So, your doctor has said “Yup! Your fracture has healed!” But why is it still so painful after your cast has been removed? Even the slightest movement is painful, so you're struggling to believe that the fracture has really healed.
In this article I'll explain why a limb can be painful after your cast has been removed, and what you can do to get rid of the pain and get back to your normal activities.
Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call.
In this article:
We've also made a video about this:
When is pain after cast removal normal … and when not?
It's absolutely normal to have some pain, stiffness, and discomfort right after your cast has been removed. That body part has been stuck in a cast for several weeks, so it's not going to feel just fine and move normally right away.
You might even experience sharp, stabbing pains when you take it into certain position. But usually this pain is not extreme, and it only really hurts when you take it into positions where you're forcing the movement.
As your movement and strength improve, the pain usually dissipates. Depending on the area you fractured and how severe it was, you can expect it to take at least three months to get 95% of your normal function back.
When the pain isn’t normal
The pain that this article is about is extreme pain and discomfort. So, we’re talking about a disproportionate level of pain that stops you from doing most things and actually prevents you from progressing with your rehab as well.
First, make sure it has healed
If this is the case, the first step is to go back to your doctor. They have to check whether the fracture has indeed healed properly and that there's nothing wrong with the bones. Some fractures can cause complications afterwards, and it can sometimes be missed in the first instance.
They will likely order an X-ray or perhaps even an MRI scan, depending on the type of fracture and what's happened in there, because different types of scan can show different things better.
If that comes back clear and it shows that the fracture has healed and your bones are nice and healthy, then we know that the healing process is not the problem.
So now it's very likely your pain system that has been dialled up in such a way that it is overreacting. Often, this goes together with some other symptoms, such as swelling, hair loss, or discolouration at the affected area.
The type and intensity of the symptoms can vary. Severe cases might get diagnosed as “complex regional pain syndrome” or “hypersensitivity syndrome”; in other cases it might not even be given a label.
💡 The name doesn’t really matter – the common problem is that your nervous system has become “too good” at protecting you.
So, how do we get things back to normal? We treat the pain system so it can calm down. To do this, you must first understand how pain is created and what influences its intensity.
A new understanding of how pain works
We used to think that pain was quite simple: You have pain receptors everywhere in your body, you get injured, it triggers the receptors, and that creates the pain. And the more severe the injury is, the more painful it is.
Thanks to recent advances in the field of scanning and interpreting injuries inside our bodies, we now know that there is not necessarily a link between how bad an injury is and how much pain we experience.
There have been many instances of people whose scans showed severe injuries while they experienced very little or no pain.
Also, people without injuries (or whose injuries have healed completely) who had extreme pain.
And of course, sometimes the pain reacts like we expected it to in the “old days”: You have an injury, and it’s painful. As the injury heals, things get better, and the pain goes away totally.
❓ So, why does that happen in the expected way for some people while for others there seems to be a disconnect between the pain and the injury?
Why and how pain is created
What we now understand about the nervous system is that we don’t have “pain receptors”.
What we do have is sensors that are constantly measuring things that could potentially affect our tissue health. These are things like pressure, stretch, chemicals, and temperature – some of which are present all the time. And these sensors are constantly sending our subconscious brain messages or signals about these.
Obviously, the brain will go haywire if it were to react to all these messages, so there’s a threshold above which it goes “Hey, this seems like it could be dangerous to the body I’m inhabiting!” It then creates pain because it wants you to take action to reduce those signals.
It is important to note that this is your subconscious at work here – you have no direct control over it. That is why “mind over matter” is not a way to deal with pain, and in fact that approach might even increase your pain. However, this is also not to say that pain is “all in the mind” – your body undergoes actual physical changes in reaction to it.
Why pain can get dialled up
The signals from the sensors are not the only things that determine whether and to what extent your subconscious creates pain. There are other factors at play that could make your subconscious interpret these signals as more dangerous or less dangerous as what they are conveying and which, in turn, make your subconscious dial the pain up or down accordingly.
Here are some examples. Often, several of these factors combine to sensitize the pain system.
Physical changes to the pain system “hardware”
If you’ve had pain or an injury in a specific area for several weeks, you develop more of those little sensors, and they get triggered more easily and fire off more messages to the brain.
📢 So, your body becomes better at creating the signals that trigger a pain response. It’s as if the body feels you’re ignoring it, so it wants to make more noise to get your attention.
I think this might explain why people who have not been very comfortable in their cast, experiencing pain while they were wearing it for all those weeks, could be hypersensitive to pain in the formerly injured area after the cast has been removed. Something about the position they were in, despite it looking correct on x-ray, kept triggering the pain system, and as a result it has become really good at firing off at the slightest provocation.
Past experiences with pain
If your past experience of a running injury tells your subconscious brain “Nah, that type of pain goes away quite quickly, I just have to have a couple of days of rest, then I can run again” it's not going to pay that much attention to that area, and your pain will just calm down as the tissue calms down.
However, if the last time you had pain in that area caused you to not be able to run or exercise for six months to a year, it is going to pay heavy attention to it, and it's likely going to create more pain than how severe the actual injury is.
If your father has had bowel cancer and you suddenly get pain in your stomach, your subconscious brain might go “Oh shucks, Dad had bowel cancer! Now my stomach's hurting. It must be bowel cancer!” and it might create more pain than is warranted.
There have been experiments where they've measured people's pain before they see a doctor, then they see the doctor, they get a diagnosis that the injury is not serious, and they come out, and they measure the pain again, and it has decreased by nearly 50%. Obviously, no physical healing has taken place during the duration of the consultation, but the subconscious brain has been reassured that this is not as dangerous as it had thought it was.
Emotions such as stress and fear
Stress (work, family, life) and fear cause the body to release stress hormones. These can cause the pain to be dialled up or down.
In the short term, when you experience a high-stress crisis situation, your subconscious might dial down the pain to allow you to deal with a dangerous situation. This is why some people in car accidents have been able to rescue fellow victims in dire need of help while they themselves had a broken arm or leg, and only hours later do they realise they have broken something.
But if those stress hormones are elevated for days on end, your subconscious brain starts to increase the pain response. For instance, if you fear that your injury is going to prevent you from continuing to earn a living and provide for your family, the pain might get dialled up to way beyond what the physical nature of the injury warrants.
A disconnect between your brain and the injured limb
Using MRI scans, the people in the white lab coats have figured out which part of your brain lights up when you move, say, your leg or even when you just think about your leg – and it’s the same part of the brain – on the opposite side – for either leg.
They have found that for people with persistent injuries that last for several months (say, an injury to the right ankle), the brain doesn’t light up in the same way anymore that it still lights up for the left ankle.
The area that lights up for the injured or painful side is smaller, and it looks like the uninjured side becomes more prominent. They’ve also found that, as chronic injuries or pain starts to improve, the brain’s representation of that area returns closer to normal.
This has led them to speculate that the subconscious brain has started to disregard that limb as a part of the body, which might contribute to the pain being dialled up. The good news is that they’ve also identified very simple techniques that can help to get things back to normal. I share them in the sections below.
Inflammatory/autoimmune reaction
And then lastly, there is some evidence that in some people it might be an excessive inflammatory or autoimmune reaction that's causing the hypersensitivity.
This might be why women between the ages of 50 and 70 are more prone to this. We know that some of the symptoms of menopause are linked to autoimmune reactions.
In summary, the pain is being dialled up because your pain system has become “too good” at protecting you. So, how do we reverse this?
How to get rid of the pain
The first step should always be to see your doctor. They have to make sure that your fracture has healed properly and your bones are healthy – one shouldn’t just assume it is the pain system that is dialled up.
Once you’ve ticked that box, you can approach the situation from several angles. Most likely, you will have to combine most or all of these to get on top of things.
“Mindful” rehab to reconnect your subconscious brain with the painful limb
Now, I'm very aware of how airy-fairy the term “mindful exercises” sounds, but hear me out.
Remember how I said that MRI scans show how your brain starts to light up differently for an injured limb? Researchers have found that you can change how the brain lights up back to normal simply by paying attention to the limb rather than ignoring and overprotecting it.
You have probably been prescribed rehab exercises to improve your movement after you’ve come out of your cast. Rather than watching TV while you are doing your exercises, you should switch off the TV and think about what you are doing – pay attention.
Look at it while you move it, observe what you feel and how it moves, and really try to control the movements properly. If it’s an exercise for your arm, this is your way of telling your subconscious brain “This is my arm. We are moving my arm. And see, it is okay to move my arm.”
💡 In the research they ask patients to move their injured limb to the beat of a metronome or to slow the movement down and focus on moving for "x" seconds in one direction before switching. The method isn't important – what matters is that, by having to match a rhythm, the brain is forced to pay attention, and this improves its control over the limb.
Self-talk
Self-talk has to do with all those thoughts and worries that pop into your head throughout the day, but also while you're doing your exercises and doing your activities.
If you catch yourself having thoughts like “I'm never going to be able to work again. What am I going to do if I don't get this function back?” you should answer yourself along the lines of “No, I will get better. I will get my function back. This is just hypersensitive. The sensitivity will calm down.”
So, identify all those negative thoughts – all the fears. They might be legitimate fears, but identify those creeping thoughts and feelings that are making you more worried. That little voice that's sitting here on the shoulder – get it to shut up. And don't just tell it to shut up. Reason with it. Explain to it that “No, it will be okay. It is going to take time, but it will gradually calm down.” It doesn't like to just be ignored or told to shut up; you have to “convince” it.
Breathing
Why breathing? It's the most effective way they have found so far that you can get your vagus nerve to calm down. The vagus nerve is in charge of your fight-or-flight reaction or your stress response. And if you can get the vagus nerve to calm down, it actually helps your stress hormone levels to calm down, and that can desensitise your pain system.
So, we’re talking slow, deep breathing – the kind that makes your belly move in and out. You don't have to get fancy about it. Just every now and again, tell yourself to breathe.
You can approach this two ways or use both. First, make sure that you breathe deeply while you are doing your rehab exercises and focus on relaxing as you do it.
But you can also have one or two sessions a day where you just do deep breathing for a few minutes. You could stick on a YouTube video about yoga where they teach you about breathing and just follow along.
Getting tactile – touch and massage
There's good evidence to show that touch and massage can decrease pain and desensitise nerve endings.
And research has shown that that touch or massage that comes from a loved one works even better. But when you have an injury that's this painful, rather start off by doing it yourself, because your subconscious brain trusts you more than anyone else.
👐 The massage doesn’t have to be fancy. Don’t let people tell you you've got to rub it this way or do it that way because otherwise you're going to cause damage. You’re never going to cause damage by just rubbing it gently.
All you do is, get some cream, and you rub it into the area that's painful, and you do it at a level that's comfortable. You will feel bumps, you will feel lumps. You're going to feel tendons and other weird stuff, especially in the wrist area. That's all normal.
Now, if it's really sensitive, even a rubbing action might upset it at first. You might have to start by just holding it and pressing it gently. And while you’re doing this, think about how comfortable it feels, do some deep breathing (see above), and tell yourself how you're helping all of this to recover.
If you're going to use a massage gun, have it on a really light setting, and don't dig in with it. We're not trying to break up adhesions or scar tissue or any of those nonsense things that some people say you can do with it. The aim here is to desensitise, and if you go really hard with a massage gun, you can injure yourself.
Heat and cold
Cold usually aggravates things for people with a hypersensitised pain system. But if you have an autoimmune reaction and you've got active inflammation going on, cold therapy might be very useful.
But, if you don't have active inflammation, heat is usually the better option. What I often tell my patients is to put their body part, if they can, in warm water and do some gentle massage in that position, or do their exercises in warm water, because it can really make it all feel more comfortable.
Acupuncture
This is probably not going to work if you're scared of needles, because that will actually increase your stress hormones and cause your pain to feel worse.
But if you're not bothered with needles, acupuncture is something that could be useful to decrease pain.
However, it doesn't work for everybody, and you shouldn't just go for the sake of going. If you've gone three or four times and you haven't seen any improvement, it's likely not going to work for you, and it's not worth forking out even more.
Movement
You have to start moving that limb. There’s evidence to show that over-protecting it causes the subconscious brain to think more and more of that area of the body as “not part of your body”.
🤝 So, a big part of “reclaiming” your limb and connecting it to your brain again is to start moving it.
Where people often go wrong at the start is to think they should really push it. You don't have to. If it's really painful, you just start with what it can do without much pain. And you apply all the other things I’ve discussed above while you're doing it, and you just keep doing that and reassuring yourself and getting things moving again.
Your physio will help you to understand what the best exercises are for the type of fracture you've had.
Regaining strength
You also want to build strength. And at the start, you don’t even have to move to make some progress. Isometric exercises are when you contract a muscle while keeping the limb still, e.g. pushing against a wall with your arm.
Also, use your limb for everyday things as much as you can. If you’ve had a broken wrist, see whether you can start by picking up tiny things, even if you have to wear a wrist support while doing it.
Be careful not to overdo the exercises, because if it’s too painful, it will enforce your subconscious brain’s scepticism about the movement. You have to do it at a level that makes it slightly apprehensive, but doesn't scare it. And then, tomorrow or the day after, you can take things a little further.
👍 It is usually OK and expected to experience some discomfort while doing your exercises, but it should not cause very strong pain. And if it does increase your pain, that increased pain must settle down back to its previous level within 24 hours of doing the exercises.
Medication
If your doctor has established that you have an autoimmune reaction, they might prescribe medications that can be really useful. And there are certain types of medication that can work for nerve pain, so you might be prescribed one of those.
Have patience
It's important that you give it time. This is not something that's going to get better within a week or two weeks or four weeks, even. It's going to take several months.
But the good news is that even for the most extreme cases – complex regional pain syndrome – the research is showing that when they check up on these patients a year later, the majority of them have no symptoms left.
So, this can improve, and it very likely will improve. You just have to continuously stick with all of these ways to improve the situation.
People who can help
There are some people who can help to speed up your recovery. They can help by reassuring you, giving you specific exercises, and creating better strategies to cope with the pain and to eventually desensitise your pain system.
Occupational therapists are good at this, especially for wrist and hand rehab.
Physiotherapists can also help with getting the balance between rest and exercise right and how to make the exercises progressively more challenging.
If you're a strong-minded person who is inclined to “get on with it and get things done” it can be annoying when somebody tells you “But your brain and your thoughts and your feelings can contribute to this pain experience.”
🤔 And their first reaction – mine too – is typically to rebel against that. But the research shows that it's the Type A personalities – perfectionists and high-achievers who tend to be able to get on with things and who like high-stress situations – who tend to suffer more with ongoing pain.
Pain psychologists and sports psychologists can be really useful people to consult in such cases.
So, do make sure that you work on the mental side as well, and don't try to fix this from a physical point of view only.
How we can help
Need more help with recovering from an injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.
We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.
About the Author
Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.