Physical Therapy Videos - Foot & Ankle
Basic Anatomy
The calcaneus, or heel bone, is a complex shaped bone located just below your ankle and extending to the back of your foot. The calcaneus not only provides support as you walk, but also connects your calf muscles to your foot. This allows you to push off as you take a step forward.
Mechanism and Epidemiology
The calcaneus is located at the back of your foot and bears the full weight of your body. It is therefore often injured in falls from ladders or roofs or in car accidents. The calcaneus can break through the weight bearing joint or outside the joint. If it breaks where the calf muscles connect to the heel bone, those muscles can pull the broken pieces close to the skin. This can cause issues for the skin and may even require emergency surgery.
Initial Treatment
Calcaneus fractures usually hurt and get very swollen right after the injury. The broken bone and swelling may cause you to feel throbbing where the bone is broken. You may see blisters form. Your doctor will examine your heel and foot, and get an x-ray to see if it is broken or not. Often, they will obtain a CT scan of the heel bone as well, to get a better look at the broken bone. Usually you will be placed into a very well-padded splint, boot, or partial cast to help protect the broken bone from further injury. You should make an appointment with an orthopaedist or your primary care doctor for follow-up.
People typically do not need to be admitted to the hospital for an isolated calcaneus fracture. This is because surgery is often delayed until the swelling goes down, which can take up to several weeks. Sometimes the break is so displaced that the broken bone is pressing from the inside on the skin around the heel. This may mean more urgent surgery is required. In this case you may be admitted to the hospital immediately for surgery.
General Treatment
Some, but not all, calcaneus fractures require surgery. The broken bone will take 3-4 months to heal with or without surgery. If surgery is not needed, there will still be a time where movement and weight bearing is limited. Calcaneus fractures that benefit from surgery often involve breaks within the subtalar joint (the joint just below your ankle joint). The subtalar joint lets your foot move from side to side, as compared to the ankle joint, which moves your ankle up and down. Surgery may be also be needed to address changes in the shape of your bone: typically flattening, widening, or the bone has shifted into a bad position. You should discuss your specific injury and the advantages of surgery vs. non-surgical treatment with an orthopaedic surgeon. Surgery is almost always required if the bone came through your skin or is close to breaking through the skin. If surgery is needed, an incision, or "cut," is generally made along the outside part of your foot over the heel bone. The bone fragments are put back into the right place, and metal plates and screws are used to fit and hold the bone pieces back together until your bone heals.
Post-operative Care
While your broken calcaneus is healing, you will not be able to put weight on your foot. You will likely be immobilized in a well-padded splint. Sometimes physical therapy is prescribed to help with motion and weight bearing once the bone heals. Your ability to move your foot and ankle and put more weight on your leg will improve as your bone heals. Typically, you will not be able to put any weight on your broken foot for 4 to 12 weeks. When you start putting weight on it, it may only be part of your weight. It can take 3 months or longer of healing before you are able to put your full weight on your injured foot. This may occur whether you had surgery or not. For best results, it is important to follow instructions from your surgeon regarding your care.
Long Term
Long-term issues after calcaneus fractures (with or without surgery) commonly include a limp and/or stiffness in the foot or ankle. The heel can also remain swollen compared to the uninjured side. Some patients have lingering pain with walking, especially on uneven ground. The swelling, pain, and stiffness typically improve over time but it may always look and/or feel different from your other side. Your ankle joint and subtalar joints (joints between the calcaneus and the talus) in the injured foot are also at risk for developing arthritis.
If surgery is done, your surgeon will keep a close eye on the surgical wound to make sure it heals well. Surgeons generally do everything possible to avoid an infection or wound problem. The plate and screws are rarely noticed under the skin. However, these may be removed after the fracture has healed (about half the time). In rare cases, the bone does not heal whether you had surgery or not. If the bone doesn’t heal or there is a complication like an infection, another surgery may be needed.
While most calcaneus fractures can heal without surgery, sometimes they do not heal, or they might heal in a position that causes discomfort or trouble with walking or wearing shoes. Surgery to get the bone to heal or to line up the broken pieces becomes more difficult the longer surgery is delayed. In such cases, a fusion surgery for your subtalar joint (the joint below your ankle) may be recommended. This can lead to decreased motion at the back of your foot. However, it may also improve the pain and function for your foot and ankle. If you are still having difficulty with your foot and heel after a healed calcaneus fracture, you should talk to your surgeon about whether or not you may benefit from surgery.
Physical Therapy Videos - Foot & Ankle
More Information
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Matthew D. Riedel, MD
Edited by Christopher Domes, MD and David W. Sanders, MD
Unless otherwise credited, all images taken from the personal collections of Dr. Riedel and Dr. Domes