The Language of Pain: Towards Objective Reporting in Orthopaedic Medicolegal Assessments

In the highly scrutinised world of medicolegal assessments, the language used by orthopaedic surgeons matters profoundly. Our reports guide legal outcomes, compensation decisions, and appropriate care pathways.

At times I read subjective or potentially stigmatising language in orthopaedic reports, for example:

"His entire presentation is related to a psychiatric phenomenon far more likely to be a conversion disorder rather than any physical explanation."

"There is likely to be an overlay of a functional component related to the claim."

"This is a highly fragile individual who has abnormal coping mechanisms and I am certainly sceptical with regard to the connection between the transport accident and the pathology found."

As orthopaedic surgeons, we are experts in the musculoskeletal system—bones, joints, ligaments, tendons, nerves, and blood vessels. We are trained to identify structural and organic pathology. However, when an examinee’s reported pain does not match the physical findings, reports can sometimes default to wording that dismisses the pain as “non-organic” or purely psychological.

In my opinion, this subjective language has no place in a modern, objective medicolegal report. We need a more rigorous, evidence-based framework for evaluating pain that respects the examinee’s experience while remaining clinically accurate and defensible.

The Solution: A Mechanistic Approach to Pain Classification

One solution is to re-frame our evaluation of pain using the three distinct mechanistic classifications recognised by authoritative bodies, such as the International Association for the Study of Pain (IASP).

This terminology provides a scientific, objective framework for classification:

Reference: Merskey, H. and Bogduk, N. (1994) Part III: Pain Terms: A Current List with Definitions and Notes on Usage. In: Classification of Chronic Pain, Second Edition, IASP Task Force on Taxonomy, 209-214.

The Three Types of Pain:

Nociceptive Pain: This type of pain arises from the activation of sensory nerves due to actual or potential harm to non-nervous body tissue. It is the body's normal alarm system. Examples include pain following a straightforward fracture or joint dislocation.

Neuropathic Pain: This pain is a direct consequence of damage or disease affecting the major sensory system pathways used to detect touch, temperature, and pain signals. Examples include a direct injury to a peripheral nerve leading to shooting or burning sensations.

Nociplastic Pain: This is the crucial third category. It describes pain that originates from altered functioning of pain signalling within the central nervous system (the brain and spinal cord) itself, despite a lack of ongoing tissue damage or clear nerve injury. The nervous system becomes highly sensitive, resulting in persistent, often widespread, pain. The underlying physiological process is central sensitisation.

These types may exist in isolation or as part of a mixed pain state.

Objective Language in Reporting

When an examinee’s presentation does not fit a clear structural or neurological pattern, the focus must shift from subjective speculation ("sceptical," "abnormal coping") to objective observation and appropriate referral.

Here is the professional language we could use:

Describing Findings (Objective Language):

• "The examinee's subjective report of pain intensity is markedly disproportionate to the objective clinical findings identified during the orthopaedic examination."

  
  

• "The pain description provided by the examinee is diffuse and does not conform to a typical neuroanatomical distribution."

  
  

• "Specific clinical observations during testing, such as variable responses to light touch and non-anatomic tenderness upon palpation, were noted."

  
  

• "While the examinee reports significant functional impairment, there are no corresponding clinical or radiological findings that establish an organic structural basis for the current pain presentation."

  
  

• "The current clinical picture is complex and suggests the involvement of significant psychosocial factors that appear to be influencing the perception and reporting of pain."

Recommending Further Evaluation (Multidisciplinary/Psychiatric):

• "Given the lack of objective structural pathology correlating with the reported symptoms, the examinee’s presentation would benefit from assessment within a multidisciplinary pain management framework."

  
  

• "To provide a comprehensive view of the examinee's condition and address all contributing factors (as per the biopsychosocial model of pain), a referral for formal psychiatric evaluation is recommended to identify potential psychological or emotional comorbidities that may be impacting recovery and pain modulation."

A Professional Shift: Assisting the Court Impartially

The ultimate goal of a medicolegal expert is clarity, objectivity, and assisting the court and the examinee toward a fair and effective resolution.

Shifting our focus from "Is the pain real?" to "How can this complex pain best be understood and managed?" improves the quality of our reports, maintains professional integrity, and helps to assist the Court impartially on matters relevant to our area of expertise.