A fracture of the calcaneus, or heel bone, can be a painful and disabling injury. This type of fracture commonly occurs during a high-energy event—such as a car crash or a fall from a ladder—when the heel is crushed under the weight of the body. When this occurs, the heel can widen, shorten, and become deformed.
Calcaneus fractures can be quite severe. Treatment often involves surgery to reconstruct the normal anatomy of the heel and restore mobility so that patients can return to normal activity. But even with appropriate treatment, some fractures may result in long-term complications, such as pain, swelling, loss of motion, and arthritis.
The bones of the feet are commonly divided into three parts: the hindfoot, midfoot, and forefoot. Seven bones — called tarsals — make up the hindfoot and midfoot. The calcaneus (heel bone) is the largest of the tarsal bones in the foot. It lies at the back of the foot (hindfoot) below the three bones that make up the ankle joint. These three bones are the:
Together, the calcaneus and the talus form the subtalar joint. The subtalar joint allows side-to-side movement of the hindfoot and is especially important for balance on uneven surfaces.
Calcaneus fractures are uncommon. Fractures of the tarsal bones account for only about 2% of all adult fractures and only half of tarsal fractures are calcaneus fractures.
A fracture may cause the heel bone to widen and shorten. In some cases, a fracture may also enter the subtalar joint in the foot. When this occurs, damage to the articular cartilage covering the joint may cause long-term complications such as chronic pain, arthritis, and loss of motion.
The severity of a calcaneus injury depends on several factors, including:
When the bone breaks and fragments stick out through the skin or if a wound penetrates down to the bone, the fracture is called an "open" fracture. An open fracture often causes more damage to the surrounding muscles, tendons, and ligaments and takes a longer time to heal. Open fractures have a higher risk for infection in both the wound and the bone. Immediate treatment to clean the wound is required to prevent infection.
The calcaneus is most often fractured during a:
The severity of a fracture can vary. For example, a simple twist of the ankle may result in a single crack in the bone. The force of a head-on car collision, however, may result in the bone being shattered (comminuted fracture).
Similar fractures can result from different mechanisms. For example, if you land on your feet from a fall, your body's weight is directed downward. This drives the talus bone directly into the calcaneus. In a motor vehicle crash, the calcaneus is driven up against the talus if the heel is crushed against the floorboard. In both cases, the fracture patterns are similar. As a rule, the greater the impact, the more the calcaneus is damaged.
In a high-energy fracture, other injuries, such as fractures of the spine, hip, or other heel, can occur.
Patients with calcaneus fractures usually experience:
With some minor calcaneus fractures, the pain may not be enough to prevent you from walking — but you may limp. This is because your Achilles tendon acts through the calcaneus to support your body weight. If, however, your calcaneus is deformed by the injury, your muscle and tendon cannot generate enough power to support your weight. Your foot and ankle will feel unstable, and you will walk differently.
It is important that you tell your doctor the circumstances of your injury. For example, if you fell from a ladder, how far did you fall?
It is also important that you tell your doctor if you have any other injuries or medical problems, such as diabetes, or if you take medications or smoke.
After discussing your symptoms and medical history, your doctor will perform a careful examination. He or she will:
Imaging studies will help confirm the diagnosis of a calcaneus fracture:
X-rays. This test is the most common and widely available diagnostic imaging technique. X-rays create images of dense structures, such as bone. An x-ray can show if your calcaneus is broken and whether the bones are displaced.
Computed tomography (CT) scans. Because of the complex anatomy of the calcaneus, a CT scan is routinely ordered after a fracture has been diagnosed on x-ray. A CT scan will produce a more detailed, cross-sectional image of your foot and can provide your doctor with valuable information about the severity of your fracture. This information will help your doctor recommend the best plan for treatment.
Your doctor may share both your x-rays and CT scans with you to help you better understand the nature and severity of your injury.
Your doctor will consider several factors in planning your treatment, including:
Because most calcaneus fractures cause the bone to widen and shorten, the goal of treatment is to restore the normal anatomy of the heel. In general, patients whose normal heel anatomy is restored have better outcomes. In most cases, recreating the normal heel anatomy involves surgery. Your doctor will discuss the different treatment options with you.
Nonsurgical treatment may be recommended if the pieces of broken bone have not been displaced by the force of the injury.
Immobilization. A cast, splint, or brace will hold the bones in your foot in proper position while they heal. You may have to wear a cast for 6 to 8 weeks — or possibly longer. During this time, you will not be able to put any weight on your foot until the bone is completely healed.
If the bones have shifted out of place (displaced), your doctor may recommend surgery.
Surgery to repair a calcaneus fracture can restore the normal shape of the bone but is sometimes associated with complications, such as wound healing problems, infection, and nerve damage. Nonsurgical treatment of some fractures, however, can also lead to long-term complications, such as pain, arthritis, and a limp. Your doctor will review the details of your injury and talk with you about the risks and benefits of surgical versus nonsurgical treatment.
Timing of surgery. If the skin around your fracture has not been broken, your doctor may recommend waiting until swelling has gone down before having surgery. Elevating your leg and keeping it immobilized for several days will decrease swelling. It will also give stretched skin a chance to recover. Waiting before the operation may improve your overall recovery from surgery and decrease your risk of infection.
Open fractures, however, expose the fracture site to the environment and must be treated immediately. They require surgery to clean the wound and remove damaged tissue
Early surgery is also often recommended for an avulsion fracture. Although uncommon, a piece of the calcaneus can be pulled off when the Achilles tendon splits away from the bone (avulsion). For this type of fracture, emergent surgery can decrease the risk of injury to the skin around the Achilles tendon.
Surgical procedure. The following procedures are used for various types of calcaneus fractures:
Bones have a remarkable capacity to heal. The more severe your injury, however, the longer your recovery may be. Patients with more severe fractures are also more likely to suffer some degree of permanent loss of function, regardless of treatment.
After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.
Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.
Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.
Whether your treatment is surgical or nonsurgical, your rehabilitation will be very similar. The time it takes to return to daily activities will vary depending on the type and severity of the fracture and whether you have other injuries.
Some patients can begin weight-bearing activities a few weeks after injury or surgery; others may need to wait 3 months or more before putting weight on the heel. Most patients are able to begin partial weight bearing between 6 and 10 weeks after injury or surgery.
Complications often occur with calcaneus fractures. Minor complications include:
Major complications include:
It is important to tell your doctor if you are a smoker. Smoking affects both bone and wound healing. With or without surgery, your bone may take longer to heal if you smoke.
Additional surgery is usually required in cases of infection or wound healing complications. If all attempts to resolve an infection or a wound healing complication fail, an amputation may be necessary.
If your injury is minor, such as a crack in the bone with little muscle damage, you may be able to resume normal activities from 3 to 4 months after surgery. If your fracture is severe, however, it may take from 1 to 2 years before recovery is complete.
Despite the best efforts of the doctor and patient, normal foot and ankle motion is rarely regained after a severe fracture and patients do not typically resume their pre-injury level of function. A patient who is not very active might tolerate a foot that is not normal. On the other hand, a patient whose job or recreational activities require a lot of walking or climbing will notice more.
Common problems that may persist after recovery include:
If you have chronic pain or experience other complications, you may need further treatment. This may include:
There is no universal agreement among experts as to the best treatment method for calcaneus fractures. No single method works the same for everyone. Patients whose x-rays show good healing and normal heel anatomy often have ongoing symptoms after treatment. On the other hand, the calcaneus can look quite deformed on an x-ray, but the patient may have few, if any, symptoms.
Studies have compared results in patients whose fractures were treated with and without surgery. Some studies show a significant benefit of surgery, while other studies show less benefit for certain patients. Researchers continue to look for ways to improve the outcomes of treatment for different types of calcaneus fractures, as well as for patients who smoke or have other health considerations. Your doctor will talk with you about the best treatment options in your case.