Do heel bone fractures require surgery?

Question

Hi doctor,

I slipped down the stairs five months ago and got a fracture. My orthopedic doctor diagnosed it as a heel bone fracture in both legs. I mean intra-articular calcaneal fracture. I have lost subtle movements in the heel and ankle area. He advised me to walk on my toes for 20 minutes twice a day. He did not prescribe any medicine other than a painkiller. But, he told me that the painkiller has to be taken only when there is unbearable pain. He told me that it will take at least a year for complete recovery and if not then we will plan for surgery. At present, I can walk very slowly and I cannot walk on my toes as the doctor prescribed. I would like to have a second opinion on this. Do all intra-articular calcaneal fractures require surgery? Why my doctor did not recommend surgery right now? Please help me in this regard.

Answer 1

Hi,

Welcome to icliniq.com.

Intra-articular fractures of the calcaneum if displaced require fixation otherwise there will be a loss of movement at the subtalar joint. However, in this case, tiptoe movement should have been preserved because it is through the ankle joint proper. I need your current X-ray of ankle AP (anteroposterior) and lateral view to comment on your present condition. Only after seeing your old x-ray, I can say whether fixation should have been advised at that time or not. Ankle physiotherapy can improve range of movements if joint congruity is still maintained. So, continue with physiotherapy till I see the x-ray.

Thank you.

Answer 2

Hi,

Welcome back to icliniq.com.

I have gone through your history in detail. I have checked your x-rays (attachment removed to protect patient identity). The subtalar joint space has decreased and foot movement will not be possible to some extent now. You should follow the advice of your doctor. A lot of time has elapsed since the injury so any surgical procedure to relieve pain has to be done once the fracture has consolidated completely. Pain and swelling will subside with time. Use soft cushioned shoes (sports shoes) for routine daytime use and also use silicon heels in these shoes for additional comfort. Do physiotherapy and heat therapy with lukewarm water daily. It will take almost a year to get subtalar joint fusion. There is no need of any local injection into the ankle.

Thank you.

Answer 3

Hi,

Welcome back to icliniq.com.

Please do not be afraid or be in fear of anything. Surgery whether required or not can only be said after a year or so after seeing the x-ray at that time along with your physical examination. Subtalar joint fusion is not a big surgery. Calcaneal surgeries are associated with complications. Therefore, the decision of surgery is based on the benefit-to-complication ratio. According to your ortho doctor's notes, movements at the subtalar joint are lost. Therefore, walking on uneven surfaces and running are not possible at present. Depending upon the range of movement achieved with physiotherapy you can perform those activities in the future. Other questions can be discussed with an affirmative answer only. Everything at this point is mere speculation. I would recommend you stick with your doctor's advice for the moment. Continue with physiotherapy; stop worrying about the future condition.

Thank you.

Answer 4

Hi,

Welcome back to icliniq.com.

The role of physiotherapists is to teach you to exercise once in person and then you have to follow the same at home. I have not recommended you see a physiotherapist as no therapy such as ultrasonic or heat therapy is required in your case. If ankle exercises are shown to you then it is only to perform the exercises at home. The need for surgery, type of surgery, whether the implant will be used or not, and whether it will be subtalar fusion or some other surgery all depends upon the final state of your ankle, and currently, all questions are with a lot of assumptions. My recommendation is to stop worrying about the same. The exercises are meant to increase the range of motion and your friends are right that the condition will improve with time and exercises. Your doctor advised walking on your toes to improve ankle movement and range of motion exercises help to reduce stiffness and keep your joints flexible and maintain or increase muscle strength. There are a lot of chances that you can get a good range of motion, overcome your pain and enjoy walking, running, and yoga. Pain is a subjective perception, be cheerful and stop worrying. Continue with your exercises and resume your activities as tolerated. Your condition will improve with time. You are currently having unbearable pain which is common during recovery of ankle injuries; it will get better with time and exercises. Avoid taking painkillers until the pain is unbearable. Use Paracetamol 600 mg if uncomfortable with Nucoxia P.

Thank you.

Answer 5

Hi,

Welcome back to icliniq.com.

I will try to answer your question one by one as much as possible. Your tip-toe movement should be preserved and your foot inwards and outwards turning movements will be lost as per x-ray. However, these things can only be said confirmative after physical examination as nothing can substitute physical examination. Yes, ankle physiotherapy and exercises help to improve the range of motion if joint congruity is maintained or minimal displacement. If the joint is completely obliterated, movements at that joint cannot take place. Your earlier x-ray shows minimal displacement and conservative treatment was the satisfactory approach to your case. Later x-rays are not much clear. Difficult to comment on those X-rays. CT scan is advised at times for calcaneal fractures. Heat therapy in the form of diathermy or wax bath or infrared as given by physiotherapists is not required. However, exercises in lukewarm water will facilitate your ankle movements. Ice therapy is used in an acute setting after the ankle sprain. RICE (rest, ice, compression, and elevation) is the standard line of treatment for ankle sprain. I cannot comment on what injections were given and what treatment protocol he followed without detailed notes. Your doctor's advice for toe walking is exercise/physiotherapy. Do not apply any local tube over the ankle. It can harm more than do any good. Your condition will take time to heal. Slowly your range of movement will improve; certain activities which are painful now will become pain-free. Rotation of the foot is difficult as in clinical notes which you have shown say movement at the subtalar joint is lost. Leg shortening can only be determined after the physical examination. Give some more time for your injuries to settle and continue with your exercises as they will strengthen your muscles, and improve stretchability once healing is complete we can see what can be done for the residual issues, till give yourself some time.

Thank you.

Answer 6

Hello,

Welcome to icliniq.com.

Chronic pain after injury can last for many reasons such as Sudeck's dystrophy (chronic regional pain syndrome) or ligamentous instability. This can at times be determined by physical examination, or if no cause is established, it can be regarded as the pain of unknown etiology. Time is one factor with which this pain settles in a majority of patients. Whether your situation will improve in a year time or not, cannot be said indeed. The chances of pain settling down are much more than it to remain the same. Surgery is delayed until the final picture after initial injury is seen. The initial fracture would have healed by now.

Yes, subtalar fusion is a hardware fixation. You might not require it as your subtalar movements are already lost as shown in the report. Whether you can have normal movement with surgery is not the question. Surgeon job is to provide as near to normal function as possible. You had an injury, surgeon/doctor is not responsible for the certain inabilities caused by the injury. The doctor tries to bring as much as function as possible, you have to adjust the life accordingly. Bring your issues to the doctor and discuss what can be done best for you.

Whether you can do yoga later cannot be commented right now, even if you can, to what extent can only be observed later on. You walk with your knees bend while toe walking. Knee, ankle and hip examination are required to determine the cause. Ankle swelling can be both during normal healing phenomenon or abnormal; the exact cause can be determined only after review. My recommendation is to visit an orthopedic surgeon.

Alendronate is not to be taken in patients during fracture healing and bone remodeling. I have no clinical experience or qualification regarding ayurvedic preparations and cannot discuss anything about Maida-lakdi.

Answer 7

Hello,

Welcome to icliniq.com.

I had spoken with you numerous times before and said this almost every time that worrying will not help you. The condition mentioned in my previous post are various causes of unsettling pain, which resolve slowly with time. You wish to be a yoga therapist which require a whole range of movement of the entire body. Your affected ankle has lost mobility at the subtalar joint as mentioned in the report. It is unlikely to recover after seeing your x-ray. This is a post-injury sequela which cannot be changed. Physiotherapy/exercises are aimed at maintaining muscle strength, preventing the wasting, at ensuring the range of motion is maintained.

A year or more is required at times for complete healing of such patients. Walking, running and jumping is possible in most. Walking on an uneven surface is at times difficult. Whether yoga is possible or not can only be discussed later when the discussion is to be done in person about various movements required in yoga are reasonable or not. Nothing can be said at this time.

You should stop taking alendronate/Osteofos. Yes, it is not indicated in your case. You should take vitamin D and calcium only if there is a deficiency of them.

My recommendation is the same as earlier. Stop worrying and continue with exercises. There will be an improvement from your present state but never expect pre-injury status to return. Visit local Orthopedic surgeon preferably medical college and stay with their advice and follow up.

Answer 8

Hello Hemant, Thanks for posting your query at icliniq. I have read your current query and again read your previous queries as well. Its great to see that in 9 months you have improved from the point of painful limping walk to pain free walk and able to run, although presntly it is slow but with continued effort you'll be able to run faster. Your physiotherapist is correct in saying that the swelling will eventually subside but providing a time frame in which it'll subside is virtually impossible. Most patients with such injuries have swelling for a year or two, may take longer time depending on individual physiology. Swelling is not the cause of pain and neither it is related to pain nor does it affect the range of motion of ankle joint or knee joint. If you continue with your current exercise program, you will surely improve after 2 years provided proper supervised exercises are done to ensure improvement in range of motion. Along with tip toe walking, you should also try active quadriceps exercises, squatting exercises with tip toe and squatting exercises with foot flat on ground. Sorry, I won't be able to coomeent on 7th question without clinical examination and seeing the current radiological picture of the joint. You have taken great effort with physiotherapy and improved immensely and do continue the same effort to achieve good results. Follow up for further discussion. Regards

Answer 9

Hello,

Welcome back to icliniq.com.

I will answer your all questions the order might be a little haphazard. The range of motion exercises means any exercise in which the joint is able to perform all the movements normally possible, for example, knee joint range of motion is from completely straight knee to leg touching the back of the thigh. Active quadriceps exercises are sitting on the chair and extending your legs straight and keeping the legs in the same position for few seconds and then repeating the same in sets. While walking there is normally some bending of the knee for ground clearance. whether you gait is normal or not can only be assessed after examining gait. I have mentioned previously that it cannot be said the duration of days swelling will take to subside. Radiological assessment is Xray of the affected region and if indicated CT scan after seeing the X-rays. Pain on going downstairs could be because of weakness or because of a different pattern of weight transfer i.e. on walking upstairs weight is mainly on the forefoot and while coming downstairs its mainly on heel area. Your difficulty with Yoga assana is to assess on an individual basis for each movement. Since subtalar movements were already lost as mentioned in the previous clinical report so it is to be examined whether this movement is involved in your aasana or not. I hope all your questions are answered. feel free to discuss. Regards

Answer 10

Hello Hemant, Welcome to icliniq Here is my reply to your questions 1. My Physiotherapist said me to use bicycle rather than motorcycle or car. He told me that it will make my thigh stronger. I am surprised because my heel are fractured and not thighs then why is so important to do exercise to strength thigh muscles. What is the connection between heel and thigh ? Quadriceps weakness is common after injury and this weakening affects gait and causes more strain at knees. The only relation of the muscle with the heel is that during walking contraction of quadriceps straighten the knee before heel strike phase of the gait cycle. It's strengthening is part of any lower limb rehabilitative protocol. 2. You said that “Swelling is not the cause of pain but my PT said that when swelling will go, pain will also decreased. Post injury swelling is usually unrelated to pain. As in my previous post I ahave asked for xrays, this swelling could be due to synovitis of the ankle joint. Synovitis in post ttraumatic scenario arises from osteoarthritis which causes pain. 3. Should I try to do small jumps and run fast ? Should I start walking on uneven surfaces i.e. fields, stairs etc If you are able to do these activies to some extent you can try to perform them. As per your previous clinical examination finding there was loss of subtalar movements so walking on uneven surfaces can be painful. 4.When I raise the heels keeping the knee straight, it raises only 2-3 inches (extreme painful). I feel as if my bones are locked. My PT told me that pain I feel is cure for me. Dr. Patel (Ahmedabad) also told me to walk on toes keeping the knee straight even if tears come out of eyes. Pain on joint movements can be due to altered joint space or stiffness of the soft tisssues around it. To determine the cause, different views of ankle and heel are required. 5. What should I do “Standing on toes” or “Walking on toes” or both? Start with Standing on toes and when you start feeling conmfortable slowly progress to walking on toes. Currently you have extreme pain while standing on toes so I think asking you to walk over toes is too much to ask for. 6. Do I really not need medicines as Dr. Patel did not write any medicine ? Pain killers can be taken for extreme pain or un bearable pain but not on regualr basis. If there is need for regular medicaion, kindly consult your treating physcian. 7. I feel stiffness in both legs (Ankle area). What should I do for that ? A Xray is required for determinning whether the stiffness is due to bony factor or joint is normal and stiffness is realted to soft tissue factor around it. soft tissue related stiffness can be corrected by physoitherapy but bony stiffness can not be corrected by it and the individual cause for it has to addressed. 8. When I asked my PT how much time should I give to exercises, he told me as much as time you give to exercise, faster will be recovery. Because I do this exercise whenever I get time including morning and evening. For example in the night at 11 pm is I am not sleeping I do the exercises. Is it true that overdoing exercises will not make any harm. It is unkiely for such exercises to harm you, however you should listen to your body and the intensity of exercises should be according to it. 9. In diagnosis of Dr. Patel, my both heels are broaden. Does it cause walking, running, yoga etc ? Boadening of heel is due to calcaneal fracture leading to loss of calcaneal height and alters the biemechanoics of foot, puts more strain on ankle and foot leading to pain over foot/ankle. 10. Lastly most important, will my condition improve or it will remain for lifetime this question can only be answrerd after physical examination and investigation to know if there is more scope for increased moveemnt or not. I hope your queries are answered, if there is anything else, feel free to discuss. Regards

Answer 11

Hello, Here are the answers to your questions 1) Which type of calcaneal fracture is it? I mean is it undisplaced, displaced, open, close or comminuted. Is it same in both legs ? The intensity of injury is equal in both legs. Is this fracture is severe or normal ? Is it curable or not ? From the current x-ray, there is subtalar joint sclerosis with increased angle of Gissane indicating healed displaced intraarticular fracture calcaneum now arthritis of the subtalar joint has ensued. Intensity is almost similar in both feet with left side a little more affected as compared from the right side. Fracture has already healed. 2) After seeing the X-Ray, What do you think surgery is needed or not ? Can you also diagnose ligaments and tendons injury after seeing the X-Rays ? In legs, I feel stiffness, is it because of ligaments or tendon injury or soft tissue injury ? Ligament or tendon injury cannot be diagnosed from x-ray, your stiffness in ankles is due to arthritis of the subtalar joint. 3)Dr. Patel is very senior doctor in Ahmedabad (37 Years of experience). He simply told for toe-walking. Except toe-walking, he did not anything about physiotherapy. By toe-walking, your ankle movements are preserved. You had gone to him late, you had an injury in July and by November when you visited him, the fracture is already healed and is starting to consolidate, your ankle movements at subtalar joint were already lost, surgery is not indicated at that stage so the only thing left to do is toe-walking. 4) I am doing squatting and quadriceps exercise as per your guidance. I have purchased a bicycle. And wherever I need to go I use a bicycle, does it help in improving. I also do ROM exercises. Squatting and Quadriceps exercises will prevent atrophy of the lower limb musculature commonly seen after bilateral lower limb injury. 5) You said in one reply “Swelling is not the cause of pain and neither it is related to pain nor does it affect the range of motion of ankle joint or knee joint.”. But I am still getting pain while raising the heel and trying to stand on toes. And pain is on the swollen area. ( I have attached pictures of my both ankles.) You have arthritis of the subtalar joint giving rise to pain and synovitis (inflammation of synovium; appears as swelling). So your pain is related to arthritis rather than swelling, it is a co-existent finding. 6) When I walk there is very mild limping in my right foot. I can feel it but people cannot see it. For them, I am walking normally. What should I do to remove this mild limping ? Due to arthritis there you feel pain/mild limping, but on walking on even surface subtalar joint movements don't come in action so the gait is grossly normal or there is a subtle change in gait which requires gait examination, before making a comment on that. 7)Do you agree with Dr. Patel’s line of treatment or you will recommended any medicine ? I totally agree with the treatment prescribed and won't add anything. Only medication required at present is a painkiller SOS ( on severe/unbearable pain) 8) Lastly Will I ever be OK or these effects of injury will be life-long after seeing X-Ray ? I want to do Yoga Therapist Course next year. Will I be able to achieve that condition where I can do it ? Arthritis of the subtalar joint is a permanent sequela of the injury, sorry to say but this will stay lifelong and slowly progress with time. It will be difficult to perform pain-free yoga movements, the only examination can determine which movements are lost or partially reduced and whether they can affect your yoga postures or not, in physical consultation with you. This cannot be evaluated over online consultation. I hope all answers are up to your satisfaction level and wish you a good health. Regards

Answer 12

Hello, I'm sorry if you feel my words as disappointing but I speak what is correct, I will never speak false appeasing statements to make patients happy. Some time back when I said your condition will improve with time, you were not able to walk without limping, not able to cycle. Now, you are walking without limp, able to do cycling, climb stairs, run small distances. That is improvement. This is first time current Xrays are shown, previously I have given my comments on xray taken after injury and the clinical examination notes provided. From my first reply I have made it clear subtalar joint movements are affected. If in present xray there is arthritis of the joint, I will mention it. Arthritis is a progressive disease, which will progress and cannot revert back to normal. You have suffered an injury and there are consequences of it, some are temporary while other are permanent. As a doctor I can advice regarding treatment options and explain prognosis, I can't undo the damage the injury has done. Regards

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