Normal imaging does not end the enquiry.
Soft-tissue injuries may involve muscles, ligaments, tendons and other structures that do not always produce clear findings on routine imaging. Even when the original injury has healed, pain, stiffness and reduced confidence in movement may continue.
This does not mean that every persistent symptom remains directly caused by injured tissue. It means that normal imaging cannot, by itself, answer the causation question. The expert must consider the original injury, the expected recovery period, the claimant’s progress and any other factors capable of maintaining symptoms.
A report that says “MRI normal, therefore no injury” is too blunt. A report that says “pain persists, therefore the injury has not healed” is equally unsatisfactory. Both confuse symptoms with structural damage.
Start with the early evidence.
The first few days and weeks often provide the clearest account of the initial injury. Accident and Emergency notes, GP records, physiotherapy assessments, medication history and sickness certificates may help establish what was reported at the time.
The expert should look for the site of pain, timing of onset, clinical findings, functional restrictions and treatment advised. Consistency matters, but medical records are not perfect transcripts. A brief note may omit symptoms because the consultation focused on a more urgent complaint. Conversely, a later account that expands substantially beyond the early records may require explanation.
The question is not whether every description is identical. It is whether the overall pattern is clinically coherent.
Recovery is not always linear.
Symptoms may improve and then flare after activity, poor sleep, stress or a return to work. Fear of causing further damage may lead to guarded movement and reduced activity, resulting in weakness, stiffness and a lower tolerance for ordinary tasks.
These factors can maintain disability after the original tissue damage has settled. They are not evidence that the claimant is inventing symptoms, nor should they automatically be labelled as psychiatric illness. They form part of the interaction between pain, behaviour, expectation and physical function.
In my own reports, I find it useful to separate three questions: what was injured, what is causing symptoms now, and what is preventing recovery? The answers are not always the same.
Establish the pre-accident baseline.
Persistent symptoms cannot be assessed properly without understanding the claimant’s condition before the accident. Previous neck or back pain, arthritis, headaches, mental-health difficulties, sleep problems and earlier accidents may all affect the presentation.
A pre-existing condition does not exclude an accident-related injury. The event may have caused a new problem, temporarily aggravated an existing condition or accelerated symptoms that would probably have appeared later.
The expert should state which explanation best fits the evidence and acknowledges uncertainty where it remains. Describing all post-accident symptoms as “caused by the accident” may overstate the position. Describing them all as “degenerative” may ignore a clear change in function after the event.
The opinion should distinguish between cause, contribution and continuation.
Look beyond the injured tissue.
When symptoms continue beyond the expected healing period, the assessment should widen. The expert should consider sleep, mood, medication, work demands, physical activity, beliefs about damage and the response to treatment.
Persistent pain may involve altered pain processing, increased sensitivity and protective behaviour. These mechanisms can produce genuine symptoms even where there is no continuing structural injury.
The report should explain this clearly without making psychiatric diagnoses outside the expert’s field. The absence of structural findings does not prove that symptoms are psychological. Where the presentation has become complex, further specialist input may be appropriate.
An orthopaedic or musculoskeletal expert may be able to comment on the physical injury and expected recovery period. However, where psychological distress, fear of movement or wider pain mechanisms have become prominent, input from another discipline may be needed.
Treatment history needs context.
Failure to recover after physiotherapy does not prove that the injury is permanent. Treatment may have been delayed, too brief, poorly matched to the problem or not followed consistently. The reasons matter.
Some claimants stop exercises because they increase pain. Others receive passive treatment without a structured return to activity. Waiting lists, work commitments, transport problems and fear of movement may also interfere with progress.
The expert should record what treatment was offered, what was completed and what effect it had. Any further recommendation should have a clear purpose. General advice to “continue physiotherapy” is not enough if the real barriers involve confidence, pacing, strength, sleep or psychological support.
The expert should also avoid if a failure to follow treatment necessarily reflects unwillingness to recover. There may be reasonable explanations, and these should be explored before any opinion is expressed.
Function is more useful than labels.
The severity of persistent symptoms is best judged by what the claimant can and cannot do. This includes work, driving, domestic tasks, exercise, personal care and social activity.
Continuing to work does not automatically disprove severe symptoms. People may continue through financial necessity or a strong sense of responsibility. Equally, prolonged absence from work does not establish that the accident remains the sole cause of disability.
The report should describe function in practical terms. How long can the claimant sit or stand? Have their duties changed? Are additional breaks required? Which activities have been abandoned, modified or resumed?
These details are more informative than a broad statement that the claimant is “significantly restricted.”
Prognosis should be reasoned.
The expert should resist simply extending the recovery period because symptoms remain present at examination.
A reasoned prognosis should consider the duration of symptoms, the improvement already achieved, treatment response, ongoing stressors, work status, physical conditioning and the claimant’s beliefs about recovery. The longer pain and avoidance have continued, the less useful it may be to describe the problem solely as an unhealed sprain.
Recovery may still occur when the focus shifts from repeated investigation to active rehabilitation, a graded return to normal activity and management of the factors maintaining symptoms.
The report should distinguish between tissue healing and the separate question of when pain and function may improve. A claimant’s tissues may have recovered even though their symptoms and limitations have not yet resolved.
The balanced opinion.
Persistent symptoms after soft-tissue injury rarely fit an all-or-nothing explanation. The original injury may have been genuine and modest. The tissues may have healed. Pain and disability may nevertheless continue because of deconditioning, altered pain processing, fear, poor sleep, low mood or unresolved workplace and social pressures.
The expert’s task is to explain that sequence without minimising the claimant’s experience or attributing every difficulty to the accident.
A sound report identifies what the evidence supports, what it does not support and where other factors have become important. The strongest opinion is not the one that sounds most certain. It is the one that shows clearly how the conclusion was reached.
