Calcaneus fractures (heel bone fracture)

Anatomy: Heel bone and lower ankle joint

The heel bone (calcaneus) is the largest bone in the foot and forms the subtalar joint with the ankle bone (talus). It supports a significant part of the body weight, shapes the heel and its shape influences the position of the longitudinal axis of the foot.

• Rear tread area: Contact with the ground, important for cushioning
• Articular surface to the talus: crucial for mobility (inversion/eversion)
• Insertion of the Achilles tendon: large tensile forces during push-off movements
• Lateral wall and sustentaculum tali: landmarks for diagnostics/surgery

Causes and risk factors

Typical triggers are axial forces (fall from a ladder, accident) or strong buckling mechanisms. Stress fractures due to overloading occur less frequently. Osteoporosis, smoking or metabolic diseases can increase the risk of a fracture and healing disorders.

• Falling from height and landing on the heel
• Traffic accidents or sports trauma (e.g. snowboarding, parkour)
• Severe sprain injuries with shear forces in the subtalar joint
• Osteoporosis and reduced bone quality
• Previous heel injuries

Symptoms: How do you recognize a broken heel bone?

• Acute, severe heel pain, weight bearing is hardly possible
• Severe swelling and bruising on the heel/side of the foot
• Pressure pain over the calcaneus, possibly widening of the heel
• Painfully limited mobility of the ankle and subtalar joints
• In rare cases, numbness (soft tissue damage/nerve irritation)

Warning signs that require urgent medical attention: open injuries, misalignment, severe pain at rest despite protection and cooling, numbness, paleness or cold in the foot.

First aid and when to see a doctor?

After a trauma, the PECH rule helps: break, ice, compression, elevation. Please do not burden me any further. See a doctor early - in the case of severe pain, swelling or inability to bear weight, on the same day, in the case of open injuries/misalignment as an emergency.

Diagnosis: This is how the calcaneus fracture is recognized

The diagnosis is made through history, clinical examination and imaging. The assessment of the soft tissues (skin tension, blistering) is also important as it influences the treatment window.

• Clinical: Inspection, girth measurement, palpation of the calcaneus, neurovascular status
• X-ray in 2 planes: assessment of axes, joint involvement, Böhler and Gissane angles
• Computed tomography (CT): standard for surgical planning, classification of intra-articular fractures
• MRI: if a stress fracture, ligament/cartilage damage or unclear findings are suspected
• Differential diagnoses: contusion, plantar fasciitis, talus fracture, tarsal ligament tear

The extent of the displacement (dislocation), the joint involvement and the foot axes are crucial for the treatment decision.

Conservative therapy: When to treat without surgery

Non-displaced, extra-articular or slightly displaced calcaneus fractures can often be successfully treated conservatively. The focus is on pain relief, swelling, protection of the fracture and early functional mobilization within a safe framework.

• Immobilization with a lower leg orthosis, walker boot or plaster depending on the findings
• Consistent relief using forearm crutches (usually 6-8 weeks, depending on the healing process)
• Positioning and lymphatic drainage to reduce swelling
• Drug pain therapy as needed
• Thrombosis prophylaxis during immobilization after individual risk assessment
• Physiotherapy: early exercise in the upper/lower ankle in the pain-free area
• Later: Gait training, strengthening of the calf and foot muscles, proprioception
• Aids: heel cushion, individually adapted insoles in the construction phase

The advantages of conservative treatment are the avoidance of surgery-related risks. However, the prerequisite is a stable fracture shape without any relevant misalignment. We monitor the progress closely with clinical checks and imaging.

Surgical therapy: indications, procedures, timing

Surgery may make sense if the fracture is severely displaced, the subtalar joint is significantly involved, the heel height/width is changed, or there is a risk of axial deviations. The aim is to restore the articular surface, the shape of the heel and the axes.

• Open reduction and internal fixation (ORIF) with screws/plates via lateral approach
• Minimally invasive/percutaneous screw osteosynthesis for suitable fractures
• Primary subtalar arthrodesis for non-reconstructable comminuted fractures (rare, selected cases)

The timing of the operation depends on the soft tissue: The operation is usually carried out when the swelling has reduced and the skin wrinkles have formed again. Open fractures require emergency treatment. The same applies to the operation: risks such as wound healing problems, infections, nerve irritation or thrombosis are carefully discussed in advance.

Follow-up treatment and rehabilitation

The follow-up treatment essentially determines the functional result. It is individually adapted to the type of fracture, stability of the care and general condition.

• Ability to work: Office work often after 2-6 weeks, physical work later
• Driving: only after safe full load and sufficient mobility/strength
• Scar and tissue care: soft shoes, gentle mobilization, scar treatment if necessary

Prognosis, possible complications and long-term consequences

The prognosis depends on the type of fracture, joint involvement, soft tissue situation and consistent rehabilitation. Not every serious fracture achieves complete freedom from symptoms, but resilient everyday function is often achievable.

• Possible complications: impaired wound healing, infection, nerve irritation
• Malunion with axial deviation or widening of the heel
• Post-traumatic arthrosis of the subtalar joint with pain on exertion
• Complex regional pain syndrome (CRPS), persistent swelling
• Risk of thrombosis/embolism during immobilization
• Risk factors: smoking, diabetes, vascular diseases, pronounced soft tissue damage

If symptoms persist despite optimal care, secondary measures (e.g. insoles, physiotherapy, targeted pain therapy; in individual cases joint stiffening procedures) are available - after careful indication.

Special situations: children, osteoporosis, stress fractures

• Children/adolescents: less common, pay attention to growth plates; often conservative, close control
• Elderly/osteoporosis: less force is sufficient; Address fall prevention and bone health
• Stress fractures: gradual onset, MRI helpful; Protection and load control centrally

Prevention and relapse prevention

• Safe ladder and scaffolding use, non-slip shoes
• Good footwear with heel guidance for everyday life and sports
• Strength and balance training to prevent falls
• Bone health: vitamin D, calcium, possible diagnosis of osteoporosis
• Reduce smoking – promotes bone healing

Our treatment approach in Hamburg-Winterhude

We initially rely on careful diagnostics and prefer conservative treatment if the type of fracture allows this. Precision in classifying the fracture, protection of the soft tissues and structured follow-up treatment are crucial.

• Clinical examination and evidence-based imaging (X-ray, CT if necessary)
• Individual therapy plans: conservative priority, surgical options if there is a clear indication
• Close aftercare regimen with function and stress control
• Interdisciplinary collaboration with radiological and operational partners in Hamburg
• Rehabilitation: Physiotherapy, insoles and shoe advice, work and sports planning

We would also be happy to advise you as a second opinion. A serious explanation of the benefits and risks of the respective options is a matter of course - without any promise of cure.

Schedule of your appointment: What you should bring with you

• Course of the accident and time, previous treatment measures
• Preliminary findings: X-ray, CT or MRI images (digital/on CD), discharge letters
• Medication list, relevant previous illnesses (e.g. diabetes, coagulation)
• Comfortable clothing/shoes, if necessary orthotics/crutches

Our practice is located at Dorotheenstraße 48, 22301 Hamburg. You can easily request appointments online or by email.

Frequently asked questions about calcaneus fractures

Do I always need surgery? - No. Many non-displaced or extra-articular fractures heal well with consistent offloading and functional therapy. Surgery may be considered if there is significant displacement, joint steps or axial errors.

How long am I not allowed to strain? – Often 6-8 weeks of partial to off-loading, depending on fracture type and control. The exact plan is determined individually.

When can I go back to work? – Sometimes after 2-6 weeks for sedentary work, often later for physical work. We are putting together a phased reintegration plan.

Can I drive a car? – Only when you can safely put full weight on your foot and operate the pedal reliably; medically and legally responsible. We advise individually.

Does the metal have to come out again? – Only in case of complaints, skin irritation, infection or upon request after a risk-benefit assessment. Routine removal is not always necessary.

What can I do myself? – Swelling control (elevation, cooling), consistent relief, non-smoking, physiotherapy and home exercises as recommended.