M u s c u l o s k e l e t a l I m a g i n g R ev i ew

Calcaneal Avulsion Fractures: An

Often Forgotten Diagnosis
Sarah M. Yu1
Joseph S. Yu

American Journal of Roentgenology 2015.205:1061-1067.

Yu SM, Yu JS

OBJECTIVE. The calcaneus is the primary weight bearing bone in the heel, and its many
surface contours render it a relatively difficult bone to visualize in its entirety. The stabilizing ligaments that hold the calcaneus in place occupy very specific locations, and the Achilles tendon enthesis is in a relatively constant location; therefore, avulsion fractures occur in
reproducible locations.
CONCLUSION. The mechanisms of injuries include overuse and neuropathic conditions, although most cases are related to trauma.

Keywords: avulsion, calcaneus, foot, fracture, ligament,

plantar fascia, tendon
DOI:10.2214/AJR.14.14190
Received November 24, 2014; accepted after revision
December 29, 2014.
1
Both authors: Department of Radiology, The Ohio State
University Wexner Medical Center, 395 West 12th Ave,
Ste 481, Columbus, OH 43210. Address correspondence
to J. S. Yu (Joseph.yu@osumc.edu).

AJR 2015; 205:10611067

0361803X/15/20561061
American Roentgen Ray Society

he calcaneus is the largest bone in

the foot and serves as the primary
weight bearing structure in the
heel. It is the initial striking surface of the foot during ambulation. The morphologic features of this bone are complex,
and its many different surface contours function either as attachments to tendons, muscles,
and ligaments or as sites of articulations. From
a radiographic perspective, the calcaneus is a
relatively difficult bone to visualize in its entirety. However, radiography remains the principal imaging modality for evaluating trauma
to the calcaneus, the most frequently fractured
tarsal bone. Most injuries are caused by highenergy trauma that result in intraarticular fractures [1]. However, 25% of fractures in adults
are extraarticular, and the incidence is even
higher in children [2, 3]. More than 90% of
calcaneal fractures are extraarticular in children younger than 7 years, and 60% of such
fractures are extraarticular in children 814
years old [4]. Extraarticular fractures are categorized as either compressive or avulsive
types. Of the two types, avulsion fractures
generally are more difficult to identify but are
quite specific in their locations. In this article,
we will show the characteristic appearance
and location of these fractures, discuss the
mechanisms responsible for these injuries, and
illustrate potential pitfalls to consider.
Normal Anatomy
The calcaneus is a relatively long tarsal
bone that has the shape of a pistol grip (Fig.
1). The bulbous proximal end is the calcane-

al tuberosity, and it serves as the attachment

of the Achilles tendon. It has two smaller inferior tubercles, the medial and lateral processes. The anterior part of the calcaneus is
tapered distally. Superiorly, there are three
articular facets covered by hyaline cartilage.
These facets are oriented in slightly different geometric planes and articulate with the
inferior aspect of the talus to form the anterior, middle, and posterior subtalar joints.
The posterior talar facet has a triangular
shape and a convex contour and is the largest of the three facets. Distal to the posterior
subtalar joint is a depression called the calcaneal sulcus that extends medially to terminate at the sustentaculum tali. The middle
talar facet is an inclined oval surface on the
roof of the sustentaculum. The smaller ovalshaped anterior facet lies on the superomedial surface of the anterior calcaneus. Occasionally, the middle and anterior subtalar
joints form a contiguous articulation instead
of two discrete joints. Medially, the calcaneus is concave and relatively smooth. The flexor hallucis longus tendon courses in a groove
underneath the sustentaculum tali. Laterally,
the calcaneus has two protuberances. At the
midbody level, a small prominence marks
the attachment of the calcaneofibular ligament. The fibular (peroneal) trochlea is a
bony prominence in the inferior and anterior aspect of the lateral calcaneus that serves
to separate the peroneal longus and brevis
tendons. Anteriorly, the calcaneus is entirely covered with cartilage forming the surface
that articulates with the cuboid.

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Yu and Yu
Sites of Vulnerability
Achilles TendonPosterior Surface of the
Calcaneal Tuberosity
The Achilles tendon is the strongest tendon in the body and has an average length
of 15 cm. It begins at the midcalf level and
it receives muscular fibers from three muscles: the medial and lateral heads of the gastrocnemius and the soleus muscles. Distally,
the tendon has a concave anterior and convex posterior surface tapering to its broad enthesis on the calcaneus located at the middle
third of the posterior surface of the calcaneal tuberosity. The width of the tendon at its
insertion varies from 1.2 to 2.5 cm [5]. The
tendon has a coiled collagen fiber pattern
that spirals about 90 before its attachment
[6]. This configuration gives it the viscoelasticity that allows it to absorb and adapt to
forces that can approach 612.5 times body
weight during running [7, 8].
Avulsion fractures of the calcaneal tuberosity are uncommon, accounting for 1.32.7%
of calcaneal fractures [9]. Fractures of the tuberosity are either from an avulsion or shearcompression mechanism of injury, with the
latter constituting most fractures. Avulsion
may occur from sudden tension on the Achilles tendon from falling on a plantarflexed foot
when the calf muscles are actively contracted,
hyperextension of the ankle, or while pushing
off a dorsiflexed foot such as in a sprinter beginning a race. There are four types of avulsion fractures (Fig. 2): type 1, simple avulsion
with a variable-sized bone fragment (Fig. 3);
type 2, beak fracture with a horizontal fracture extending into the posterior body; type
3, infrabursal avulsion by the superficial fibers of the middle third of the Achilles tendon (Fig. 4); and type 4, small beak fracture
avulsed from the deep fibers of the tendon [9,
10]. Type 1 fractures are likely insufficiency
fractures, occurring in elderly patients with
osteoporosis after minor trauma such as tripping. In part, this is likely related to the regional vascular anatomy of the calcaneus [11].
In type 2 beak fractures, the tendinous attachment is more proximal than classically seen
so that the avulsion involves only the proximal half of the tuberosity or because there is
a separate more anterior contribution to the
Achilles tendon by the soleus muscle [12,
13]. Types 3 and 4 fractures occur in younger
people and require more-severe trauma. The
cause is strong muscular contraction with the
heel fixed to the ground and occurs only in a
subset of patients who have a broad and extensive tendinous insertion [9].

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An important pitfall is a neuropathic avulsion fracture of the tuberosity in a patient

with long-term diabetes mellitus [13]. In
these patients, the fracture occurs without a
history of significant trauma or overuse activity. The primary fracture line is parallel to
the apophyseal scar, and the fracture affects
the superior cortex but not always the inferior cortex. The fracture also tends to extend
posteriorly with a horizontal component immediately distal to the enthesis of the Achilles tendon [14]. When the fracture is imaged
sequentially, distraction and fragmentation are common later findings. Neuropathic fractures are important because they have
a much higher incidence of infection, nonunion, malunion, and failure of fixation and
require a much longer time to heal than nonneuropathic insufficiency fractures. Another
pitfall occurs in children. A Salter 3 fracture
of the apophysis in a skeletally immature patient may mimic Sever disease when it is not
significantly displaced [15].
Plantar FasciaMedial Process of the
Calcaneal Tuberosity
The plantar fascia is a dense connective
tissue band that resides in the inferior aspect
of the foot and is composed of three cords:
medial, central, and lateral cords. Biomechanically, the central cord is the most important component of the plantar fascia. It
arises from the medial process of the calcaneal tuberosity and extends distally in a
fanlike configuration, dividing into five distinct bands that interconnect with the plantar
plates, plantar interdigital ligaments, and the
sagittal septa underneath the metatarsophalangeal joints [1618]. The fibers of the central cord envelop the aponeurosis of the flexor digitorum brevis muscle. The lateral cord
arises from the lateral margin of the medial
process and extends to the cuboid and base
of the fifth metatarsal bone, enveloping the
aponeurosis of the abductor digiti minimi
muscle. The medial cord is very thin and invests the abductor hallucis muscle.
Conditions in the fascia that produce pain
in the heel can be attributed to either plantar
fasciitis or fascial rupture. Plantar fasciitis is
the most common cause of heel pain, a degenerative process that results in fibrofatty degeneration, microtears, and collagen necrosis in
the fascial enthesis. A rupture of plantar fascia is far less common but is characterized
clinically by severe focal pain inferior to the
calcaneus that is associated with tenderness
to palpation and an acute onset [19, 20]. Frac-

tures in the medial process of the calcaneus

may occur as a result of compressive or tensile
forces. The vast majority of fractures are due
to compressive mechanisms such as striking
the heel against a ledge or from a fall from a
height so that the resulting fracture may herald a more complex fracture. Although rare,
an avulsion of the medial plantar process may
occur when forceful tension on the plantar
fascia enthesis occurs during falling from a
height while landing on the tips of the toes,
from forceful contraction of the Achilles tendon against a static long plantar ligament, or
from violent contraction of the abductor hallucis muscle by forced dorsiflexion of the first
ray [21, 22]. The characteristic radiographic
appearance is a small fleck of bone separated from the donor site in the inferior surface
of the calcaneal tuberosity or a break in the
medial process cortex (Fig. 5). Bone lysis at
the enthesis may be the only finding in many
cases (Fig. 6). A pitfall is a fracture through a
plantar fascia enthesophyte, which may occur
as a result of either direct trauma or forceful
tension on the plantar fascia.
Bifurcate LigamentAnterior Calcaneal Process
The anterior calcaneal process is a bony
promontory in the anterolateral aspect of the
calcaneus bordered distally by the navicularcuboid articulation and proximally by the
sinus tarsi. It forms the anterior facet superiorly and the calcaneocuboid joint anteriorly. The proximal attachment of the bifurcate
ligament, an important stabilizer in plantar
and dorsal flexion of the ankle, attaches to
this process. The Y-shaped ligament with its
two components, the calcaneonavicular and
calcaneocuboid limbs, is at its greatest tension when the ankle is inverted and plantar
flexed [23]. Fractures involving the anterior process are not as common as other fractures in the ankle but they are not rare, occurring in as many as 5% of patients with
ankle fractures [2426]. Patients complain
of swelling and dorsolateral pain over the sinus tarsi region. Because these fractures may
be extremely difficult to detect, either CT or
MRI is required to confirm the diagnosis in
many cases, particularly when pain becomes
chronic [23, 27, 28]. About half of these
fractures are radiographically occult even
when confirmed on MRI, whereas as many
as 6% of radiographically evident fractures
in adults are misdiagnosed as ankle sprains
[23]. Reportedly, the percentage of unrecognized fractures in children is three to four
times higher [4].

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Calcaneal Avulsion Fractures

The two mechanisms of injury that result in
a fracture of the anterior calcaneal process are
compression or impaction forces and extreme
tensile forces [29]. A compressive fracture occurs by impaction of the anterior process from
the cuboid and talus during eversion and dorsiflexion, which is referred to as a nutcracker lesion, or by forceful abduction of the forefoot with the heel fixed to the ground [30, 31].
An avulsion fracture is caused by tension on
the bifurcate ligament during forceful inversion and plantar flexion of the foot. In fact, this
fracture constitutes the most common avulsion
fracture affecting the calcaneus [26]. In general, impaction fractures tend to be larger than
avulsion fractures. These fractures are important because they have a strong association
with other foot abnormalities, such as rupture
of the anterior talofibular ligament, other tarsal fractures, and injuries of the peroneal tendons [29, 32]. A lateral radiograph of the ankle offers the most optimal opportunity for
identifying the fracture, which characteristically appears vertically through the process
(Fig. 7). Careful scrutiny of the cortex is necessary for making the diagnosis. If the lateral view is equivocal, an oblique projection of
the foot may be diagnostic [24]. Anterior process fractures are classified into three types:
type 1 fractures are small (<1 cm) and nondisplaced, type 2 fractures have minimal (>2
mm) displacement and no involvement of the
calcaneocuboid joint, and type 3 fractures are
comminuted or large with involvement the calcaneocuboid joint (>25%) [31]. Types 1 and
2 fractures usually are avulsive, whereas most
type 3 fractures are compressive. A pitfall is a
normal small ossicle, the os calcaneus secondarius, which is adjacent to the anterior calcaneal process mimicking this fracture; however,
these ossicles, which are seen in about 25% of
the population, are completely surrounded by
lamellar bone [33, 34] (Fig. 8).
Extensor Digitorum Brevis Muscle
Dorsolateral Anterior Calcaneus
An important calcaneal fracture is an avulsion of the origin of the extensor digitorum brevis (EDB) muscle [24, 32]. The EDB muscle
is broad and thin. The lateral segments course
distally to insert on the middle phalanges of the
second through fourth toes, whereas the most
medial segment forms the extensor hallucis
brevis. The function of this muscle is to extend
the first through fourth toes and the respective
metatarsophalangeal joints. Forced inversion of
the foot is considered the mechanism of injury
so that the EDB is rapidly stretched beyond its

physiologic limits resulting in a tear of the muscle along with an avulsion fracture [32]. The
fracture is best depicted on the anteroposterior
projection of the ankle or the frontal projection
of the foot, and it characteristically appears as
variably sized fragments of bone arising from
the dorsolateral aspect of the anterior calcaneus (Fig. 9). Patients with this fracture present
with pain and swelling in the dorsolateral midfoot that is similar to those who have an anterior calcaneal process fracture.
One pitfall is that an avulsion fracture of
the attachment of the calcaneofibular ligament occasionally may appear similar on
the anteroposterior ankle radiograph, but the
fracture fragment appears more posteriorly
located on the frontal radiograph of the foot
and is usually smaller. The EDB avulsion
fracture may also be mistakenly identified as
an os peroneum, but the latter resides more
inferiorly and is completely corticated. Occasionally, the fibular trochlea may present
with a separated ossification center appearing similar to a fracture on an ankle radiograph but appearing completely corticated
on a frontal foot radiograph [35].
Calcaneocuboid LigamentDistal
Anterolateral Cortex
The calcaneocuboid joint is a large lateral
joint in the midfoot. A joint capsule invests
the joint cavity, and it is stabilized superiorly
by the calcaneocuboid limb of the bifurcate
ligament, laterally by the dorsal (dorsolateral) calcaneocuboid ligament, and inferiorly by
the plantar calcaneocuboid ligament and the
long plantar ligament [3638]. The structural integrity of these ligaments as well as the
plantar fascia is necessary for proper function
of the calcaneocuboid joint [39]. Once considered rare, avulsion fracture occurring at the
calcaneocuboid joint is an important cause
of persistent pain in the lateral aspect of the
foot [40]. The margins of this joint should be
closely inspected for fractures in patients who
have an inversion or plantar flexion injury of
the foot or forced adduction injury of the forefoot. Clinically, lateral foot pain over the calcaneocuboid joint and focal soft-tissue swelling occurring proximal to the fifth metatarsal
are characteristic clinical findings. Maneuvers that adduct the forefoot exacerbate pain.
Most avulsion fractures occur at the attachments of the dorsal calcaneocuboid ligament
(Fig. 10). Andermahr et al. [38] classified
these injuries into four types depending on the
size of fracture and angulation of the calcaneocuboid joint with stress: type 1, no fracture

and an increased angle by 510; type 2, occasional fracture flake and angulation greater than 10; type 3, osseous fragment greater
than 5 mm and angulation greater than 10;
and type 4, compression fracture of medial cuboid and major joint distraction. Frontal
and oblique foot radiographs, not ankle radiographs, are most optimal for showing these
fractures, which characteristically appear as
variably small linear cortical fragments that
rotate when the joint distracts. MRI may be
necessary to confirm the diagnosis (Fig. 11).
A potential clinical pitfall is a stress fracture of the lateral aspect of the cuboid [41].
Another clinical and radiographic pitfall
may be a small avulsion fracture of the EDB
insertion; however, in our experience, even
small EDB fracture fragments contain more
bone than just the cortex so they do not have
the typical linear appearance of a calcaneocuboid ligament avulsion fracture.
Conclusion
Avulsion fractures of the calcaneus are often difficult to diagnose, but they occur in
very specific locations, with characteristic radiographic appearances. A systematic evaluation of the calcaneus with attention to areas
of vulnerability will assist those who interpret
ankle and foot radiographs in maintaining a
high diagnostic accuracy for these fractures.
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(Figures start on next page)

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Fig. 1Calcaneal anatomy. Diagram depicts key

anatomic components of calcaneus in lateral,
superior, and medial projections. FHL= flexor hallucis
longus. (Drawings by Yu JS)

Calcaneal Avulsion Fractures

American Journal of Roentgenology 2015.205:1061-1067.

Fig. 2Classification for calcaneal avulsion fractures. Type 1 is simple avulsion

with variable sized bone fragment, type 2 is beak fracture with horizontal fracture
extending into posterior body, type 3 is avulsion by superficial fibers of middle third
of Achilles tendon, and type 4 is small beak fracture avulsed from deep fibers of
tendon. (Drawings by Yu JS. Adapted with permission from Lee et al. [9])

A
Fig. 359-year-old man with type 1 calcaneal
avulsion fracture who felt pop and acute posterior
heel pain. Lateral radiograph shows superiorly
displaced bone fragment (curved arrow) and donor
site defect in superior aspect of calcaneal tuberosity
(straight arrow).

Fig. 443-year-old man who fell off horse and experienced pain and bruising in back of ankle.
A, Postsplint radiograph obtained 2 days after injury depicts ossific fragment (arrow) in Achilles tendon
approximately 5 cm above enthesis.
B, Sagittal T1-weighted MR image obtained 6 weeks after injury shows thickened Achilles tendon. There is
heterogeneous signal intensity within tendon and focus of low signal intensity (straight arrow) approximately 5
cm above enthesis. Defect in tubercle was similar in size to avulsed fragment (curved arrow) and likely its source.

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Yu and Yu

Fig. 5Images of medial plantar process.

A, Frontal 3D CT image of calcaneus in cadaver
shows shelflike prominence of medial plantar
process (arrow) where central and lateral cords of
plantar fascia inserts.
B, 27-year-old male baseball player with acute heel
pain after pushing off base while accelerating.
Lateral radiograph shows linear break in medial
plantar process (arrow).

American Journal of Roentgenology 2015.205:1061-1067.

Fig. 645-year-old woman who felt ripping

sensation in bottom of her ankle 2 weeks ago.
A, Lateral radiograph shows fracture (straight arrow)
through enthesophyte emanating from medial plantar
process. Note saucerlike defect in inferior aspect of
calcaneus from bone lysis (curved arrow).
B, Sagittal STIR MR image shows avulsion of central
cord of plantar fascia with perifascicular edema (arrow)
as well as bone edema surrounding bone defect.

A
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Fig. 725-year-old man who fell while skiing.

A, Lateral radiograph shows linear lucency (arrow)
through anterior calcaneus process corresponding to
type 2 fracture.
B, Oblique view of foot affords another opportunity to
identify fracture (arrow).

Fig. 8Type 1 fracture versus os calcaneus

secundarius in two patients.
A, 22-year-old man who sustained fracture during
football game. Sagittal T1-weighted MR image shows
small fragment of bone (straight arrow) arising from
anterior calcaneus process corresponding to type
1 fracture. Portion of bifurcate ligament is shown
(curved arrow).
B, 30-year-old man who did not have trauma. Oblique
view of foot shows incidental ossicle (arrow) located
between calcaneus, talus, navicular, and cuboid that
mimics type 1 anterior process fracture. This ossicle
is referred to as os calcaneus secundarius and is
differentiated from fracture by lack of donor site in
calcaneus.

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Calcaneal Avulsion Fractures

American Journal of Roentgenology 2015.205:1061-1067.

Fig. 932-year-old female tennis player who

inverted her foot and had dorsolateral bruising in
foot.
A, Ankle radiograph shows rotated fragment of bone
(arrow) with adjacent soft-tissue swelling that is
characteristic of avulsion of attachment of extensor
digitorum brevis muscle.
B, Foot radiograph shows that fragment of bone
(arrow) is located in dorsal and lateral region of
anterior calcaneal body.

Fig. 1021-year-old male basketball player who

inverted his foot and had pain laterally.
A, Close-up of oblique view of foot shows linear piece
of bone (arrow) just proximal to calcaneocuboid joint.
B, Axial CT image shows that avulsion fracture
(oval) corresponds to proximal attachment of dorsal
calcaneocuboid ligament.

Fig. 1128-year-old male hockey player with

twisting injury.
A, Frontal radiograph shows swelling in lateral
foot with its epicenter just proximal to base of fifth
metatarsal bone (straight arrow). There is small linear
bone fragment located lateral to calcaneocuboid joint
(curved arrow).
B, Axial proton-density MR image shows that
avulsion occurred distally at cuboid attachment
manifested as gap (arrow) between ligament and
cuboid. Proximal aspect of ligament can be visualized
to its calcaneal attachment.

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