Calcaneus fracture (heel bone fracture)

Anatomy: Heel bone and hindfoot

The calcaneus (heel bone) is the largest bone in the foot and, together with the talus (ankle bone), forms the lower ankle joint (subtalar joint). It transfers loads, serves as an attachment for the Achilles tendon and shapes the heel width, which is important for gait stability.

• Articular surfaces: posterior, middle and anterior facet parts to the talus/os cuboid
• Insertion of the Achilles tendon at the tuber calcanei (lever arm for the calf muscles)
• Böhler angle and Gissane angle for radiological assessment of bone shape
• Surrounding structures: peroneal tendons laterally, tarsal tunnel medially, skin/soft tissue with sensitive blood supply

Causes and risk factors

Typically, a calcaneus fracture occurs due to axial compression, such as after falling from a ladder or when landing from a height. Traffic or sports accidents are less common. There are also overload fractures (stress fractures) that occur gradually.

• High-speed trauma with axial compression
• Sports with jumps/landings (e.g. parkour, ball sports)
• Bone quality: osteoporosis, vitamin D deficiency
• Smoking, diabetes mellitus, peripheral vascular disease (increased risk of wound healing problems)
• Occupational exposure: working at heights, construction

Symptoms and warning signs

Severe heel pain, swelling and bruising are typical, often with inability to walk. In the case of high-energy injuries, there may be accompanying injuries (talus, spine).

• Severe pain and rapid swelling of the heel
• Hematoma, tenderness, heel widening
• Painfully limited mobility of the hindfoot
• Inability to bear weight, limping
• Warning signs: open wound, blistering of the skin, numbness - seek medical advice immediately

Diagnostics: imaging and classification

Diagnosis begins with anamnesis and clinical examination, followed by x-rays in two planes. For intra-articular and complex fractures, computed tomography (CT) is standard to assess joint steps, fragments and axes.

• Lateral/axial x-ray: assessment of Böhler angle and Gissane angle
• CT: Classification of intra-articular fractures (e.g. Sanders I–IV)
• MRI: if a stress fracture or bone marrow edema is suspected
• Soft tissue status: swelling, blisters, open injury
• Differential diagnoses: Talus fracture, ankle fracture, heel bruise, plantar fascia tear

A classic distinction is made between extra-articular fractures (without joint involvement) and intra-articular fractures (joint involvement, often with dislocation). The severity influences the treatment decision.

Conservative therapy: check first

Many calcaneus fractures can be treated non-operatively - especially extra-articular fractures without relevant malalignment and non-displaced intra-articular fractures. The aim is low-pain healing, maintaining the shape of the heel and early, guided mobilization.

• Immobilization in a lower leg orthosis or walker boots
• Elevation, cooling, relief (crutches), lymphatic drainage if necessary
• Pain therapy as needed, thrombosis prophylaxis depending on the risk profile
• Early functional mobilization: passive/active movement exercises of the upper/lower ankle joint
• Increase in load gradually (usually 6-8 weeks of partial load, then build up)
• Physiotherapy: gait training, strengthening of the calf and foot muscles, proprioception

Regular follow-up checks (clinical and imaging) are important to monitor the position and detect complications early. We discuss realistic expectations: complete freedom from symptoms often takes months.

Surgical therapy: indications and procedures

Surgery is considered if there is a relevant misalignment or joint level, if the heel is significantly widened/shortened or if there are open fractures. The goal is to restore the joint surface, heel height/width and axles - with the aim of reducing the subsequent rate of osteoarthritis. A guaranteed benefit is not certain; The decision is made individually after informed consent.

• Indications (examples): displaced intra-articular fracture (Sanders II–III), relevant flattening of the Böhler angle, varus/valgus deformity, impending skin complication, open fracture
• Time of operation: after the swelling has gone down (so-called “wrinkle sign”), except in emergencies (open/suspicious compartment)
• Procedure: minimally invasive screw osteosynthesis, angle-stable plate osteosynthesis (lateral), percutaneous reduction techniques
• Special case: primary subtalar arthrodesis in selected comminuted fractures with an unreconstructable articular surface

Risks are discussed transparently: wound healing disorders (especially due to smoking/diabetes), infection, thrombosis, nerve irritation, secondary osteoarthritis, malhealing. The surgical strategy depends on the type of fracture and soft tissue damage, always with the lowest possible risk in mind.

Follow-up treatment and rehabilitation

The follow-up treatment is crucial for the result. A structured plan takes into account the type of fracture, type of therapy and individual healing. The aim is to safely increase stress, mobility and resilience in everyday life, at work and in sport.

Ability to work varies: office work often after 4-8 weeks, physical jobs much later. Only drive a car when you are fully loaded and have sufficient ability to react.

Possible complications and long-term consequences

Despite optimal treatment, symptoms can persist. The risk depends on the severity of the fracture, the soft tissue situation, comorbidities and treatment involvement.

• Subtalar arthrosis (pain on uneven surfaces, reduced inversion/eversion)
• Malunion with varus/valgus, heel widening, impingement
• Delayed healing or nonunion (rare)
• Wound healing disorders, infections, nerve irritations
• Complex regional pain syndrome (CRPS), thrombosis
• Exercise-related residual pain, exercise-related bone marrow edema

If symptoms persist, we examine conservative options (adapted insoles/shoe adjustments, physiotherapy, pain management). In selected cases, corrective surgery or subtalar arthrodesis may make sense - always after careful consideration.

Special cases: children, stress fractures, accompanying injuries

Children and adolescents have different healing properties; Fractures are often less displaced and can be easily treated conservatively. Calcaneal stress fractures occur during running or jumping sports and present with stress-dependent pain without trauma.

• Pediatrics: protection, orthosis, if necessary plaster; close monitoring of the growth plate status
• Stress Fracture: Rest, gradual load management, training and footwear adjustments; MRI for confirmation
• Check for associated injuries: talus/ankle fractures, spinal compression fractures

Prevention and relapse prevention

Not all accidents are avoidable. Nevertheless, the risk can be reduced through education, training and adjustments to everyday life.

• Fall prevention: safe ladders/workstations, anti-slip shoes
• Sport: Technique training for landings, measured training structure, regeneration
• Foot/lower leg strengthening, mobility, proprioception
• Osteoporosis screening with risk profile, vitamin D and calcium as recommended
• Quitting smoking to improve bone and wound healing

When to see a doctor? What is an emergency?

If you have a heel injury with significant swelling, hematoma and inability to bear weight, you should see a doctor as soon as possible. Open injuries, sensory disturbances, blistering of the skin, severe pain at rest or cold feet are emergency signs - please go to an emergency room immediately.

We are available in Hamburg for further outpatient care, second opinions or rehabilitation management.

Our treatment approach in Hamburg

We value structured, conservatively oriented treatment with clear indications for surgical procedures. Therapy is planned individually – based on imaging, functional status, everyday needs and your goals.

• Precise diagnostics: X-ray, ordered CT/MRI if necessary
• Conservative measures first: orthotic management, physical therapy, pain and swelling management
• Interdisciplinary coordination with foot surgery partners if an operation makes sense
• Transparent information about benefits and risks, without promises of cure
• Rehabilitation with a step-by-step plan, return to work/sport according to individual performance

Location: Dorotheenstraße 48, 22301 Hamburg. Appointments can be easily requested via Doctolib or by email.