Beyond Broken Bones: Why We Must See Soft Tissue Injury as a Red Flag for Child Abuse
By Ruth Reymundo Mandel, Chief Business Development Officer and Credible Expert, Safe & Together Institute
By the time I was seven, my femur had been shoved into my hip bone from violent restraint during child sexual abuse. Fluid filled the space where supportive ligaments had been torn. My pelvis tipped under the pressure of bilateral hip injuries. My left shoulder’s rotator cuff tore from being yanked and restrained. Microtears radiated into the surrounding support tissue from repetitive yanking and mis treatment and lack of medical attention. My neck formed a reverse curve from shaking. The left side of my neck shortened from injury to the sternocleidomastoid muscle. I developed hearing loss on my left side from repetitive blows to the head, and fluid formed in my neck from damage due to shaking and strangulation.
None of these abuse-perpetrated injuries showed up as broken bones. But they broke something just as foundational: my body’s structure, my limbic regulation, and my lifelong health. And I was in chronic pain, which was ignored due to medical neglect, coverup, and denial of the physical and sexual violence I was experiencing. My little 7-year-old body endured a lot of abuse, and that was materially impactful to the health trajectory of my life.
What We Miss When We Only Look for Fractures
In child protection, healthcare, and legal systems, bruises and radial fractures are often the evidence that triggers intervention. And while broken bones are serious, they are not the only—or even the most long-lasting or impactful—form of physical harm a child can endure.
Soft tissue and ligament damage sustained in early childhood can profoundly alter the development of a child’s:
Skeletal alignment and posture
Muscular stability and flexibility
Sensory regulation and vestibular balance
Pain thresholds and pain expression
Autoimmune function
Quality of life
Yet these injuries rarely appear on the radar of medical professionals unless a child is lucky enough to encounter a trauma-literate practitioner who is curious about that child’s pain. For many children, the signs are dismissed or reinterpreted as emotional dysregulation or behavioral problems, and that child is then marked as “emotionally” problematic, further made vulnerable, and often repeatedly re-abused.
Symptoms of Hidden Harm
A child with chronic pain or soft tissue injury might show:
Limping or altered gait
Avoidance of touch, movement, or physical activity
Sleep disturbances
Flinching when clothed, examined, or lifted
Gastrointestinal distress and inflammation
High cortisol levels and immune dysfunction leading to inattention and symptoms of ADHD
Fatigue, migraines, or mysterious “growing pains”
When these children are First Nations, Black, or Brown, the likelihood of their pain being ignored or pathologized—as defiance, aggression, or ADHD—only increases. Their distress is not met with investigation into possible trauma but with discipline or criminalization.
When Pain Is Mislabeled as Personality
The child with a torn hip flexor becomes “needy.” The child with fluid buildup in her neck and shoulder becomes “emotional.” The child whose rotator cuff was torn through repeated restraint becomes “attention-seeking.” The child with high inflammation and autoimmune symptoms becomes “sensitive” and “difficult.”
We do not ask: Where does it hurt? We ask: Why can’t she calm down? Why do they become overstimulated?
Violence Leaves No Fingerprints—But It Leaves Damage
If we are to protect children from lifelong harm, we must expand our lens. We must:
Understand soft tissue injury and dislocation as potential indicators of abuse
Train professionals to assess function and mobility alongside bruising
Connect neurobiological stress responses with chronic illness and pain
Recognize that limbic dysregulation can come from being in a body constantly bracing against trauma
And most importantly, we must connect the dots between physical pain and perpetrator behavior.
The Safe & Together Model Calls for This Shift
The Safe & Together Model teaches us to focus on the pattern of perpetrator behavior and how it impacts child and family functioning. That means understanding:
That a child limping to school may not be clumsy—but injured and traumatized
That autoimmune conditions may be rooted in a body chronically under siege and constantly under the stress of a perpetrator
That the signs of harm are often invisible unless we are trained to look for them
Survivors should not have to prove their pain in a courtroom or clinical office to be believed. And children should never be forced to live in pain simply because their injuries don’t match our outdated image of what child abuse looks like and how it manifests.
Let the Body Be the Evidence
This is a call to every child welfare professional, doctor, educator, and judge: If a child flinches when picked up, if they limp, if they refuse to move a limb—believe them, image them. If a child complains of stomach pain, if they cry during P.E., if they sleep sitting up—listen to them, believe them, image them, test them. If a child is described as “needy,” “emotional,” or “too sensitive”—ask where it hurts, believe them, assess them.
Because the body remembers. And it’s telling the truth, even when we don’t yet know how to read it.
Additional Resources
Safe & Together Institute’s domestic abuse–informed trainings
Safe & Together Institute’s upcoming events
David Mandel’s book Stop Blaming Mothers and Ignoring Fathers: How to Transform the Way We Keep Children Safe from Domestic Violence
