A calcaneal fracture is a break of the calcaneus bone or heel bone, which is a large bone that forms the foundation of the back part of the foot. The subtalar joint is located between the talus bone and calcaneus. This joint is responsible for ankle inversion (turning in) and eversion (turning out). In some cases, calcaneal fracture is associated with breaks of the hip or back.
- The most common cause is trauma, which can result from falls or incidents such as traffic accidents.
- Participation in sports or other high impact activities can also cause calcaneal fracture
- Calcaneal fracture is also occurred when the ankle is either twisted or rolled, usually with an awkward or uneven step.
Fractures are acute injuries (occur suddenly) therefore symptoms can often be noticed immediately following injury.
- Sudden, sharp pain in the ankle over the heel area, especially when the heel is palpated or squeezed
- Swelling, bruising, and tenderness over the heel area
- Visible deformity of the bones over the heel area
- Inability to move the ankle or foot without pain
- Inability to weight bear on the involved leg
In the event that an individual suspects they may have sustained calcaneal fracture, a radiographic evaluation (X-Ray) will be essential to a proper diagnosis. A bone can fracture in different ways, causing complications or secondary conditions that your physician will look for. Conditions that can be related to calcaneal fracture include:
- Comminuted fracture: a bone that is broken in several pieces
- Dislocation: a bone that is not properly aligned in the correct joint
- Greenstick fracture: a fracture on only one side of a bone (commonly seen in children)
- Malunion: when the bone heals in the improper position
- Nonunion: when the ends of the broken bone do not fuse together properly
- Growth plate injury: in children, areas at the ends of bones (near the joint) are responsible for growing the bone as the child develops. If the growth plate is injured it may affect the growth of the bone. It is essential to future development that the growth plate is realigned and heals properly.
The most common course of treatment for calcaneal fracture is realignment (referred to as reducing the fracture) and casting or placing the foot and ankle in a boot to immobilize the joint, and give the bones time to heal. For more severe fractures, surgery may be needed to realign the bones properly. Pins, screws, plates or wires may be used to hold the bones properly in place. How much movement should be restricted following the fracture will depend on the severity of the break.
Once cleared by the physician, a physical therapy program should be initiated to reverse the effects of immobilization and restore ankle motion. In more involved fractures recovery can take more time. Formal therapy and compliance with an extensive home program is essential to restoring function of the ankle.
- Post calcaneal fracture immobilization can have detrimental effects that can be improved through physical therapy. These effects include:
- Joint articular cartilage softening
- Shortening and atrophy of musculotendinous units
- Decreased circulation
- Loss of active and passive motion
- Weakness
Goals for physical therapy post-fracture immobilization of the ankle are optimal loading and restoration of normal tissue relationships to improve motion, strength and the ability to perform functional activities of daily living.
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, and joint mobilization by a physical therapist to modulate pain and reduce any soft tissue or tendon irritation and restore normal joint mechanics and range of motion.
- Therapeutic Exercises (TE) including exercises to improve strength and performance of the calcaneus bone and surrounding muscles.
- Neuromuscular Reeducation (NMR) to restore stability, begin retraining the lower extremity, improve proximal joint stability and improve movement technique and mechanics (for example: jumping, running etc) in use of the involved lower extremity in daily activities.
- Modalities that can include the use of ultrasound, electrical stimulation, ice, cold and laser to decrease pain, improve mobility and reduce inflammation of the ankle and surrounding muscles and tendons.
- Home program development should include strengthening, stretching and stabilization exercises as well as instructions to help the person perform daily tasks and advance to the next functional level.
Most fractures can be diagnosed with X-Ray studies and when necessary a CAT Scan. The use of pain medications, immobilization, rest and ice are the first line of treatment. Surgical intervention may be required in more severe fractures or when the injury affects the integrity of the joint.
Prognosis
Rate of recovery and the prognosis from calcaneal fracture will depend on a number of factors:
- Severity – Minor fractures do well with immobilization and physical therapy, while fractures that are more severe and require surgery or effect joint integrity take longer to heal. Patients may have residual motion and strength deficits.
- Age- Younger individuals recover faster and are less likely to have residual deficits. Younger individuals heal quicker, have better circulation, are stronger and usually have better pre-injury tissue integrity.
- Prior activity level plays an important role in post-injury recovery. Those who exercise regularly are stronger and more flexible, and generally have an easier and more complete recovery.
- Compliance- Patients that are committed to their rehabilitation program and are compliant with their home program are more successful in returning to full function.
