Fracture or Bone Bruise? How to Tell

March 20, 2019 Updated: March 20, 2019

You’re in the shower, the soap and hot water running down over you, and you’re thinking about the workday ahead. Suddenly, you slip just a little, but enough to whack your elbow or knee on the shower wall, and ouch! You either fractured your bone or given yourself a bone bruise. What is the difference and what do you do now?

Trauma to the bone is very painful. Bone is a type of dense connective tissue that can be injured and generate a lot of pain. Injury can occur from forceful impact during daily activities, sports, accidents, or even repetitive compressive forces.

This hard tissue’s function is to support the neuromuscular system (nerves and muscles), protect the organs, and in combination with the skeletal soft tissues (muscles, tendons, and ligaments), produce movement.

Anatomy of the Bone

bone Anatomy
Illustration (Designua/Shutterstock)

The hard, outer layer is called the compact or cortical bone. It is dense and gives bone its smooth, white, and solid appearance.  The periosteum is the thin covering around bone that generates pain through nociceptors, or pain receptors.

The inside of the bone is the trabecular or spongy bone tissue, which houses blood vessels and marrow. It is very porous, contains a matrix of rod and plate-like elements (known as trabeculae), and in here blood surrounds the spongy tissue.


When a bone has been damaged with enough force, a fracture can occur. A fracture is a break in the continuity of the bone. All of the trabeculae in a part of a bone are broken. The bone and surrounding tissue will bleed and form a clot, similar to when you cut yourself and lay down bone cells that mineralize.

Callus formation or evidence of hardened bone tissue takes about six weeks in an adult. Bone continues to heal for up to 18 months as the bone remodels (initial bone replaced by mature bone). In an adult, the bone strength is 80 percent by three months after injury.


Fractures are confirmed by X-ray. Depending on where and what type of fracture occurs, that will determine if you are put into an external brace or have some other sort of surgical fixation device.

bone Fractures are confirmed by X-ray
Illustration (Minerva Studio/Shutterstock)

Sometimes, you do not need any external device in order to heal. This is a slow process of healing with multiple doctor visits to confirm both the break and the healing process.

It is a waiting game as the bone needs to repair itself on a deep cellular level to restore its integrity. You are typically limited in flexibility or movement, muscle strength, and support of your own body weight for a prolonged period of time.


A bone bruise is an injury to the bone where only a few of the trabeculae are injured. It may be considered the stage before an actual fracture. Bone bruises commonly occur in the knee or femur, but can also occur in the wrist, heel, foot, hip or pelvis.

There are three types of bone bruises: subperiosteal hematoma, interosseous bruise, and subchondral bruise. The depth of these goes beyond the scope of this article so please contact your physician to learn more and confirm if you have one of these injuries.

Bone bruises are confirmed by magnetic resonance imaging (MRI), not by X-ray.

Symptoms of a bone bruise include significant pain and swelling. The pain is more severe than a soft tissue bruise and can last for weeks to months. Swelling includes blood and fluids and pools in the adjacent soft tissue (skin and muscles).

If the bruise is near a joint, the swelling may spread into the joint. There may also be discoloration and there is palpable tenderness on the bone itself.

A chef client of mine recently exacerbated his tennis elbow after bruising his elbow bone in the shower. Injury to his bone led to the above symptoms but without the discoloration. It also caused muscle dysfunction.

Because of the attachments of the muscle on the bone, and the irritation and inflammation in the bone, the muscle cannot contract appropriately. It caused a return of his elbow pain with the use of his hand and persistent localized swelling and pinpoint tenderness on the elbow bone.

Treatment for bone bruises includes immediate application of cold therapy onto the area to minimize excessive swelling and pain.

Oral anti-inflammatory medication can help reduce inflammation and pain but please consult your physician if you have any gastrointestinal issues. To support and protect the bone near a joint, you can wear a brace.

Avoid aggravating activities to minimize pain during activities as well as swelling after activities.

Consult a physical therapist to learn more about your injury and distinguish between the two. You’ll learn what exercises are appropriate for your present state as well as how and when to progress them. You’ll learn to use the tools you can do yourself to minimize the pain, inflammation, and swelling, and to prevent re-injury in your daily routine.

Karena Wu is a graduate of Columbia University’s program in physical therapy and owner of ActiveCare Physical Therapy in midtown Manhattan. Her style of physical therapy is holistic, manual and Pilates-based rehabilitation. To learn more, check out her website: