The source of “boot nail guy,” a popular medical anecdote about pain without injury/nociception
Four articles on PainSci cite Fisher 1995: 1. The Complete Guide to Patellofemoral Pain Syndrome 2. Complete Guide to Plantar Fasciitis 3. Pain is Weird 4. Mind Over Pain
PainSci commentary on Fisher 1995: ?This page is one of thousands in the PainScience.com bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.
This small item in the “Minerva” column of the British Medical Journal from 1995 is the source of a widely cited medical anecdote, popular because it supports a very popular idea: that pain can occur without injury or nociception (danger signalling from injured tissues). Is the story for real? There is at least a somewhat credible source. If you are determined, you can verify the citation with a free trial membership for BMJ.com. But there is not much to verify: barely more than a photo with a caption, in the full text of the “Minerva” column. It is not a formal case study.
There is not much reason to doubt the overall veracity of the story, but there certainly are reasons to doubt that it is exactly what it seems to be, or that it actually constitutes compelling evidence of pain-without-nociception. Most notably, even though Boot Nail Guy probably did have an unpleasant trip to the hospital, it’s also possible (even likely) that the incident did not play out just exactly as described, and it seems very plausible to me that the whole thing was not so much perfectly uninjured person experiences terrible pain and more like slightly injured person is really freaked out until proven safe.
This slightly formal anecdote is not compelling “evidence” of pain without nociception at all, but it can be a credible example of pain that may have been exaggerated by the mind. For a more detailed discussion of this odd source and its significance, see The legend of Boot Nail Guy reconsidered, or Pain is Weird (where it is put into a broader context).
~ Paul Ingraham
original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.
A builder aged 29 came to the accident and emergency department having jumped down on to a 15 cm nail. As the smallest movement of the nail was painful he was sedated with fentanyl and midazolam. The nail was then pulled out from below. When his boot was removed a miraculous cure appeared to have taken place. Despite entering proximal to the steel toecap the nail had penetrated between the toes: the foot was entirely uninjured.
This page is part of the PainScience BIBLIOGRAPHY, which contains plain language summaries of thousands of scientific papers & others sources. It’s like a highly specialized blog. A few highlights:
- Inciting events associated with lumbar disc herniation. Suri 2010 Spine J.
- Prediction of an extruded fragment in lumbar disc patients from clinical presentations. Pople 1994 Spine (Phila Pa 1976).
- Characteristics of patients with low back and leg pain seeking treatment in primary care: baseline results from the ATLAS cohort study. Konstantinou 2015 BMC Musculoskelet Disord.
- Effectiveness and cost-effectiveness of universal school-based mindfulness training compared with normal school provision in reducing risk of mental health problems and promoting well-being in adolescence: the MYRIAD cluster randomised controlled trial. Kuyken 2022 Evid Based Ment Health.
- No long-term effects after a three-week open-label placebo treatment for chronic low back pain: a three-year follow-up of a randomized controlled trial. Kleine-Borgmann 2022 Pain.