Heel Dislocation: Types, Symptoms, Treatment, and Prevention

Is it possible to dislocate your heel?

Yes, while a true, isolated dislocation of the calcaneus (heel bone) is exceedingly rare due to its robust anatomical support, it is possible for the bones surrounding the heel to dislocate, most commonly in the form of a subtalar dislocation.

Understanding the Heel and Ankle Anatomy

To understand the possibility of a "heel dislocation," it's crucial to first grasp the anatomy of the foot and ankle. The "heel" primarily refers to the calcaneus, the largest bone in the foot. This bone is a critical component of the ankle and foot complex, serving as a foundation for weight-bearing and locomotion.

The calcaneus forms joints with two primary bones:

• Talus: Superiorly, the calcaneus articulates with the talus, forming the subtalar joint. This joint is crucial for inversion and eversion movements of the foot, allowing us to adapt to uneven terrain.
• Cuboid: Anteriorly, the calcaneus connects with the cuboid bone, forming the calcaneocuboid joint, part of the midtarsal (Chopart's) joint line.

The entire ankle and foot structure is reinforced by an intricate network of strong ligaments, tendons, and muscles, providing remarkable stability and limiting excessive motion.

The Nature of a Dislocation

A dislocation is defined as the complete separation of two bones that normally form a joint, resulting in a loss of their normal anatomical alignment. This injury typically involves significant damage to the joint capsule and surrounding ligaments that hold the bones together. While some joints, like the shoulder, are inherently more prone to dislocation due to their shallow socket and wide range of motion, others, like those in the foot, are designed for high stability.

Can the Calcaneus (Heel Bone) Dislocate?

While the term "dislocate your heel" might suggest the calcaneus completely separating from all its surrounding bones, a true, isolated dislocation of the calcaneus from both the talus and cuboid is extraordinarily rare. The immense forces required to achieve this would almost invariably result in multiple fractures of the calcaneus or surrounding bones before such a pure dislocation could occur.

However, a more common, though still uncommon, "heel-related" dislocation is a subtalar dislocation.

• Subtalar Dislocation: This is the most prevalent form of dislocation involving the heel region. It refers to the dislocation of the talus from the calcaneus and the navicular bone, while the ankle joint (talocrural joint) itself remains intact.

  • Mechanism: Subtalar dislocations typically result from high-energy trauma, such as falls from significant heights, motor vehicle accidents, or severe twisting injuries during sports. The foot is often forcefully inverted or everted, causing the talus to displace from the calcaneus and navicular.
  • Types: Subtalar dislocations are classified based on the direction of the foot's displacement relative to the talus. The most common types are:
    • Medial dislocation: The foot displaces medially (inward) and is usually caused by a strong inversion force.
    • Lateral dislocation: The foot displaces laterally (outward) and is typically caused by a forceful eversion injury.
    • Less common types include anterior and posterior dislocations.
  • Associated Injuries: Due to the high forces involved, subtalar dislocations frequently occur with associated injuries, including:
    • Fractures of the talus, calcaneus, or malleoli (ankle bones).
    • Extensive ligamentous tears.
    • Damage to surrounding soft tissues.

• Calcaneocuboid Dislocation: While exceptionally rare in isolation, dislocation of the calcaneocuboid joint is theoretically possible but almost always occurs in conjunction with other severe foot injuries, such as a Chopart's fracture-dislocation (dislocation through the midtarsal joint line).

Why True Calcaneal Dislocation is Rare

The extreme rarity of an isolated calcaneal dislocation, or even a pure subtalar dislocation, is attributed to several anatomical and biomechanical factors:

• Strong Bony Congruence: The shapes of the talus, calcaneus, and cuboid bones provide a high degree of inherent stability, with interlocking surfaces that resist displacement.
• Robust Ligamentous Support: The joints around the calcaneus are heavily reinforced by numerous strong ligaments, including:
  • The interosseous talocalcaneal ligament (a very strong ligament within the subtalar joint).
  • The calcaneofibular ligament.
  • The deltoid ligament complex (medially).
  • The spring ligament (plantar calcaneonavicular ligament), which supports the arch.
  • The bifurcate ligament.
  • These ligaments act as strong tethers, making dislocation without ligamentous rupture or bone fracture highly improbable.
• Surrounding Musculature and Retinacula: The tendons of various muscles (e.g., peroneal, tibialis posterior) and their retinacula (bands of connective tissue) further stabilize the foot and ankle, adding another layer of protection.
• Energy Absorption: The foot and ankle are designed to absorb significant impact forces. In high-energy trauma, these forces are more likely to result in bone fractures (which dissipate energy) rather than clean dislocations of highly stable joints.

Symptoms and Diagnosis

If a subtalar dislocation or other severe foot dislocation occurs, symptoms are typically dramatic and include:

• Severe pain: Immediate and intense pain around the ankle and foot.
• Obvious deformity: The foot will appear significantly misshapen, often displaced medially or laterally relative to the leg.
• Swelling: Rapid and extensive swelling.
• Inability to bear weight: It will be impossible or excruciatingly painful to put weight on the injured foot.
• Skin compromise: In severe cases, the skin may be tented, blanched, or even broken, indicating an open dislocation, which is a medical emergency due to increased infection risk.

Diagnosis is typically made through a physical examination, which reveals the characteristic deformity. X-rays are essential to confirm the dislocation and identify any associated fractures. A CT scan is often crucial for a detailed assessment of the bony alignment, identifying subtle fractures, and planning treatment, especially given the complex anatomy of the hindfoot.

Treatment and Rehabilitation

A dislocated heel (subtalar dislocation) is a medical emergency requiring prompt attention to prevent complications.

• Emergency Reduction: The primary goal is to reduce (realign) the dislocated joint as quickly as possible. This is usually performed under sedation or general anesthesia in an emergency room setting. The manipulation involves specific maneuvers to guide the talus back into its correct position relative to the calcaneus and navicular.
• Immobilization: After successful reduction, the foot and ankle are typically immobilized in a cast or walking boot for several weeks (e.g., 4-6 weeks) to allow the damaged ligaments and soft tissues to heal.
• Rehabilitation: Once the initial immobilization period is complete, a comprehensive rehabilitation program is initiated. This typically involves:
  • Pain and swelling management: R.I.C.E. (Rest, Ice, Compression, Elevation).
  • Progressive weight-bearing: Gradually increasing the amount of weight placed on the foot.
  • Range of motion exercises: Restoring flexibility to the ankle and subtalar joint.
  • Strengthening exercises: Rebuilding muscle strength in the foot, ankle, and lower leg.
  • Proprioception and balance training: Re-educating the body's sense of position and balance to prevent re-injury.
• Surgical Intervention: In some cases, surgical intervention may be necessary if:
  • The dislocation cannot be reduced by closed manipulation (open reduction).
  • There are significant associated fractures that require fixation.
  • There is instability after reduction.
• Potential Complications: Dislocation of the subtalar joint carries a risk of complications, including:
  • Avascular necrosis (AVN) of the talus: A serious complication where the blood supply to the talus is disrupted, leading to bone death.
  • Post-traumatic arthritis: Degenerative joint disease that can develop years after the injury due to cartilage damage.
  • Chronic pain and stiffness: Persistent discomfort and limited range of motion.
  • Instability: Recurrent dislocation or a feeling of giving way.

Prevention and Risk Factors

While high-energy trauma leading to a subtalar dislocation is often unpredictable, certain factors and precautions can mitigate risk:

• High-Impact Activities: Individuals participating in sports or activities with a high risk of falls or twisting injuries (e.g., football, basketball, gymnastics, trail running) are at higher risk.
• Occupational Hazards: Jobs involving work at heights or heavy machinery can increase risk.
• Proper Footwear: Wearing appropriate, supportive footwear for specific activities can help prevent ankle sprains and potentially severe dislocations.
• Strengthening and Proprioception: Regular exercises to strengthen the muscles around the ankle and improve balance can enhance joint stability.

In conclusion, while a true isolated dislocation of the calcaneus is almost unheard of, the concept likely refers to a severe injury like a subtalar dislocation. These are serious injuries requiring immediate medical attention and a dedicated rehabilitation process to optimize recovery and minimize long-term complications.