What is the best course of action for an adult patient with Achilles tendinitis pain after a fall that has not resolved after 2 weeks?

Achilles Tendinitis After Fall Not Resolving After 2 Weeks

At 2 weeks post-fall with persistent Achilles tendinitis pain, you should intensify conservative treatment with immobilization (walking boot or cast), continue NSAIDs, initiate eccentric strengthening exercises, and obtain imaging to rule out partial rupture or other structural damage. 1

Immediate Clinical Assessment

Given the traumatic mechanism (fall) and 2-week duration without improvement, you must first exclude:

• Partial Achilles tendon rupture - Palpate for focal tenderness, gaps, or asymmetric thickening; assess for weakness with single-leg heel raise 1, 2
• Calcaneal fracture - Check for diffuse heel pain and focal bony tenderness 1
• Complete but missed rupture - Test for absent plantar flexion strength and positive Thompson test 1

Imaging Strategy

Order plain radiographs now to evaluate for calcaneal avulsion fracture, spurring at the Achilles insertion, or soft tissue swelling 1. The traumatic mechanism makes this essential. 1

Consider MRI or ultrasound if radiographs are negative but clinical suspicion remains high for partial tear, as these modalities show partial tears, tendon thickening, and chronic degenerative changes with moderate-to-high sensitivity (78-95%) 1. MRI provides slightly better sensitivity and specificity than ultrasound for Achilles pathology. 2

Treatment Escalation at 2 Weeks

Since initial conservative measures have failed, the American College of Foot and Ankle Surgeons guidelines indicate you should escalate treatment before the 6-8 week mark: 1

Immobilization

• Apply a walking boot or fixed-ankle walker-type device immediately - This is specifically recommended for acute or refractory cases of insertional Achilles tendinitis 1
• Consider short-leg cast if the patient cannot comply with boot use 1
• Duration: Continue immobilization for 4-6 weeks with gradual weaning 1

Pharmacologic Management

• Continue NSAIDs (e.g., naproxen 500 mg twice daily) for pain relief, though evidence shows they provide only short-term benefit and don't alter long-term outcomes 1, 3
• Avoid corticosteroid injections into or near the Achilles tendon - These are explicitly not recommended due to risk of tendon weakening and spontaneous rupture 1

Physical Therapy Interventions

• Initiate eccentric strengthening exercises once acute pain subsides (typically after 2-3 weeks of immobilization) - This has the highest evidence-based effectiveness for Achilles tendinopathy 1, 2
• Apply cryotherapy for 10-minute periods through a wet towel for pain relief 1
• Add heel lifts (approximately 1-2 cm) to reduce strain on the Achilles insertion 1, 4

Activity Modification

• Enforce relative rest - Allow only activities that don't worsen pain; complete immobilization risks muscle atrophy 1
• Prohibit running, jumping, and hill walking until symptoms substantially improve 4

Timeline for Specialist Referral

Refer to a podiatric foot and ankle surgeon or orthopedic surgeon if:

• No improvement occurs by 6-8 weeks despite escalated conservative treatment 1
• Imaging reveals partial rupture, significant tendinosis, or insertional pathology 1
• Patient cannot tolerate immobilization or requires expedited return to high-level athletics 1, 2

The guidelines are clear that surgical intervention is reserved for patients failing 2-3 months of conservative therapy, with approximately 25% of athletes with Achilles tendon overuse injuries eventually requiring surgery. 5

Critical Pitfalls to Avoid

Do not inject corticosteroids - Despite their effectiveness for acute pain relief in other tendinopathies, peritendinous or intratendinous corticosteroid injections near the Achilles tendon reduce tensile strength and predispose to spontaneous rupture 1. This is explicitly contraindicated in the guidelines. 1

Do not allow continued athletic activity - About 75% of Achilles tendon ruptures occur during sports activities, and continued loading of an injured tendon risks progression from tendinosis to partial or complete rupture 5

Do not assume this is simple overuse tendinopathy - The traumatic mechanism (fall) increases the likelihood of structural damage requiring imaging evaluation 1

Expected Recovery Timeline

Most patients with Achilles tendinopathy recover within 3-6 months with appropriate conservative treatment (approximately 80% success rate) 1. However, the traumatic onset and 2-week lack of improvement warrant more aggressive initial management with immobilization. 1 If symptoms persist beyond 6-8 weeks despite escalated treatment, surgical consultation becomes appropriate. 1