How to diagnose a broken or sprained calcaneus?

Diagnosing a Broken vs. Sprained Calcaneus (Heel Bone)

A broken calcaneus (heel bone) is best diagnosed through radiographic imaging, while a sprain typically presents with less severe symptoms and no fracture on imaging. 1

Clinical Presentation

Signs of a Calcaneal Fracture:

• History of significant trauma (most commonly a fall from height onto the heel) 1, 2
• Severe, poorly localized pain in the rearfoot area 1
• Pain on compression of the calcaneus (highly suspicious for fracture) 1
• Tenderness at the lateral wall of the calcaneus 1
• Visible swelling and warmth 1
• Inability to bear weight

Signs of a Calcaneal Sprain/Soft Tissue Injury:

• Less severe trauma history
• More localized pain
• Pain relieved when walking barefoot (if associated with Haglund's deformity) 1
• Tenderness lateral to the Achilles tendon 1
• Able to bear weight, though painful

Diagnostic Approach

1. Physical Examination:

   • Assess for focal tenderness on palpation of the calcaneus 1
   • Perform calcaneal compression test (pain on lateral compression suggests fracture) 1
   • Check for swelling, bruising, and deformity
   • Evaluate ability to bear weight

2. Imaging Studies:

   • Plain Radiographs: First-line imaging for suspected calcaneal injury 1, 3

     • Multiple views needed (lateral, axial, oblique)
     • May miss subtle fractures or stress fractures

   • CT Scan: Gold standard for definitive diagnosis 3

     • Essential for characterizing fracture patterns
     • Helps determine if fracture is intra-articular (involving joint surfaces) or extra-articular
     • Critical for surgical planning if fracture is present

   • Bone Scan: Useful for suspected stress fractures when radiographs are negative 1

     • Can detect fractures before they appear on X-ray

Management Algorithm

If Calcaneal Fracture Confirmed:

1. Simple/Non-displaced Fractures:

   • Immobilization (cast or boot)
   • Non-weight bearing status
   • Referral to orthopedic or podiatric surgeon 1

2. Displaced/Intra-articular Fractures:

   • Immediate orthopedic referral
   • Likely surgical intervention 1, 3

If Sprain/Soft Tissue Injury:

1. Initial Treatment:

   • Open-backed shoes (to reduce pressure) 1
   • NSAIDs for pain and inflammation 1
   • Decreased activity and rest
   • Ice application for acute pain
   • Heel lifts or orthoses 1

2. If No Improvement (6-8 weeks):

   • Referral to podiatric foot and ankle surgeon 1
   • Consider immobilization cast or walker boot 1

Common Pitfalls and Caveats

• Missed Stress Fractures: Calcaneal stress fractures may not appear on initial radiographs. Consider bone scan if clinical suspicion is high despite negative X-rays 1

• Misdiagnosis of Heel Pain: Multiple conditions can cause heel pain (plantar fasciitis, Achilles tendinopathy, bursitis). Ensure proper diagnosis before treatment 1

• Delayed Treatment: Calcaneal fractures require prompt treatment to prevent long-term disability, as the calcaneus is critical for stable gait 4

• Rare Presentations: Consider unusual causes such as calcaneal spur fractures, which can occur after trauma and cause heel pain 2

• Anatomical Variations: The calcaneus has significant morphological differences between individuals and sexes, which can affect injury patterns and treatment 4