A dislocated heel typically refers to a subtalar dislocation, which involves the simultaneous separation of the talocalcaneal and talonavicular joints within the rear portion of the foot, known as the hindfoot. While possible, this type of injury is rare and highly severe, representing only about 1% to 2% of all dislocations in the body. The foot is inherently stable, held together by strong ligaments and a tight joint capsule. Therefore, a dislocation can only occur when extreme force overcomes these natural restraints.
Recognizing the Signs of a Dislocated Heel
The immediate aftermath of a subtalar dislocation is marked by severe, unmistakable symptoms that demand emergency medical attention. The most obvious indicator is intense, immediate pain in the foot and ankle area, making any attempt at movement unbearable. This pain is coupled with an inability to put any weight on the affected foot, making walking or standing nearly impossible.
A visible deformity is almost always present, where the foot appears grossly misaligned or crooked. This deformity is often a medial displacement, which gives the foot an “acquired clubfoot” appearance. Rapid and significant swelling and bruising occur almost immediately due to extensive soft tissue damage.
The skin around the area may appear stretched or “tented” over the displaced bone fragments, which can quickly lead to tissue damage if the joint is not realigned promptly. The severe trauma can also cause neurological symptoms, such as numbness or tingling in the foot, signaling potential nerve or blood vessel damage. Medical assessment must immediately check pulses and sensation to ensure blood flow remains intact.
Common Causes and Injury Mechanisms
The rarity of a heel dislocation underscores the powerful trauma required to destabilize the subtalar joint. This injury typically results from high-energy mechanisms, such as motor vehicle accidents or a fall from a significant height. In these scenarios, the body’s weight and momentum are channeled through the foot upon impact.
The specific mechanism often involves the foot being forcefully twisted while planted in a plantar-flexed position. Medial dislocations, the most frequent type, usually occur from a powerful inversion (inward turning) of the foot. This inversion force tears the ligaments and forces the foot to pivot around the talus.
Lateral dislocations are less common and require a high-energy eversion (outward turning) force. These are often associated with open injuries where the bone breaks through the skin. The trauma must overcome the strong interosseous talocalcaneal ligament and surrounding soft tissues that provide tremendous stability to the hindfoot.
Medical Assessment and Diagnosis
Medical professionals must act quickly to assess and diagnose a suspected heel dislocation, prioritizing the patient’s overall trauma status. The initial physical examination focuses on evaluating the limb for neurovascular compromise, checking for adequate sensation and confirming the presence of pulses in the foot. Skin integrity is also carefully checked for signs of tenting or open wounds, which dramatically change the urgency and treatment plan.
Imaging is necessary to confirm the diagnosis and determine the extent of the injury. Standard X-rays, taken from multiple angles, are the first line of defense, clearly showing the loss of normal alignment between the talus and the calcaneus or navicular bones. These images also help to identify any associated fractures, which occur in a high percentage of cases.
A Computed Tomography (CT) scan is often performed after the joint has been realigned, or if initial X-rays are difficult to interpret due to gross deformity. The CT scan provides a detailed, three-dimensional view of the bones and joint surfaces. This is instrumental in identifying small fractures or pieces of bone and soft tissue that may be blocking the joint from being reduced, which is crucial for planning surgical intervention.
Treatment Options and Recovery Outlook
Closed Reduction
The immediate goal in treating a subtalar dislocation is an urgent, closed reduction, which involves manually realigning the bones back into their correct anatomical position. This procedure is performed as quickly as possible, often under sedation or general anesthesia to relax the powerful calf muscles. Prompt reduction is necessary to relieve pressure on the stretched skin, prevent tissue necrosis, and restore normal blood flow to the foot.
The technique generally involves applying gentle, continuous inline traction to the foot and heel while the knee is flexed. The physician attempts to reverse the mechanism of injury to guide the displaced bone back into the joint socket. Post-reduction X-rays are immediately taken to confirm successful realignment and ensure no new fractures occurred during the process.
Open Reduction and Fixation
If the closed reduction fails, or if soft tissue (such as a tendon or joint capsule) is trapped within the joint space, an open reduction is required. This surgical procedure involves making an incision to access the joint, remove any blocking structures, and secure the bones in place. Surgery is also necessary if the dislocation is open (bone piercing the skin) or if associated unstable fractures require internal fixation with plates or screws.
Immobilization and Rehabilitation
Following a successful reduction, the foot is immobilized in a non-weight-bearing cast or splint, typically for four to eight weeks, allowing torn ligaments and soft tissues to begin healing. Some studies suggest that earlier mobilization, sometimes after only two to four weeks for uncomplicated cases, may lead to better long-term range of motion.
The recovery outlook is guarded due to the severity of the initial injury, and the timeline is long. Total recovery, including the full course of physical therapy, can take many months with a gradual progression to full weight-bearing. Physical therapy focuses on regaining range of motion in the foot and rebuilding strength in the supporting musculature.
Long-Term Complications
Long-term complications are common following this high-energy joint trauma. The most frequent issue is post-traumatic arthritis, affecting 50% to 80% of patients due to damage to the joint cartilage sustained during the dislocation. Patients also often experience significant stiffness and chronic pain because of the extensive ligamentous injury and subsequent scarring. Those with high-energy dislocations, particularly the lateral type, generally have a more challenging prognosis.