You Might Just be Making Your Heel a Little Nervous!
Believe it or not, the number of heel bone (calcaneal) fractures that Foot and Ankle specialist see in their office tends to increase around this time of year. Certainly we get an increase in ankle fractures when the snow starts to arrive, but often people wonder about why heel fracture numbers go up. I’ll tell you a little secret: people start climbing ladders to hang holiday lights, and if they fall off the ladder and manage to land on their feet, they might just fracture their heel bone!
Calcaneal fractures are high-energy injuries, meaning that there needs to be a large force to create a fracture. If you think about it, falling off a ladder and landing on your heels creates a large force, as the entire weight of your body crashes into the concrete! Another common mechanism of injury for calcaneal fractures are motor vehicle accidents; another high-energy pattern. Therefore, patients who suffer from a calcaneal fracture must be evaluated fully for other injuries and fractures created during this force. The most commonly associated injury (although not common at all) is a lumbar spine (lower back) fracture. The force into the calcaneus tends to travel up the body and compacts the lower back making it more susceptible to injury.
If you have fallen from a ladder recently and suspect any kind of lower extremity injury, it is important to see you Podiatrist! They can evaluate you, take x-rays and rule out a fracture if you’re suspecting one. If there is a fracture present, they can initiate treatment as soon as possible to get you on the road to recovery! Symptoms that one might notice include severe pain! In addition there may be a distinct “black-and-blue” mark extending from the heel into the arch of the foot. As you know, we Podiatrist’s have names for everything, and call that “black-and-blue” a Mondor’s sign. In addition you will have difficulty moving the foot up and down at the ankle joint and pain with moving your foot inwards and outwards. A comparison of your feet from behind will reveal a slightly wider heel/foot on the affected side when compared to the non-affected foot.
Once you have been evaluated, any other injuries to the body have been ruled out, and x-rays confirm the diagnosis of a calcaneal fracture, the decision then becomes whether surgery is indicated or not, in order to repair the calcaneus. The answer to this question and the recommendation that your Podiatrist will make will be largely based on the location of the fracture, how far the pieces of the fracture are away from where they belong and if the Subtalar joint (the one that sits underneath the ankle) is disrupted.
In the best-case scenario, the fracture will be minimally displaced and the Subtalar joint will be unaffected, sparing you from surgical correction. In this instance, you will need to be casted for 6-8 weeks with crutches to avoid that any weight is put onto the affected foot. After those 6-8 weeks, when healing can be confirmed via x-ray, you will slowly be transitioned into a walking cast and finally back to a supportive sneaker.
In the worst-case scenario, the fracture will be largely displaced and the Subtalar joint will be severely affected, indicating surgical correction for realignment. The goal of surgical intervention is to repair the Subtalar joint with the hope that the height of the calcaneus can be regained and normal function of that joint can be restored. In order to accomplish this, a metal plate with several screws will be inserted against the heel bone to bridge the area and allow for healing in the corrected positioning. The length of time that you will be casted and non-weight bearing with crutches is closer to 12 weeks, again with transition to a walking cast and finally backs to a sneaker over the next several weeks. The treatment course for a severe fracture like this is about 6 months until you are able to return to normal activity, while the long-term effects last a lifetime.
Patients who suffer calcaneal fractures where the joint is involved, typically require an additional surgery down the line. The indication for this surgery is post-traumatic osteoarthritis, which we discussed over the last several weeks. PTOA is virtually impossible to avoid with this type of fracture pattern, but the initial surgery is important in managing PTOA in the long-term. It has been reported that patients who have initial reduction of their calcaneal fracture as indicated, do better down the line with managing their PTOA and although they end up having a joint fusion (a joint that will no longer move) they are more pain-free than their counterparts!