.
Initially, this can be sensible. However, if you continually avoid movement because you are frightened that it will cause damage, you may gradually become weaker, less fit and less confident. The movement can then feel increasingly unfamiliar and threatening.
This can create a cycle:
Pain → fear of movement → less activity → reduced strength and confidence → increased sensitivity → more pain.
The answer isn't to ignore your pain or simply push through it. Once you have been appropriately assessed and it is safe for you to move, the aim is to gradually rebuild your confidence and capacity.
Tame the Beast emphasises that movement can help retrain an overprotective pain system, while Retrain Pain similarly focuses on using movement to help people move forward without fear. (Tame the Beast)
What if movement makes my pain worse?
This is one of the most common questions people with persistent pain ask.
"If the exercise makes my pain worse, doesn't that mean I'm damaging myself?" Not necessarily.
When your pain system has become more sensitive, it may respond strongly when you introduce something new. You may experience an increase in pain even though the activity is safe for your body.
That doesn't mean you should ignore severe pain or force yourself through an activity that feels wrong. Instead, once you've been assessed and advised that movement is safe, you can gradually expose your body to movements and activities that you have been avoiding.
Think of this as teaching your nervous system that movement is safe. You might experience some discomfort along the way. The aim is not to repeatedly test how much pain you can tolerate. It is to find a manageable level of activity and gradually build from there.
Tame the Beast makes the important distinction that an increase in pain does not necessarily mean an increase in injury, particularly when an overprotective pain system is involved. (Tame the Beast)
Find your starting point
A useful way to approach rehabilitation is to work out what you can do reliably, rather than focusing on what you can manage on your very best day.
For example, perhaps you can normally walk for 10 minutes before your symptoms become difficult, but on a good day you can manage 25 minutes. If walking for 25 minutes regularly leaves you struggling for the rest of the day or the following day, 25 minutes may not be a useful starting point.
Instead, you might start with something manageable, such as 10 minutes, and gradually increase it as your confidence and capacity improve. Live Well with Pain recommends using activity diaries to understand your current pattern of activity, rest, sitting, lying down and sleep. This can help identify patterns that might otherwise be difficult to recognise. (Live Well with Pain)
The aim isn't to stay at your starting point forever.
Your starting point is simply where you begin.
Avoid the boom-and-bust cycle
One of the most common problems associated with persistent pain is doing too much on a good day. You feel better, so you decide to catch up with everything. You clean the house, do the gardening, go shopping and take a long walk.
Then the pain catches up with you.
The following day you are exhausted and sore, so you do very little.
After a couple of days you start feeling better again and repeat the process.
This is often called the boom-and-bust cycle.
Pacing is one of the key skills recommended by both Live Well with Pain and the Pain Toolkit. The idea is to balance activity and rest so that you don't repeatedly push yourself until pain or tiredness forces you to stop. (Live Well with Pain)
Pacing isn't about doing less forever.
It is about finding a level of activity that you can manage consistently and then gradually increasing it.
A useful question is:
"How much can I do regularly, rather than how much can I manage on my best day?"
Take breaks before you need to
An important part of pacing is learning to take a break before you are completely exhausted or your pain has become overwhelming.
Live Well with Pain suggests thinking about pacing using three simple questions:
What activity can I pace today?
When should I take a break?
How much effort am I putting in?
This can be particularly helpful for activities such as housework, gardening, shopping, walking or exercise. (Live Well with Pain) You may also find it helpful to stop thinking that everything has to be completed in one go.
Instead of:
"I must get all the gardening done today."
Try:
"I could do some today and some tomorrow."
Pacing is not giving in to your pain. It is a way of gradually increasing what you are capable of doing.
Set goals that actually matter to you
"Exercise more" isn't a particularly inspiring goal. A much more useful goal might be:
"
I want to walk around the park with my grandchildren."
"I want to get back to gardening."
"I want to stand long enough to cook dinner."
"I want to return to playing golf."
"I want to be able to go shopping without needing to sit down."
Meaningful goals give rehabilitation a purpose. Live Well with Pain recommends setting SMART goals and using a goal ladder, breaking a larger goal into smaller achievable steps. The Pain
Toolkit similarly identifies goal setting and action planning as one of its five key self-management skills. (Live Well with Pain)
For example, if your ultimate goal is to walk for 30 minutes, your first step might only be five or ten minutes.
Once that becomes manageable, you can move to the next step.
Small wins add up.
Meaningful movement
Exercise doesn't have to mean joining a gym. Movement can include walking, gardening, swimming, cycling, dancing, strength exercises, playing with your grandchildren or simply spending less time sitting.
The most useful movement is often movement that means something to you.
The Pain Toolkit calls this "meaningful movement" and encourages people to keep active through appropriate stretching, exercise and other activities that have value to them. (Pain Toolkit)
If you enjoy walking, walk.
If you enjoy gardening, build your gardening capacity.
If you want to play with your grandchildren, make that the goal.
Your physiotherapist can help you decide how to safely build towards the activities that matter to you.
What about bad days and flare-ups?
Setbacks are a normal part of living with persistent pain. You may have several good days followed by a difficult one. You may have increased your activity too quickly, slept badly, become unwell or simply had a particularly demanding day.
A flare-up doesn't automatically mean that you have caused damage or that your rehabilitation has failed.
This is why it can be helpful to have a setback plan.
Your plan might include temporarily reducing your activity, breaking tasks into smaller pieces, continuing some gentle movement, getting additional help and then gradually returning to your normal routine as symptoms settle.
Both Live Well with Pain and the Pain Toolkit emphasise planning for setbacks rather than being caught unprepared when they occur. (Live Well with Pain)
Sleep and persistent pain
Pain and sleep can have a frustrating relationship.
Pain can make it difficult to sleep, while poor sleep can leave you tired, less active and more sensitive to pain.
This can create a cycle:
Pain → poor sleep → tiredness → reduced activity → increased sensitivity → more pain.
Improving your sleep isn't necessarily going to make your pain disappear, but it can be an important part of managing persistent pain.
Live Well with Pain includes sleep as one of its Ten Footsteps and provides specific resources to help people develop better sleep habits. (Live Well with Pain)
Small changes can help, such as keeping a reasonably consistent sleep routine, building some daytime activity into your routine and allowing yourself time to wind down before bed.
Stress, relaxation and your pain
When we are stressed or worried, the body becomes more alert.
This can influence how we experience pain.
Again, this doesn't mean that pain is "all in your head". It means that your brain and nervous system are constantly assessing whether you are safe or under threat.
Relaxation, breathing exercises, mindfulness and other strategies can help reduce some of this heightened alertness.
Live Well with Pain includes relaxation and mindfulness as part of its Ten Footsteps approach, alongside sleep, activity, communication and managing mood. (Live Well with Pain)
You don't have to become an expert in meditation. Even finding a few minutes each day to slow down, breathe and relax can be a useful starting point.
What about medication?
Medication can be an important part of managing persistent pain, but it isn't always the whole answer.
It is worth regularly reviewing whether your medication is helping you achieve the things that matter to you and discussing this with your GP or pharmacist if you have concerns.
Live Well with Pain includes medicines and nutrition as one of its Ten Footsteps and provides specific information about reviewing pain medicines alongside other approaches to living well with pain. (Live Well with Pain)
If you take prescribed medication, don't stop or change it suddenly without appropriate medical advice.
Medication can be one part of your pain-management toolkit alongside movement, sleep, pacing, relaxation and other strategies.
You don't have to manage everything on your own
Self-management doesn't mean being left to deal with your pain alone.
It means becoming an active participant in your recovery and developing skills that help you manage your symptoms day to day.
Your physiotherapist, GP, pharmacist, pain specialist or other healthcare professional can help you understand your symptoms, rule out conditions that require specific treatment and develop an appropriate plan.
The Pain Toolkit describes teamwork as an important part of self-management, while Tame the Beast encourages people to work with healthcare professionals who can help them understand their pain system and develop a gradual recovery plan. (Pain Toolkit)
Don't be afraid to ask questions such as:
"Is it safe for me to move?"
"What can I safely work towards?"
"What should I do if I have a flare-up?"
"How can I gradually build my strength and confidence?"
Understanding what is happening can itself be an important part of rehabilitation.
Recovery isn't about winning a battle against pain
Persistent pain can make you feel as though your body has become fragile or unreliable.
You may start avoiding things because you're frightened that they will make you worse. Alternatively, you may push yourself hard whenever you have a good day and then spend several days recovering.
Neither approach is particularly helpful.
A better approach is to understand your pain, find a sensible starting point and gradually build from there.
The Pain Toolkit identifies five key self-management skills:
Goal setting and action planning
Pacing daily activities
Problem solving
Meaningful movement
Having a setback plan (Pain Toolkit)
Live Well with Pain expands this into its Ten Footsteps, covering pain and the brain, acceptance, pacing, goals and activity, relaxation, sleep, communication, managing mood, medicines and nutrition, and managing setbacks. (Live Well with Pain)
These aren't quick fixes.
They are skills that you develop over time.
What can you do today?
You don't need to change everything at once.
Choose one small thing that is achievable and meaningful to you.
Perhaps you could take a short walk, break up a long period of sitting, practise an exercise your physiotherapist has recommended, spend five minutes doing something you enjoy, work on your sleep routine or set yourself a small goal for the week.
Then build from there.
You may have good days and difficult days. You may sometimes need to take a step backwards before moving forwards again.
That's okay.
Progress doesn't have to be perfect to be progress.
When should you seek medical advice?
Understanding persistent pain should never be used to dismiss new, severe or unexplained symptoms.
Pain can sometimes indicate an injury or illness that requires further assessment. You should seek appropriate medical advice if you develop new or rapidly worsening symptoms, particularly following an injury, or symptoms such as significant new weakness, loss of bladder or bowel control, numbness around the groin or saddle area, unexplained weight loss, fever or other symptoms that concern you.
The information in this article is intended to help you understand persistent pain and develop useful self-management strategies. It is not a substitute for an individual assessment or medical advice.
The key message
Persistent pain is real.
But pain isn't always a reliable measure of tissue damage.
Your nervous system can become more sensitive and protective over time, but it can also adapt. Understanding your pain, gradually increasing activity, building strength and fitness, pacing yourself, improving sleep, managing stress and setting meaningful goals can all help you regain confidence and control.
You don't necessarily have to wait until you are completely pain-free before you start doing the things that matter to you.
The aim is to gradually make your life bigger than your pain.
You may still have some pain, but you can become stronger, more confident and more capable of doing the things that are important to you.
Your pain is real. But pain doesn't have to be in charge.
Useful resources
The following websites are excellent sources of further information about persistent pain and self-management:
Live Well with Pain – A comprehensive patient resource covering understanding pain, pacing, setting goals, getting active, relaxation and mindfulness, sleep, communication, mood, medicines and managing setbacks.
Pain Toolkit – Practical advice for people living with persistent pain, focusing on goal setting, pacing, problem solving, meaningful movement and having a plan for setbacks.
Retrain Pain – Science-based patient education explaining pain, the nervous system, why persistent pain can develop and how understanding pain can help you move forward.
Tame the Beast – A particularly useful introduction to the idea of pain as a protective system and why the pain system can become overprotective and more sensitive over time.
How can Physio at Home help?
If you are living with persistent pain, physiotherapy can be useful in helping you understand your symptoms, gradually build your strength and activity, and regain confidence in movement. The right type of physiotherapy and the right setting will depend on your individual circumstances.
For some people, attending a physiotherapy clinic is the best option. A clinic may provide more space and specialist equipment, and can sometimes make it easier for a physiotherapist to assess certain problems or provide particular types of treatment. If you are able to get out of the house safely and comfortably, this can be a good option.
For others, getting to a clinic can be difficult, tiring or stressful, particularly if pain has affected their mobility, they have recently been unwell or in hospital, or they have lost confidence getting out and about. This is where home-based physiotherapy can be particularly helpful.
At Physio@Home, we provide physiotherapy in your own home across Mid Cornwall, including Truro, Falmouth, Penryn, Helston, Perranporth, Feock, St Agnes and surrounding areas. We work with people recovering from illness, injury, surgery or falls, as well as people experiencing reduced mobility, weakness, balance problems or loss of confidence.
One of the advantages of a home visit is that we can see how you actually move and manage in your everyday environment. Rather than assessing mobility only in a clinic, we can look at things such as getting in and out of a chair, moving around the house, using the stairs, getting in and out of bed or managing activities that are important to you. Where appropriate, we can also consider the home environment and whether small changes could make everyday activities safer or easier.
Our approach is focused on helping you become more independent rather than creating unnecessary dependence on physiotherapy. We take time to understand what you want to achieve, assess your movement, strength, balance and function, and develop a realistic rehabilitation plan around your goals.
Physio@Home is run by Ben and Hannah, both HCPC-registered physiotherapists and members of the Chartered Society of Physiotherapy, with a combined experience of more than 35 years. We have a strong background in rehabilitation following illness, injury, surgery and falls, as well as helping people improve strength, mobility, balance and confidence.
If you're unsure whether home physiotherapy is appropriate for you, we are always happy to have a conversation first. Sometimes we may feel that another service or a clinic-based assessment would be more appropriate, and we'll be honest about this. Our priority is finding the approach that is most useful for you.
Find out more about Physio@Home
If you live in Mid Cornwall and would like to find out whether home-visit physiotherapy could help you, you can find more information about our service, the areas we cover and how to get in touch on our website:
Phone: 07440 542208 Email: physio-at-home@outlook.com
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