Is crutch use necessary for a 21-year-old male with ankle pain and calcaneal tenderness post MVC, who is weight-bearing with a boot?

Crutches Are Not Necessary for This Patient

For a 21-year-old male with ankle pain and calcaneal tenderness post-MVC who is already weight-bearing in a boot, crutches are not required. The patient is already demonstrating the ability to bear weight, which is the key functional criterion that determines the need for assistive devices.

Clinical Reasoning Based on Ottawa Ankle Rules

The decision to use crutches should be guided by the Ottawa Ankle Rules (OAR), which are validated tools for determining the need for imaging and, by extension, the severity of injury 1:

• If the patient can bear weight immediately after injury and ambulate 4 steps, radiographs are not indicated unless there is point tenderness over specific bony landmarks 1
• Your patient is already weight-bearing in a boot, which demonstrates functional capacity beyond the OAR threshold 1
• The OAR have high accuracy for ruling out fractures and can guide clinical decision-making about weight-bearing restrictions 1

Weight-Bearing Status and Assistive Devices

The evidence on weight-bearing after ankle injury supports your current approach:

• Early weight-bearing (within 3 weeks) leads to better ankle function compared to delayed weight-bearing, with no increased risk of complications 2
• Early weight-bearing probably improves outcomes in the first six months after ankle injury, though the difference may be small 2
• There is no increased re-operation risk with early weight-bearing (RR 0.50,95% CI 0.09 to 2.68) 2

When Crutches Would Be Indicated

Crutches or other assistive devices are recommended in specific circumstances that do not apply to your patient:

• Inability to bear weight immediately after injury 1
• Inability to ambulate 4 steps in the emergency department 1
• Confirmed fracture requiring protected weight-bearing during healing 1
• Severe pain limiting ambulation despite immobilization 3

The Role of the Boot

A removable ankle support (boot) provides adequate immobilization and protection:

• Removable ankle supports lead to better ankle function (MD 6.39,95% CI 1.69 to 11.09) compared to non-removable supports after surgery 2
• They probably improve health-related quality of life with no increased re-operation risk 2
• Below-ankle devices provide adequate support for most ankle injuries when fracture has been excluded 3

Important Caveats

Reassess if clinical status changes 1:

• If pain significantly worsens or new inability to bear weight develops, re-evaluate for occult fracture 3
• Reexamine 3-5 days post-injury if initial examination was limited by swelling, as excessive swelling within 48 hours can obscure findings 3
• If pain persists beyond 1-3 weeks with negative radiographs, consider advanced imaging (MRI or CT) to exclude occult fracture or osteochondral injury 1, 3

Stress fractures may not be initially visible on radiographs and symptoms often precede radiographic findings 3. However, your patient's mechanism (MVC) and acute presentation make stress fracture unlikely.

Monitor for complications of prolonged immobilization including muscle weakness, atrophy, and contralateral limb pain from altered gait mechanics 1. The boot allows for earlier mobilization compared to casting, reducing these risks.