Initial Management of Heel Bruise and Imaging Decision
Apply the Ottawa Ankle Rules to determine if imaging is needed: obtain radiographs only if the patient has point tenderness over the calcaneus AND either cannot bear weight immediately after injury or cannot take 4 steps in the emergency department. 1
Clinical Assessment for Imaging Decision
The Ottawa Ankle Rules provide a validated, high-sensitivity (92-99%) framework for determining when imaging is necessary: 1
- Check for point tenderness directly over the calcaneus – this is a required criterion 1
- Assess weight-bearing ability – the patient must be unable to bear weight both immediately after injury AND unable to take 4 steps in the emergency department 1
- If Ottawa Rules are negative, do not order any imaging 1
Important Caveats When Applying Ottawa Rules
Do NOT use Ottawa Rules in these situations (obtain imaging regardless): 2
- Penetrating trauma
- Pregnancy
- Open skin wounds over the injury site
- Patients transferred with radiographs already obtained
- More than 10 days after trauma or return visits for continued pain
- Polytrauma patients
- Altered mental status
- Neurologic abnormality affecting the foot
- Underlying bone disease or diabetic neuropathy
Imaging Protocol When Indicated
If Ottawa Rules are positive, order a standard three-view foot series (AP, lateral, and oblique) PLUS an axial calcaneal view. 2
The axial calcaneal view is specifically recommended to increase both specificity for diagnosing calcaneal fractures and sensitivity for distinguishing intra-articular from extra-articular fractures. 2 This additional view is critical because it provides unique visualization of the calcaneal body and subtalar joint that standard views may miss.
Advanced Imaging Considerations
- Do not order CT, MRI, bone scan, or ultrasound as initial imaging for acute heel trauma 1
- CT may be reserved for complex fracture characterization for surgical planning or polytrauma patients, but only after plain radiographs 1, 2
Initial Management
If Imaging is NOT Indicated (Negative Ottawa Rules)
- Rest, ice, elevation
- Protected weight-bearing as tolerated
- Analgesia
- Clinical reassessment if symptoms persist beyond expected timeframe
If Calcaneal Fracture is Identified
Urgent orthopedic consultation is required for calcaneal tuberosity avulsion fractures because these compromise the thin posterior skin over the Achilles insertion and risk skin breakdown and tissue necrosis if treatment is delayed. 3 This subset of calcaneal fractures requires urgent attention, unlike most closed calcaneal fractures which can have delayed surgical management.
For other calcaneal fracture patterns, definitive management is typically delayed (mean 9.8 days) to allow soft tissue swelling to subside, though orthopedic consultation should still be obtained in the acute setting. 4
Critical Pitfall to Avoid
Do not delay evaluation or treatment of posterior heel injuries with suspected avulsion fractures – these require urgent intervention to prevent skin necrosis, unlike the majority of calcaneal fractures which are managed with delayed surgery. 3 The thin posterior skin over the Achilles insertion is particularly vulnerable to pressure necrosis from displaced bone fragments.