The calcaneus is the largest tarsal bone in the foot and acts as the foundation and lever for the foot and lower leg. Calcaneus fractures most commonly occur from high-energy impacts to the heel that drive the talus down onto the calcaneus. They present with pain and swelling in the heel and difficulty walking. Treatment depends on the fracture type but often involves initial immobilization, physical therapy to regain range of motion and strength, and progression to full weight bearing over several months to allow healing. Surgical fixation may be required for displaced fractures to realign the bones.

1. Azhaan Mohammad Asiad
17SMAS101050 [Galgotias University]
[CALCANEUM FRACTURE]

2. Calcaneum Fracture
The calcaneus (os calcis) is the largest of the tarsal bones.
It is specifically designed to support the body and endure a great degree of force. It is situated
at the lower and back part of the foot, forming the heel.
The calcaneus has four important functions:
 Acts as a foundation and support for the body’s weight
 Supports the lateral column of the foot and acts as the main articulation for
inversion/eversion
 Acts as a lever arm for the gastrocnemius muscle
complex
 Makes normal walking possible
Mechanism of injury:
 High-energy axial load applied to the heel, which drives
the talus downward onto the calcaneus.
 Fall from height or motor accidents.
 Approximately 80% to 90% of the calcaneal fractures happen in males between 21 and 40
years, mostly in industrial workers.
 Mostly, injuries occur in isolation. Most seen concomitant injuries were lower limb (13.2%)
or spinal injuries (6.3%)
Characteristics / Clinical Presentation:
 Sudden pain in the heel, most importantly pressure pain.
 Swelling in the heel area
 Bruising of the heel and ankle
 Generalized pain in the heel area that usually develops slowly (over several days to weeks):
typically for stress fractures
 Edema
 A hematoma or pattern of ecchymosis extending distally to the sole of the foot.
 Heel tenderness
 Difficulty walking
 Inability or difficulty to bear weight on the affected side
 Limited or absent inversion / eversion of the foot.

3. Types of fracture calcaneum:
 Undisplaced fracture - resulting from a
minimal trauma.
 Extra-articular fracture - where the articular
surfaces remain intact, and the force splits the
calcaneal tuberosity vertically.
 Intra-articular fracture - where the articular
surface of the calcaneum fails to withstand the
stress. This is the commonest type of fracture.
Examination:
 To diagnose and evaluate a calcaneal fracture, the foot and ankle surgeon will ask
questions about how the injury occurred, examine the affected foot and ankle and order x-
rays. In addition, advanced imaging tests such as CT-scans are commonly required after a
fracture. These provide more detailed, cross-sectional images of your foot.
 The physiotherapist will examine the ankle to see if the skin was damaged or punctured
from the injury.
 He will check for a pulse to see if there is a sufficient blood supply at the injured area. Also,
he should check if the patient can move his toes and feel at the bottom of his foot to
determine if there are any other injuries that occurred with the calcaneal fracture.
 Other techniques like squeezing the heel causes pain over the calcaneal protuberances. A
thorough neurovascular examination is also essential.
Medical Management:
Treatment of calcaneal fractures depends on the type of fracture and the extent of the injury.
There is no universal treatment or surgical approach to all displaced intra-articular calcaneal
fractures. The choice of treatment must be based on the characteristics of the patient and on
the type of fracture.
Non-Operative Care –
R.I.C.E
 Rest: The affected foot must rest and the patient is not allowed to use the foot. This is to allow
the fracture to heal.

4.  Ice: Several times a day the patient has an ice treatment to reduce inflammation, swelling and
pain.
 Compression: Bandage / Compression stocking
 Elevation: The initial management is to reduce the swelling with rest in bed with the foot
slightly above heart level.
Immobilization:
Partial or complete immobilization is used if the fracture has not displaced the bone. Usually a
cast is used to keep the fractured bone from moving. In the cast, the ankle is in neutral
position and sometimes in slight eversion. To avoid weight bearing, crutches may be needed.
Physical Therapy Management:
After the surgery, active range of motion exercises may be practiced with small amounts of
movement for all joints of the foot and ankle. These exercises are used to maintain and regain
the ankle joint movement. When needed for the involved lower extremity, the patient may
continue with elevation, icing and compression.
During the therapy, the patient will progress to gradual weight bearing. Patients may find this
very difficult and painful. The physiotherapist conducts joint mobilization to all hypo mobile
joints.
Acute Stage –
Immobilization. A cast, splint, or brace will hold the bones in your foot in proper position while
they heal. You may have to wear a cast for 6 to 8 weeks — or possibly longer. During this time,
you will not be able to put any weight on your foot until the bone is completely healed.
Pre-Surgery –
Preoperative revalidation consist on:
• Immediate elevation of the affected foot to reduce swelling
• Compression such as foot pump, intermittent compression devices or compression wraps.
• ICE
• Instructions for using wheelchair, bed transfers, or crutches.
Management: Weeks 1-4:
Goals:
 Control edema and pain
 Prevent extension of fracture or loss of surgical stabilization
 Minimize loss of function and cardiovascular endurance

5. Intervention:
 Cast with the ankle in neutral and sometimes slight eversion,
 Elevation
 Ice
 After 2-4 days, instruct in non-weight bearing ambulation utilizing crutches or walker
 Instruct in wheelchair use with an appropriate sitting schedule to limit time involved
extremity spends in dependent-gravity position
 Instruct in comprehensive exercise and cardiovascular program utilizing upper extremities
and uninvolved lower extremity
Management: Weeks 5-8:
Goals:
 Control remaining or residual edema and pain
 Prevent re-injury or complication of fracture by progressing weight-bearing safely
 Prevent contracture and regain motion at ankle/foot joints
 Minimize loss of function and cardiovascular endurance
Intervention:
 Continued elevation, icing, and compression as needed for involved lower extremity.
 After 6-8 weeks, instruct in partial-weight bearing ambulation utilizing crutches or walker.
 Initiate vigorous exercise and range of motion to regain and maintain motion at all joints:
tibiotalar, subtalar, midtarsal, and toe joints, including active range of motion in large amounts
of movement and progressive isometric or resisted exercises.
 Progress and monitor comprehensive upper extremity and cardiovascular program.
Management: Weeks 9-12:
Goals:
 Progress weight-bearing status
 Normal gait on all surfaces
 Restore full range of motion
 Restore full strength
 Allow return to previous work status
Intervention:
 After 9-12 weeks, instruct in normal full-weight bearing ambulation with the appropriate
assistive device as needed.

6.  Progress and monitor the subtalar joint’s ability to adapt for ambulation on all surfaces,
including graded and uneven surfaces.
 Joint mobilization to all hypo mobile joints including: tibiotalar, subtalar, midtarsal, and to toe
joints.
 Soft tissue mobilization to hypo mobile tissues of the gastrocnemius complex, plantar fascia,
or other appropriate tissues.
 Progressive resisted strengthening of gastrocnemius complex through the use of pulleys,
weighted exercise, toe-walking ambulation, ascending/descending stairs, skipping or other
plyometric exercise, pool exercises, and other climbing activities.
 Work hardening program or activities to allow return to work between 13- 52 weeks.