It is timely to write about stress fractures with the recent news on Jack Wilshere and his on-going injury problems. The Arsenal and England midfielder is currently dealing with a stress fracture of his right heel (calcaneus).

Stress fractures are usually seen in sports involving impact and high tissue strain, in other words running. These small breaks reflect the repetitive nature of the activity and the bone health. This will link into general health status, training regimes, footwear, recovery time opportunity, diet and previous musculo-skeletal history.

Treatment of stress fractures includes a necessary period of protection that, in the case of the foot, means taking the weight off the limb and wearing a special boot. Cumbersome and devoid of fashion sense as it may be, this is a necessary course of action. Following a specified time frame that would be prescribed by the specialist, gradual weight-bearing begins. Progressively increasing the load allows the bone tissue to adapt and strengthen. The surrounding muscles, tendons and ligaments also need to adapt to the normal stresses and strains of movement. Restoring normal movement and control of movement is a further key part of the rehabilitation.

While the foot is kept in a non-weight-bearing status, there are a number of activities that can be used to work on fitness and function, including upper body training and pool-based exercise. However, you should always take the advice from your specialist on the content of your rehabilitation programme.

When we immobilise a part of the body, there are changes that naturally occur as a result of the tissues not being moved. There are two sides to this story. There is the tissue end, the foot in Wilshere’s case, and the brain end. In our brains we have a number of maps of the body. In short, this is how the brain controls movement, allocates sensations and how we feel our bodies. The research behind this understanding was originally performed many years ago and has been repeated in recent times with the use of functional MRI scan studies. At the tissue end we have the healing process that needs to be optimised by managing the injury.

Healing is a series of overlapping stages that start with inflammation, progressing to repair and regeneration. Whilst immobilisation and non weight-bearing can be important, movement and gradual strain upon the healing tissues is required for healing to be optimised. Making sure that healing progresses normally also involves ensuring the right balance of movement of the rest of the body, adequate rest and sleep, following a good diet and in some cases using supplementation or stimulation. Wilshere is reported to be using the Exogen ultrasound bone healing system; a state-of-the-art treatment to accelerate repair of bone fractures.

On a brain level we can use some of the newer techniques that we know activate and nourish the body’s representation in the cortex, the outer part of our brains. Additionally we can use high quality education and cognitive strategies to address negative thinking, emotions and behaviours that can affect the healing process. Recent data demonstrated that catastrophising about one’s pain has an affect upon inflammatory molecules, highlighting the very real physiological responses to thinking.

The biopsychosocial approach to pain and injury is the contemporary way to address the problem(s). Pain and movement are related and require attention at tissue and brain levels but also considering other body systems involved in protection and healing. This includes the immune system, the autonomic nervous system and endocrine system (hormones). We have to think about the physiology of what is happening, the thoughts, emotions and beliefs of the individual, addressing those that can affect the ability to recover, and the social impact in relation to work, sports and family life.

In summary, turning back to Wilshere’s case in the light of the aforementioned biopsychosocial approach, we can think about optimising local healing processes but also consider other vital controlling aspects that are beyond the tissues.