When to Worry About Your Pain: 4 Rules

By Julie Silver, MDAssistant Professor, Harvard Medical School, Physical Medicine and RehabilitationDr. Silver is the author of You Can Heal Yourself and an award-winning book from the American Cancer Society titled What Helped Get Me Through: Cancer Survivors Share Wisdom and Hope.

Posted on | By Julie Silver, MD

Learning to treat pain effectively takes years. As a medical doctor who specializes in Physical Medicine and Rehabilitation (PM&R), I have extensive training in treating pain. Doctors who specialize in PM&R are formally called physiatrists and are sometimes informally referred to as pain doctors.

One of the first things we learn is when to worry about pain. Since we are taught to treat so many different kinds of pain, we need to know when to sound an alarm about a patient’s condition and how to act to treat them most effectively. If you’ve been experiencing pain, it’s important that you learn to think like a pain doctor. While these “rules” about when to worry certainly do not cover every person and every situation, they are important to know to get to the source of your problem.

How to Think Like a Pain Doctor


1. Two-Week Rule
Any pain that lasts for more than two weeks should be checked out. A lot of people think that new pain means that they have cancer. In fact, most new pain is due to bones, joints, nerves and other musculoskeletal structures. Many doctors use the two-week rule because a lot of musculoskeletal pain will resolve within a two-week period. Also, a two-week delay in diagnosis is very unlikely to change someone’s prognosis if the pain is due to cancer. Though the two-week rule applies to most pain, there are times when doctors ignore this rule and become immediately concerned (See Rules 2, 3 and 4).


2. Acute-Trauma Rule
Doctors should immediately check all pain associated with acute trauma, such as a car accident or fall off a ladder. Usually, people aren't overly worried that cancer is causing their pain if they have trauma that results in immediate or even slightly delayed pain. However, all pain associated with trauma necessitates an evaluation; this includes a physical examination and possible imaging tests such as x-rays or MRIs.


3. Worst Pain of My Life Rule
Doctors should be alarmed at any new and severe pain that a patient reports. It’s not unusual for a patient to actually say, “This is the worst pain I’ve ever experienced!” Often, the “worst pain of my life” is not cancer, but may be the result of something serious, such as a heart attack, appendicitis or ruptured blood vessel (aneurysm). If the pain is severe but chronic and has been worked up previously, then the “alarm bells” ring less vigorously.


4. I Can’t Sleep Rule

Doctors should be concerned about any pain that awakens a patient at night. Sometimes, night pain is more serious than pain that occurs during the day with normal activities. This is because, usually, when you rest, pain improves. Pain that doesn’t improve with rest is sometimes worrisome. However, resting too much with chronic pain leads to weakness and more pain. If you have chronic pain, try and alternate rest with activity to stay strong and keep your overall pain levels down. Cancer pain is one type of pain that often doesn’t improve with rest and will awaken people at night. However, it’s important to know that a lot of musculoskeletal pain problems will bother patients at night. Hip bursitis or shoulder tendinitis can often keep a patient awake if they lie on the affected side and put pressure on the injured part of the body. It’s important not to make assumptions about what is causing night pain, and to identify the cause and treat it appropriately.   


There is no doubt that pain is undertreated and that physicians and patients need to work together to find solutions. When someone tells me, “I’ve tried everything,” I often ask if he or she has had a consultation with a physiatrist. Often the answer is no. To find out more about doctors in your area who specialize in treating pain and helping people to function at the highest possible level, visit the American Academy of Physical Medicine and Rehabilitation.

Article written by Julie Silver, MD
Assistant Professor, Harvard Medical School, Physical Medicine and Rehabilitation. Dr. Silver is the author of You Can Heal...