A question often asked in the clinic is “what is the most painful injury you treat?”, or “they say this is worse than child-birth, is that true?”

This question is somewhat difficult to answer accurately as pain is a subjective and complex experience, in which the injured persons previous injury history, gender, age, and cultural background all play a significant role in the severity of  the pain experience.

Anyone who has any experience of persistent pain syndromes will know that even for a GIVEN injury within a single person their pain can be exacerbated by mood, stress, temperature change, fatigue  – none of which actually increase the tissue damage – so what gives?

Well, even with the above taken into account there are still certain injuries that will be universally so painful that the injured-person will often be unable to remember them clearly (which is an evolutionary blessing) due to the massive amount of our brain’s stress hormone, Cortisol, being released.

This hormone causes our brain to improve memory retention at low doses, but when our brain is flooded with it due to extreme pain or stress then we don’t lay down long term memory. These are the sort of injuries that make us wince when we hear about them, and can leave some people feeling nauseous. It is to these sort of injuries that we’ll turn our attention.


Tibial Compound Fracture: Something about the combination of the high-force fracture of one of our main weight-bearing bones and then having the sharp bone end tear through the muscle and skin is enough to leave even the strongest stomach quivering.

Bone is lined with tissue called periosteum, which is really rich in blood vessels and nerves, and it is this layer that makes the fracture so painful and causes so much bruising. Add to this the soft tissue damage and scarring that is caused by the subsequent exit wound of the fractured bone end, and you have an injury that will ensure you have a long and fruitful relationship with your orthopaedic surgeon and physiotherapist.

Ouch Factor: 9.5

Sequestered Lumbar Disc Prolapse: Disc bulges are common, so common in fact that some studies report over 60% of the asymptomatic population will show signs of disc bulge on MRI  scan. So if so many people have them, why are some people crippled by them and others are not? The answer lies in the degree.

Discs can bulge broadly as a result of degeneration of facet joints with age, meaning the vertebra that attach to the disc settle closer to each other and reduce disc-space. This causes some the the disc to bulge toward the spinal canal.

This is not a problem unless it is large enough to start causing compression of the spinal cord, or the exiting nerve roots. A focal prolapse, however,  is a smaller region of the disc, but with a larger extrusion of the disc material, leading to a prominent lump. This by itself can cause significant pain due to nerve compression (classical sciatica – back pain and referred pain and tingling/numbness down one  leg). If the trauma is severe enough, or continues over long enough period, this disc prolapse can “sequester” which means to detach or cut off.

This fragment can then  slip into either the spinal canal or nerve exit hole, and in either  place can lodge and cause severe and unremitting compression of the nerve root or spinal cord. Since the  lumbar spine is under load in almost all static positions, relief from pain can be difficult to find. Coughing, sneezing or toileting can severely increase the pain, and given that most opiate pain-killers given for this type  of pain cause constipation, this can be really problematic.

Ouch Factor: 9

Flail Chest: Defined as at least two ribs broken in at least two places (each) this high force trauma injury occurs when a section of the rib-cage becomes broken away from the rest, and is able to move  independently of the rest of the chest.

The worst thing about this is that when the injured person tries to inhale, the negative pressure in the chest cavity pulls the flail segment in while the chest expands with air rushing into lungs, and then during exhalation the opposite occurs, causing the flail segment to move outward  while the chest is deflating. Imagine the broken ends of several ribs grating against each other with every breath in and out! It is little wonder that often sedation is required, along with high-level non-opiate pain relief (opiates cause respiratory depression and in a patient who is already likely to under-breathe this is dangerous) as well as positive pressure ventilation to splint the flail segment during inspiration.

This can occur in sports like football from shoulder charges, but is often due to motor vehicle accident.

Ouch Factor:  10

Ankle Sprain: One of the most common injuries we see in the clinic, but has the potential to be one of the most painful.

The ankle joint is the closest joint to the ground, and such has the most weight bearing role. Due to this it is supported by some strong ligaments, but in high force situations like landing on someones foot after jumping, or mis-stepping on the edge of a gutter or pot-hole these ligaments are no match for the weight of the body, plus the additional acceleration of gravity as the body approaches the earth.

Patients are constantly surprised by just how much it hurts to do a proper sprain, and the length of time it takes to return to normal. It’s not unusual to be entirely unable to weight bear for a few days following a high-grade sprain, and to have bruising and discoloration up as far as the knee.

Even rolling in bed can cause a gasp and a few choice words. It is also one of the injuries for which physiotherapy treatment can make the quickest improvement, so early assessment and treatment is advised (however the treatment can be nearly as painful as the initial injury!).

Ouch Factor: 8

Elbow Dislocation: Not only severely painful, this injury is one of those that makes even the witnesses tend to feel nauseous. This occurs when extreme pressure is applied to an elbow that is already in the fully extended position, leading to damage and stretching of the collateral ligaments, and then followed by the elbow folding back past the point of full extension.

I think because we as humans are so reliant on and focussed on our ability to manipulate the world with our hands, anyone can sympathise with the loss of function you would experience for weeks after having this happen. If anyone thinks this injury shouldn’t be on the list, just search for “Andrew Bogut Elbow Injury” on your favourite video streaming site, you’ll reconsider once you stop wincing.

Ouch Factor: 9

All of these injuries are horrifically painful and involve significant rehabilitation to return to full function. If you’ve had anything like this happen in the past and still feel like you are not functioning fully, best bet is to see your physiotherapist and see if there’s anything that can be done about it.