The COMprehensive BSI Assessment and Treatment - Recovery (COMBAT-R) model: a biopsychosocial approach to addressing bone stress injuries in military training

BACKGROUND: Bone stress injuries (BSIs) affect between 5% and 21% of military trainees and impose a significant financial burden on the U.S. military. Current management strategies for the prevention and rehabilitation of BSIs focus primarily on biological risk factors, often neglecting psychosocial elements (such as resilience, kinesiophobia, and recovery expectations) that significantly influence attrition and return to duty. PURPOSE: To propose the COMprehensive BSI Assessment and Treatment - Recovery (COMBAT-R) Model, a biopsychosocial framework designed to support longitudinal assessment and management of BSIs across the military training continuum. METHODS: This theoretical article synthesizes evidence regarding the relevant biological risk factors for developing a BSI (e.g. sex and bone mineral density), as well as the psychosocial factors related to military attrition (e.g. depression and low hardiness). It integrates these findings into the "cycle of decline," where psychological distress may trigger physiological stress responses, such as elevated cortisol, that could impair bone healing. The model organizes these factors into three phases: preventative resilience (prior to training), response resilience (during training), and recovery resilience (post-injury). RESULTS: The COMBAT-R model advances whole-person care by proposing a psychosocial screening component composed of brief measures to inform future assessment and rehabilitation planning. COMBAT-R also provides a conceptual framework for considering targeted psychosocial interventions, such as Pain Neuroscience Education and Acceptance and Commitment Therapy, as adjuncts to standard physical rehabilitation for trainees diagnosed with a BSI during basic training. CONCLUSION: COMBAT-R offers a conceptual framework to guide whole-person BSI care, address the cycle of decline, and inform future efforts to reduce avoidable medical discharge from basic training.