In 2002, "Hurt" was covered by Johnny Cash to commercial and critical acclaim; it was one of Cash's final hits released before his death, and the related music video is considered one of the greatest of all time by publications such as NME. Reznor praised Cash's interpretation of the song for its "sincerity and meaning", going as far as to say "that song isn't mine anymore."
The song includes references to self-harm and heroin addiction, although the overall meaning of the song is disputed. Some listeners contend that the song acts as a suicide note written by the song's protagonist, as a result of his depression, while others claim that it describes the difficult process of finding a reason to live in spite of depression and pain and does not have much to do with the storyline of The Downward Spiral.
The music video for Nine Inch Nails' original version of "Hurt" is a live performance that was recorded before the show in Omaha, Nebraska, on February 13, 1995, and can be found on Closure and the DualDisc re-release of The Downward Spiral. The audio portion appears on the UK version of Further Down the Spiral.
The version released on Closure differs slightly from the video originally aired on MTV. In addition to using an uncensored audio track, the Closure edit shows alternate views of the audience and performance at several points during the video.
To film the video, a scrim was dropped in front of the band on stage, onto which various images, such as war atrocities, a nuclear bomb test, survivors of the Battle of Stalingrad, a snake staring at the camera, and a time-lapse film of a fox decomposing in reverse, were projected, adding visual symbolism to fit the song's subject matter. A spotlight was cast on Reznor so that he can be seen through the images. Compared to the live renditions performed on future tours, this version most resembles the studio recording with its use of the song's original samples.
During the Dissonance tour in 1995, when Nine Inch Nails opened for David Bowie, Bowie sang "Hurt" in a duet with Reznor, backed by an original melody and beat. This served as the conclusion to the dual act that began each Bowie set.
Since the 2005–06 Live: With Teeth tour, Nine Inch Nails has been playing "Hurt" in a more toned-down style, featuring only Reznor on keyboard and vocals until the final chorus, when the rest of the band joins in.
The song was brought back to its original form during the Lights In The Sky tour in 2008, before returning to the toned down style on the 2009 Wave Goodbye tour.
Cash's cover of the song had sold 2,148,000 downloads in the United States as of March 2017.
When Reznor was asked if Cash could cover his song, Reznor said he was "flattered" but worried that "the idea sounded a bit gimmicky." He became a fan of Cash's version, however, once he saw the music video.
I pop the video in, and wow... Tears welling, silence, goose-bumps... Wow. [I felt like] I just lost my girlfriend, because that song isn't mine anymore... It really made me think about how powerful music is as a medium and art form. I wrote some words and music in my bedroom as a way of staying sane, about a bleak and desperate place I was in, totally isolated and alone. [Somehow] that winds up reinterpreted by a music legend from a radically different era/genre and still retains sincerity and meaning – different, but every bit as pure.
The music video was directed by former Nine Inch Nails collaborator Mark Romanek who sought to capture the essence of Cash, both in his youth and in his older years. In a montage of shots of Cash's early years, twisted imagery of fruit and flowers in various states of decay, seem to capture both his legendary past and the stark and seemingly cruel reality of the present. According to literature professor Leigh H. Edwards, the music video portrays "Cash's own paradoxical themes".
Romanek had this to say about his decision to focus on the House of Cash museum in Nashville:
It had been closed for a long time; the place was in such a state of dereliction. That's when I got the idea that maybe we could be extremely candid about the state of Johnny's health, as candid as Johnny has always been in his songs.
When the video was filmed in February 2003, Cash was 71 years old and had serious health problems. His frailty is clearly evident in the video. He died seven months later, on September 12; his wife, June Carter Cash, who is shown gazing at her husband in two sequences of the video, had died on May 15 of the same year.
In July 2011, the music video was named one of "The 30 All-TIME Best Music Videos" by Time. It was ranked the greatest music video of all time by NME.
The house where Cash's music video for "Hurt" was shot, which was Cash's home for nearly 30 years, was destroyed in a fire on April 10, 2007.
The Johnny Cash cover was given the Country Music Association award for "Single of the Year" in 2003. It ranked as CMT's top video for 2003, No. 1 on CMT's 100 Greatest Country Music Videos the following year, and No. 1 on the Top 40 Most Memorable Music Videos on MuchMoreMusic's Listed in October 2007. As of March 2016, the single occupies the number nine spot on Rate Your Music's Top Singles of the 2000s. The song is also Cash's sole chart entry on the Billboard Modern Rock Tracks chart, where it hit No. 33 in 2003. In June 2009, the song was voted No. 1 in UpVenue's Top 10 Best Music Covers.
ITV Sport used this version in a montage of England's exit from the 2006 FIFA World Cup after losing a penalty shoot out against Portugal. One montage scene showed David Beckham visibly shaken and emotional for not being able to play due to an injury during the match, being in tears at one point .