What is the proper treatment for a bruised (contused) calcaneus?

Treatment of a Bruised Calcaneus

For a bruised (contused) calcaneus, immediately implement rest, ice application, compression, and elevation (RICE protocol), combined with NSAIDs for pain control, while avoiding complete immobilization beyond 3-5 days and gradually progressing weight-bearing as tolerated to prevent muscular atrophy and facilitate recovery. 1, 2

Initial Management (First 3-5 Days)

Acute Phase Treatment:

• Apply ice to the affected area for pain and inflammation control 3, 4
• Use compression wrapping to minimize swelling 4
• Elevate the foot above heart level to reduce edema 4
• Prescribe NSAIDs (such as ibuprofen 400 mg every 4-6 hours) for pain relief and anti-inflammatory effects 3, 1
• Instruct the patient to limit standing and walking activities 3
• Consider crutches if weight-bearing causes significant pain 3

Critical Pitfall to Avoid:

• Do not maintain complete immobilization beyond 3-5 days, as this causes muscular atrophy and deconditioning, which worsens functional recovery 1

Diagnostic Considerations

Rule Out More Serious Pathology:

• Perform calcaneal compression test (squeeze the calcaneus medially to laterally) to exclude stress fracture 3, 1
• Palpate specific anatomical landmarks including the Achilles insertion, posterior superior calcaneus, lateral calcaneal wall, and medial plantar heel to localize pathology 1
• If radiographs are normal but pain persists with weight-bearing difficulty, consider MRI to confirm bone bruise and assess extent 2

When to Image:

• Obtain radiographs if the patient meets Ottawa Ankle Rules criteria (inability to bear weight immediately after injury, point tenderness over malleoli/talus/calcaneus, or inability to ambulate 4 steps) 5
• MRI is indicated when radiographs are normal but clinical suspicion for bone bruise remains high, particularly if weight-bearing is not possible 2

Progressive Rehabilitation (After Day 3-5)

Mobilization Strategy:

• Begin early weight-bearing as tolerated to facilitate faster recovery 1
• Increase mobilization and weight-bearing gradually, as bone bruises pose potential risk for chondrolysis and stress fracture if progressed too rapidly 2
• Combine mobilization therapy with active exercise therapy, as mobilization alone is insufficient for range of motion restoration 1
• Use semirigid braces over tape for functional support during rehabilitation if needed 1

Expected Recovery Timeline:

• Mild bone bruises may resolve within 2 weeks 2
• More extensive bone bruises may require partial weight-bearing for up to 4 months 2
• Complete resolution of MRI signal changes typically occurs by 6 months 2

Supportive Measures

Footwear and Padding:

• Provide over-the-counter heel cushions to reduce impact forces 3, 1
• Recommend appropriate footwear that offloads the affected area 3
• Avoid flat shoes and barefoot walking during recovery 3

Activity Modification:

• Decrease activity level temporarily during acute phase 3
• Gradually increase impact activities only after pain resolution 6
• Athletes should not resume impact training until symptoms have completely resolved, as premature return can prolong recovery 6

Referral Indications

When to Refer to Podiatric Foot and Ankle Surgery:

• No improvement after 6-8 weeks of appropriate conservative treatment 1, 7
• Need for advanced imaging or diagnostic clarification 1
• Persistent inability to bear weight beyond expected timeframe 2
• Development of neurologic symptoms such as burning or tingling, which require immediate subspecialist evaluation with EMG, nerve conduction studies, and MRI 1

Common Pitfalls

• Overlooking stress fractures: Patients often report increased walking activity before symptom onset, and radiographs may initially be negative; maintain high clinical suspicion 1, 5
• Premature return to impact activities: Starting high-impact training too early after calcaneal injury can cause or worsen bone bruising, significantly prolonging recovery 6
• Prolonged immobilization: Maintaining complete immobilization beyond 3-5 days delays functional recovery and causes deconditioning 1
• Assuming all heel pain is mechanical: Evaluate for underlying rheumatic disease or systemic inflammatory conditions, particularly with bilateral symptoms 1