So Is My Pain Structural or Coming from My Nervous System?
One of the most common questions I hear from patients is, “How do I know if my pain is caused by an injury or if it’s coming from my nervous system?” This is a really important question, because the answer shapes both how you understand your symptoms and how you recover.
Structural (tissue) based injuries and neuroplastic (nervous system) based conditions each have very unique characteristics that help you to distinguish which of these mechanisms is driving your pain experience. The Table below outlines some of the key differences between structural and nervous system based pain.
| Category | Structural / Tissue-Based Pain | Neuroplastic / Nociplastic Pain |
|---|---|---|
| Onset | Follows a clear injury, trauma, or surgery | May begin after stress, illness, trauma, or with no clear injury |
| Location | Localized to one spot or predictable referral pattern | Widespread, diffuse, or shifts between areas |
| Relation to Imaging | Imaging usually matches the pain (fracture, arthritis, tear) | Imaging often normal or mild; pain severity doesn’t match findings |
| Pain Behavior | Consistent, proportional to activity or load | Variable, disproportionate, can flare without clear cause |
| Predictability | Follows mechanical patterns: worse with use, better with rest | Unpredictable; flares may come suddenly or be delayed (wind-up effect) |
| Healing Timeline | Resolves as tissues heal (weeks–months) | Persists >3 months, even after tissues have healed |
| Response to Treatment | Improves with tissue-focused care (rest, strengthening, injections, surgery) | Poor or short-lived response to structural treatments; often worsens with repeated procedures |
| Sensitivity | Pain with clear tissue stress or mechanical load | Pain with light touch, mild activity, or even thoughts/emotions (allodynia, hyperalgesia) |
| Flare Patterns | Flare occurs with reinjury or overuse | Flares without tissue damage; pain may spread or intensify unpredictably |
| Other Symptoms | Usually isolated to injury site | Fatigue, poor sleep, brain fog, digestive upset (IBS, bloating), headaches, light/sound sensitivity |
| Psychological Links | Less tied to emotions (though stress can slow healing) | Strongly tied to fear, worry, perfectionism, trauma, or unresolved emotions |
| Mechanisms | Peripheral sensitization: nerves at injury site become more sensitive due to inflammation; protective until tissue heals | Central sensitization: brain & spinal cord amplify signals; wind-up causes delayed/stronger pain; predictive coding makes brain expect pain; neuroimmune activation keeps system overactive |
| Protective Role | Adaptive short-term: keeps you from stressing injured tissue | Maladaptive: alarm stuck on high volume, protecting you even when it’s not needed |
| Timeframe | Short to medium term (resolves with healing) | Long-term (chronic, >3 months) |
| Examples | Broken bone, sprained ankle, acute disc herniation, post-surgery pain | Fibromyalgia, chronic low back pain, tension headaches, IBS, TMJ, widespread musculoskeletal pain |
In order to gain further insight into your pain presentation and the likelihood of the nervous system as a contributing factor, the list below combines the (3) most widely accepted and validated outcome measures for chronic pain and central sensitization (nervous system pain). Give it a try yourself! Check all the boxes that apply to you, each check mark is evidence towards the nervous systems involvement in your persistent pain.
🌀 Pain Pattern & Behavior
☐ Pain moves or shifts to different areas over time
☐ Pain occurs in multiple body regions
☐ Pain is present without clear physical cause
☐ Pain intensity varies day-to-day or hour-to-hour
☐ Symptoms are disproportionate to imaging or diagnosis
☐ Gentle touch or light pressure can feel painful
☐ Pain is delayed after activity (e.g., flares the next day)
🔍 Medical History & Tests
☐ Imaging (MRI, X-ray, etc.) was normal or inconclusive
☐ You’ve been told "nothing is wrong" but still feel pain
☐ You’ve had many different treatments, but none worked long-term
☐ Surgery or injections did not reduce the pain
☐ Pain has persisted long after an injury healed
☐ You have a history of other chronic conditions (e.g., IBS, TMJ, tension headaches, fibromyalgia)
💭 Psychological & Cognitive Signs
☐ You feel fearful, anxious, or uncertain about movement
☐ You have catastrophic thoughts (e.g., “What if this never goes away?”)
☐ You tend to be self-critical or perfectionistic
☐ You ruminate or focus on symptoms constantly
☐ You’ve had stress, trauma, or emotional events around the time the pain began
☐ Pain worsens when you're feeling stressed, unsafe, or overwhelmed
🧬 Mind-Body Sensitivity
☐ You have trouble sleeping or feel unrested
☐ You feel fatigued or low energy most days
☐ You feel sensitive to light, noise, or smell
☐ You experience brain fog or poor concentration
☐ You’ve had digestive issues (IBS, bloating, nausea)
☐ Your symptoms improve with distraction or relaxation
☐ You notice symptoms worsen with focus or fear
🔁 Typical Patterns of Central Sensitization
☐ Flare-ups occur even without injury or overuse
☐ Pain spreads or intensifies unpredictably
☐ You’ve developed sensitivity to many things (foods, postures, weather)
☐ There’s a feeling of fragility, like your body could "break"
☐ You feel like doctors aren’t seeing the whole picture
Clinical Red Flags for Central Sensitization (per Nijs et al., 2014)
If ≥4 of the following are present, central sensitization is involved:
Pain disproportionate to injury or findings
Diffuse or widespread pain
Unpredictable flare-ups
Sensitivity to multiple stimuli (touch, sound, emotion, etc.)
Emotional distress (fear, catastrophizing, anxiety)
Poor response to conventional biomedical treatment
If you found yourself saying “this sounds like me!” more than a few times throughout this post, it’s highly likely that your nervous system is the dominant factor contributing to your painful experience. For a more comprehensive “Pain Test”, click the link HERE to complete our free online pain quiz, which will categorize your pain based on answers provided.
📖 References
Ashar, Y. K., et al. (2021). Effect of pain reprocessing therapy vs placebo on pain relief in chronic back pain. JAMA Psychiatry.
Kosek, E., et al. (2016). The definition of nociplastic pain. Pain.
Mayer, T. G., et al. (2012). The development and psychometric validation of the Central Sensitization Inventory. Pain Practice.
Nijs, J., et al. (2014). Treatment of central sensitization in patients with ‘unexplained’ chronic pain: what options do we have? Expert Opinion on Pharmacotherapy.Nijs, J., et al. (2021). Identifying patients with central sensitization: key clinical features and measurement tools. Journal of Pain Research.
