Do you have a fracture of the calcaneus (heel bone), or you need to ensure the rehabilitation of a patient who has broken their calcaneus?
In this article, I address the most frequently asked questions from patients, physiotherapists, and doctors regarding fractures of this heel bone.
To provide answers, I draw upon my experience as well as extensive research in international scientific publications. You will find all the sources cited at the end of the article.
Happy reading 🙂!
Last update: August 2023
Disclaimer: Amazon affiliate links
What does a calcaneus fracture look like, with or without displacement?
The calcaneus is the largest bone in the foot, located at the heel.
Fractures of the calcaneus are relatively uncommon, but the treatments and progression of this type of fracture are fairly well understood.
The calcaneus is also referred to as the calcaneum, and both terms refer to the same bone.
The following terms are used for a calcaneus fracture:
- Calcaneus fracture
- Calcaneal fracture
- Fracture of the avulsion of the calcaneal tuberosity (a part of the calcaneus)
- Fracture of the calcaneal / heel spur (another part of the calcaneus), which should not be confused with a “simple” heel spur with plantar fasciitis.
The calcaneus can also be cracked or fissured, which means the bone is damaged but less severely than in the case of a “true” fracture.
In 70% of cases, individuals who experience a calcaneus fracture also suffer from other injuries related to the trauma.
Fun fact: These fractures are also known as “lover’s fractures.” Why? Because in the past, the fractures often occurred during romantic escapades or attempts to escape from amorous encounters! 🙂
Causes of calcaneus fractures
The calcaneus most commonly fractures due to:
- Falling from a great height
- Car accidents
- Jumping on hard surfaces or sports-related accidents
- Excessive and intense running (stress fracture)
Different types of calcaneus fractures
On your X-ray report or medical/surgical consultation report, you will likely find more precise descriptions of your fracture than just “calcaneus fracture.” These fractures can be classified based on:
- Their precise location on the bone
- The number of fracture lines and bone fragments (simple or complex fracture)
- Whether there is displacement. Displacement occurs when there is a significant gap between the different broken ends of the bone.
- Whether they are closed or open fractures. An open fracture means that the bone has pierced the skin, which occurs in less than 10% of calcaneus fractures.
- Whether a dislocation is associated. Dislocation is very rare in calcaneus fractures.
- Whether it is an intra-articular or extra-articular fracture. 25% of calcaneus fractures are extra-articular, and they have a better prognosis.
The type of calcaneus fracture, especially whether it is displaced or not, will determine the treatment. However, in all cases, the treatment generally follows the same guidelines.
Source: Statpearls 2022
Symptoms and diagnosis of broken heel
A fracture of the calcaneus is rarely missed:
- There was trauma, an impact on the heel area.
- It is very painful, and putting weight on the foot is almost impossible.
- A bruise (ecchymosis) appears under the foot, around the arch.
X-rays and a computed tomography (CT scan) are usually performed. Nerve and blood vessel injuries are also checked for.
What is the treatment when you have a broken heel?
As with any fracture, the treatment will depend on the type and severity of the fracture, as well as:
- Your overall health at the time of the fracture.
- The practices of the (para)medical teams taking care of you.
Most of the time, you will receive orthopedic treatment (with immobilization) and undergo rehabilitation through physical therapy sessions.
Sometimes, surgery may be necessary in addition.
Orthopedic / Conservative treatment: Splint, cast
To ensure proper bone healing, at least two things are often implemented:
- Unloading: You will limit the weight you put on the fractured foot.
- Either by not bearing any weight on it or very little, referred to as “non-weight bearing” or “weight-bearing as tolerated.” In this case, you may use crutches or a walker.
- Alternatively (much less common), you may be allowed to place the foot on the ground and bear weight based on pain, but without carrying any additional weight, only using your body weight at most. Initially, you may still need crutches.
- Immobilization: The movement of the bone must be restricted.
- This is achieved through a cast (sometimes worn for 6 to 10-12 weeks) or a splint, either prefabricated or custom-made (worn for a few days, possibly a few weeks, rarely longer).
- In some cases, there may be no specific immobilization, but you are advised to be cautious with ankle movements.
Normally, the medical team that made the diagnosis should have provided clear information orally and in writing about this.
Physical therapists, nurses, and doctors who are involved in your care will help you interpret this information and tell you what movements are safe to perform and gradually increase over the days.
This orthopedic treatment (splint, cast, or restricted movement) is maintained for about 10-12 weeks, sometimes less. A follow-up X-ray will determine if the healing is progressing well and if the restrictions can be gradually lifted.
From my experience, we can often do without walking boot, and some people do not use them once they are purchased. It’s better to think before getting one about whether it’s necessary in your case:
- Is it to protect your foot from impacts (for example, if you have young children, pets, or if you will be walking in crowded areas soon)?
- Is it because you are having difficulty putting weight on the foot and you think it will help you gain confidence?
Calcaneus surgery and placement of plates or other materials
When the fracture is open, or when the fracture line involves the joint, surgery is sometimes necessary.
Different techniques can be used:
- Internal fixation with plates and screws
- Percutaneous pinning
- External fixator
- Subtalar arthrodesis (often done at a later stage). The calcaneus is fused with the talus. This reduces mobility but provides more stability. The risk of undergoing arthrodesis is 4 times higher if the fracture is classified as type III according to the Sanders classification, compared to a type II fracture.
- Osteotomies (Guan 2021).
You will know what you had by reading the operation report.
The surgery is often intentionally scheduled several days (or even weeks) after the fracture, when the soft tissue swelling subsides.
A meta-analysis from 2017, which included 1467 patients with intra-articular calcaneus fractures, found that:
- The rate of complications is higher with surgical intervention.
- There is better anatomical recovery with surgery.
- Functional outcomes are better, and return to work is more frequent.
Source: Wei 2017.
Physical therapy after calcaneus fracture
The rehabilitation period can be broadly divided into 2 phases:
- Rehabilitation once the healing process is underway: Physical therapy sessions are almost always prescribed during this phase. The goal is to gradually resume all your pre-injury activities, gradually allowing your leg and heel to bear weight and be in motion.
- Rehabilitation during the healing phase: The main objective is to prevent excessive deconditioning, reduce pain, and minimize complications.
Personalized advice will be provided to you to:
- Identify what you can do to remain as active as possible: which exercises can help maintain strength and flexibility? Is ankle movement possible?
- Find comfortable positions to relieve pain, aid in sleeping, or reduce swelling in the foot, which is quite common.
- Adapt your movements: which walking aids are suitable? How should you put weight on your foot when walking?
A few weeks after the fracture, you will likely have a follow-up X-ray, followed by an appointment with a surgeon or doctor. You will likely be given the green light to gradually begin weight-bearing again. Physical therapists can guide you through this crucial phase of gradually resuming walking and later engaging in sports activities.
Physical therapy sessions are there to reassure you, help you identify what you can do to maintain your physical condition, and gradually reintegrate all your usual activities once the healing process is well underway.
What is the duration of immobilization in the case of a calcaneus fracture?
Very often in France or United-States, you will be advised to be immobilized and non-weight bearing for at least 6 weeks (1 and a half months). Sometimes even up to 3 months.
Often, a follow-up X-ray will be taken to assess the progress of healing.
However, some medical teams encourage a more rapid resumption of weight-bearing on the leg, while being cautious not to put too much pressure on the heel. This is because it is known that minimal stress on the bone can be beneficial for the healing process.
For example, here are the splints and footwear used by a Korean medical team (Park 2021).
This team implemented the following walking protocol for certain patients who underwent surgery for a calcaneus fracture:
- Splint and non-weight bearing for 2 weeks.
- Afterward, permission to walk with reduced weight-bearing on the heel, using an appropriate splint or footwear (as mentioned above). Crutches are used for 2 weeks and then gradually discontinued.
- At 8 weeks after the fracture, walking with a simple silicone heel pad is allowed.
Regarding rehabilitation exercises, the following were recommended for the foot:
- Passive and active mobilization of the toes only for 2 weeks.
- After 2 weeks (after suture removal), ankle mobility exercises: attempting to make large circles with the ankle. Muscle strengthening exercises for the entire lower limb.
- At 8 weeks, permission to kneel on the knees to maximally flex the ankle with the effect of gravity.
This Korean research team points out that:
- 55% of available protocols recommend starting partial weight-bearing at half of the body weight at 6 weeks after the fracture (no weight-bearing before that).
- Recent studies encourage earlier mobilization, even before 6 weeks. For example, walking with a walking boot after 4 weeks.
According to this Korean team:
1/ although there are no studies comparing very conservative protocols (long periods of non-weight-bearing) to protocols allowing earlier weight-bearing,
2/ there is a general agreement that a more gradual progression to weight-bearing is beneficial for better recovery and healing.
What is the recovery time for a broken heel?
How long does it take for calcaneus to heal?
As soon as a calcaneus fracture occurs, an automatic repair mechanism is set in motion. New bone tissue is automatically created without the need for any specific intervention.
Certain factors can delay the healing time:
- Advanced age
- Diabetes, menopause, and other conditions that affect the function of the endocrine glands
- Administration of steroids
- Malnutrition (hence the importance of being particularly vigilant about nutrition during this healing phase)
- Smoking: it is recommended to limit or stop smoking, at least during the healing process.
The calcaneus is an bone that takes longer than average to heal. The healing process is long and gradual, so there is no specific deadline or definitive confirmation of 100% healing even with an X-ray.
It is generally estimated that a significant level of healing can be achieved between 45 days to 3 months, but complete healing may take longer. With or without surgery.
|6-12 weeks||Disappearance of foot swelling (edema)|
|Several months||Resuming walking with crutches (non-weight bearing) or with contact support (partial weight-bearing)|
|Immediately||Resuming walking with weight-bearing|
|4 weeks to 3 months||Returning to work|
|Several months||Resuming sports activities|
|6 months – 2 years||Full functional and muscular recovery|
What are the possible sequelae after a calcaneus fracture?
Your prognosis will be better than average if you are in one or more of the following situations:
- You are female.
- You are relatively young (under 50 years old).
- You have a job that involves minimal weight-bearing (e.g., desk job).
- You have had a non-displaced or minimally displaced fracture. The displacement is assessed using something called the “Bohler angle.”
Some people recover well and do not experience any lasting effects.
Among those who do have sequelae, the two most common are:
- Pain (sometimes associated with early osteoarthritis).
- Difficulties performing certain physical activities of daily living.
And what about complications?
Keep in mind that it is much more likely that you will NOT experience complications!
However, here are the complications that, rarely, can occur:
- Compartment syndrome (in less than 10% of cases). The main sign is an extremely intense sudden pain, along with a loss of mobility or numbness.
- Delayed or non-union of the fractured bone, similar to any other fracture.
- Infection in the case of surgery or an open fracture: less than 1 person out of 5, at most.
- Nerve injury in the case of surgery (up to a maximum of 15% of cases).
The main possible sequelae are pain and discomfort in certain activities, but many people recover from a calcaneus fracture without experiencing these sequelae. However, the recovery process is generally quite lengthy, taking several months or even years for some individuals, especially in cases of other associated injuries.
Source: StatPearl 2022
A calcaneus fracture is known to have the potential to significantly impact the quality of life and abilities of a significant number of individuals. However, research teams have also presented more moderate results, as the studies mainly follow people with severe fractures (Alexandridis 2015).
I personally know examples of people who have recovered very well after a calcaneus fracture, even though their fracture was initially quite serious.
Is it normal to have a lot of pain when you break your heel (calcaneus)?
You might not have pain in the days following the fracture – that’s great! Are you experiencing pain, and does it worry you?
It is normal to feel concerned about pain. However, it’s essential to know that experiencing pain is a common occurrence in the aftermath of a calcaneus fracture. The pain tends to decrease over the course of days and sometimes weeks.
If the pain is too bothersome, it can be relieved by over-the-counter medications (such as paracetamol) or prescription drugs (analgesics of level 2 or 3). Your primary care physician can prescribe these medications if you do not have a prescription.
You can also try:
- Finding more comfortable positions
- Applying cold packs to the painful area
- Elevating the foot above heart level to reduce swelling
- Using TENS (Transcutaneous Electrical Nerve Stimulation), which is more effective for acute pain than chronic pain.
Pain tends to subside over time, but it might temporarily increase when you gradually resume movement. As you gradually recover, you will learn how to manage your effort to limit the occurrence of pain.
It is typical to experience pain for a few days or even weeks after a calcaneus fracture. These pains can be relieved through various means. Experiencing isolated pain is not necessarily a sign of severity, although it can be bothersome.
Driving after a calcaneus fracture: How long should you wait?
In general, it is advisable to wait until you can bear weight on the leg and the ankle is sufficiently flexible and mobile without significant pain before resuming driving.
If the affected foot is the right or left and the vehicle is an automatic transmission, it may be possible to resume driving earlier.
However, the static sitting position in a car is not ideal for recovery.
Personally, I advise my patients to try driving when they feel ready, regardless of a specific timeframe. I recommend starting by testing their ability to operate the pedals while the vehicle is stationary. If all goes well, they can begin with a short 5-minute drive and gradually increase the time spent driving in a very progressive manner.
In general, individuals with a calcaneus fracture typically resume driving around 2 to 3 months after the fracture.
What does the French regulation say about this?
According to a decree, in cases of post-traumatic motor deficit, there may be an impossibility to maintain the driving license (Arrêté du 21 décembre 2005).
Article R. 412-6 of the French Highway Code states that “every driver of a vehicle must remain constantly capable and in a position to perform all maneuvers that are incumbent upon them easily and without delay.” Your civil and criminal liability as a driver may be called into question after an accident.
Now, let’s discuss driving after a calcaneus fracture in the United States and Canada.
What does the United States regulation say?
In the United States, there are no specific nationwide regulations regarding driving after a calcaneus fracture. Each state may have its own guidelines or recommendations.
Generally, individuals are advised to wait until they have recovered enough mobility, strength, and confidence to safely operate a vehicle.
What does the Canada regulation say?
Similarly, in Canada, there is no specific federal regulation for driving after a calcaneus fracture. Each province and territory may have its own rules and guidelines.
Returning to work after a fracture of the calcaneus: How does it work?
The French Health Insurance issues guidelines for doctors regarding the recommended duration of work leave based on certain conditions. There is a guideline for calcaneal fractures that indicates the following recommended work leave durations:
- 35 days for a non-operated fracture with a sedentary job.
- 280 days (approximately 9 months) of work leave for an operated calcaneal fracture with physically demanding work involving carrying loads exceeding 25kg.
We also have data on the average time to return to work after a calcaneal fracture in other countries. However, these data are based on individuals with relatively severe fractures, which likely extends the average duration.
Here are the data:
🇧🇪 Average duration of 260 days of work disability (over 8 months). 86% were able to return to their pre-injury job. (Mortelmans 2022)
🇺🇲 9 to 22 weeks to return, with an average of 16 weeks (4 months). 2 out of 27 individuals were unable to return to their pre-injury job. (Sword 2018)
If you feel the need to learn more about the recovery period after a broken heel, I wrote this guide in eBook format:
Here’s what I wanted to tell you about this! I wish you a very good recovery! Do you have any comments or questions? Your comments are welcome 🙂 !
You may also like:
- When does a home physiotherapist comes to your home?
- Tips to resume walking quickly after an ankle fracture
Over 200 scientific publications focusing on calcaneal fractures are listed in one of the largest international databases.
In addition to my professional experience, I have drawn on the following to write this article:
Davis D, Seaman TJ, Newton EJ. Calcaneus Fractures. [Updated 2022 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
Guan X, Xiang D, Hu Y, Jiang G, Yu B, Wang B. Malunited calcaneal fracture: the role and technique of osteotomy-a systematic review. Int Orthop. 2021 Oct;45(10):2663-2678. doi: 10.1007/s00264-021-05130-1. Epub 2021 Jul 9. PMID: 34240235.
Meena S, Gangary SK, Sharma P. Review Article: Operative versus nonoperative treatment for displaced intraarticular calcaneal fracture: a meta-analysis of randomised controlled trials. J Orthop Surg (Hong Kong). 2016 Dec;24(3):411-416. doi: 10.1177/1602400328. PMID: 28031517.
Alexandridis G, Gunning AC, Leenen LP. Patient-reported health-related quality of life after a displaced intra-articular calcaneal fracture: a systematic review. World J Emerg Surg. 2015 Dec 30;10:62. doi: 10.1186/s13017-015-0056-z. PMID: 26719760; PMCID: PMC4696241.
Yoo CH, Kang C, Hwang DS, Hwang JM, Lee GS, Park YC. Radiological and Clinical Effectiveness of a Novel Calcaneal Fracture Brace after Intra-articular Calcaneal Fracture Surgery. Clin Orthop Surg. 2018 Sep;10(3):374-379. doi: 10.4055/cios.2018.10.3.374. Epub 2018 Aug 22. PMID: 30174815; PMCID: PMC6107817.
Spierings KE, Min M, Nooijen LE, Swords MP, Schepers T. Managing the open calcaneal fracture: A systematic review. Foot Ankle Surg. 2019 Dec;25(6):707-713. doi: 10.1016/j.fas.2018.10.005. Epub 2018 Nov 5. PMID: 30467055.
Rammelt S, Marx C, Swords G, Swords M. Recognition, Treatment, and Outcome of Calcaneal Fracture-Dislocation. Foot Ankle Int. 2021 Jun;42(6):706-713. doi: 10.1177/1071100720980012. Epub 2021 Jan 21. PMID: 33478259.
Park ES, Choi Y, Lee J, Park SH, Lee HS. Calcaneal fracture: results of earlier rehabilitation after open reduction and internal fixation. Arch Orthop Trauma Surg. 2021 Jun;141(6):929-936. doi: 10.1007/s00402-020-03575-4. Epub 2020 Aug 11. PMID: 32780200.
Schepers T, van Lieshout EM, Ginai AZ, Mulder PG, Heetveld MJ, Patka P. Calcaneal fracture classification: a comparative study. J Foot Ankle Surg. 2009 Mar-Apr;48(2):156-62. doi: 10.1053/j.jfas.2008.11.006. PMID: 19232967.
Wei N, Yuwen P, Liu W, Zhu Y, Chang W, Feng C, Chen W. Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: A meta-analysis of current evidence base. Medicine (Baltimore). 2017 Dec;96(49):e9027. doi: 10.1097/MD.0000000000009027. PMID: 29245290; PMCID: PMC5728905.
Sheen JR, Garla VV. Fracture Healing Overview. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
L‘article R. 412-6 du code de la route (France)
Swords M, Simon A. Return to work after surgical treatment for displaced calcaneus fractures treated with a sinus tarsi approach. Foot & Ankle Orthopaedics. 2018;3(3). doi:10.1177/2473011418S00474
Mortelmans LJ, Du Bois M, Donceel P, Broos PL. Impairment and return to work after intra-articular fractures of the calcaneus. Acta Chir Belg. 2002 Oct;102(5):329-33. doi: 10.1080/00015458.2002.11679325. PMID: 12471765.
By Nelly Darbois
I love to write articles that are based on my experience as a physiotherapist and extensive research in the international scientific literature.
I live in the French Alps 🌞❄️ where I work as a physiotherapist and scientific editor for my own website, where you are.