BACKGROUND The risk of developing enduring post-traumatic stress reactions and mental health problems in the aftermath of disasters is substantial. However, there are inconsistencies regarding the contribution of physical injury as an independent risk factor for developing psychiatric morbidity after disasters. AIMS The aim was to assess whether physical injury was associated with post-traumatic stress reactions and general mental health after adjusting for perceived life-threat in the aftermath of the 2004 tsunami. METHODS A sample of 1501 highly exposed survivors from the 2004 Southeast Asia tsunami was selected from a cohort of Swedish survivors surveyed 14 and 36 months after the event. The impact of physical injury on post-traumatic stress and general mental health was assessed by regression models accounting for subjective life-threat. RESULTS Physical injury was associated with higher levels of post-traumatic stress reactions and poorer general mental health. These associations were observed at both 14 and 36 months after the disaster. CONCLUSIONS Physical injury has a specific contribution to the association between traumatic experience and both post-traumatic stress reactions and general mental health in victims of the 2004 tsunami. The effect is stable over several years.