Non-Fracture Causes of Pain After a Fall
Pain after a fall without fracture commonly results from soft tissue injuries including ligament sprains, muscle strains, tendon injuries, contusions, and hematomas—all of which can cause significant pain and disability even when bones remain intact.
Primary Soft Tissue Injuries
The most common non-fracture causes of post-fall pain include:
- Ligament sprains (partial or complete tears of ligamentous structures)
- Muscle strains and contusions with associated hemorrhage and edema
- Tendon injuries ranging from tendinopathy to partial or complete tears
- Soft tissue hematomas from direct impact
- Joint effusions without fracture
These injuries are particularly important because they can occur independently or coexist with fractures, and may be the primary source of pain even when radiographs appear normal 1.
Location-Specific Considerations
Ankle Injuries
Ligamentous injuries occur in approximately 15% of acute ankle injuries without radiographic fracture 2. The anterior talofibular ligament is most commonly injured, followed by syndesmotic and deltoid ligament injuries. Peroneal tendon injuries and superior peroneal retinaculum tears can also cause significant pain without fracture 2.
Hip and Pelvic Region
Muscle and tendon injuries around the hip can mimic fracture pain. While hip dislocation is a consideration in high-energy trauma, soft tissue injuries predominate in lower-energy falls 3.
Extremities
Soft tissue injuries to extremities include muscle contusions with associated hemorrhage, edema, and pain. These respond well to cold application, which decreases hemorrhage, edema, pain, and disability 4.
Fall-Related Complications
Prolonged Immobility Effects
Time spent on the floor or ground after a fall is a critical historical element that can lead to:
- Pressure injuries
- Rhabdomyolysis from prolonged compression
- Dehydration
- Hypothermia 1
Neurological Causes
Pain may result from:
- Nerve compression or entrapment (e.g., Baxter's neuropathy in heel pain) 5
- Peripheral neuropathies that contributed to or resulted from the fall 1
Diagnostic Approach
When Radiographs Are Normal
If pain persists despite negative radiographs, MRI without contrast is the reference standard for identifying:
- Bone marrow edema patterns indicating occult injury
- Ligamentous injuries with grading of severity (grades 1-3)
- Tendon pathology (tendinopathy, partial tears, complete tears)
- Soft tissue hematomas and contusions 2, 5
MRI demonstrates 15% of ligamentous injuries that show no fracture on radiography and can identify bone bruising with adjacent soft-tissue edema that correlates with acute ligamentous and tendon injuries 2.
Clinical Red Flags Requiring Further Evaluation
Beyond fracture, assess for:
- Loss of consciousness or altered mental status suggesting head injury
- Near-syncope or orthostasis indicating cardiovascular cause
- Melena suggesting GI bleeding as precipitant
- Medication effects (particularly sedatives, antihypertensives)
- Visual or neurological impairments 1
Important Caveats
Do not assume pain equals fracture—soft tissue injuries can be equally or more painful than non-displaced fractures. The question "if this patient was a healthy 20-year-old, would they have fallen?" helps identify underlying causes beyond simple trauma 1.
Bone marrow edema on MRI does not always indicate fracture—it may represent contusion or stress injury without cortical disruption 2, 5.
Multiple injury types commonly coexist—identifying one injury should not stop the search for others, particularly in elderly patients with osteoporosis who are at higher risk for both fractures and soft tissue injuries 1, 6.