How should I manage a 1‑month post‑MVC patient with persistent right ankle pain, heel tenderness, mild Achilles peritendinitis and deltoid ligament sprain who is in a boot—what are the options if his symptoms are better, unchanged, or worse, and should I refer?

Management of Persistent Ankle Pain 1 Month Post-MVC with Achilles Peritendinitis and Deltoid Ligament Sprain

Continue conservative management with structured physical therapy and reassess at 6-8 weeks; refer to podiatric foot and ankle surgery only if symptoms fail to improve after this period of appropriate conservative treatment. 1

Immediate Assessment at This Visit

Determine current symptom trajectory by asking specifically about:

• Pain level compared to 2 weeks ago (better, same, worse)
• Ability to bear weight and walk without the boot
• Morning stiffness and pain with first steps
• Swelling at end of day
• Ability to perform daily activities 2

Physical examination findings to document:

• Point tenderness over Achilles insertion versus lateral malleolus versus deltoid ligament course 1
• Calcaneal compression test (squeeze heel medial-to-lateral) to rule out stress fracture 1
• Anterior drawer test if not done at 4-5 days post-injury (84% sensitivity, 96% specificity for ligament rupture) 3
• Presence of lateral gutter swelling suggesting ongoing ligament inflammation 1

Management Algorithm Based on Symptom Trajectory

If Symptoms Are BETTER (Improving Pain and Function)

Continue current boot immobilization for total of 6 weeks from injury, then transition to:

• Semirigid or lace-up ankle support (superior to elastic bandages) 3
• Begin eccentric exercises for Achilles tendon 4, 5
• Calf muscle and plantar fascia stretching 3-5 times daily 4
• Proprioceptive exercises including ankle disk training to prevent chronic instability 3
• NSAIDs as needed for pain 3, 6
• Activity modification avoiding activities that worsen pain 4

Wean from boot gradually over 1-2 weeks while monitoring for symptom recurrence 6

Follow-up in 3-4 weeks to ensure continued improvement 1

If Symptoms Are THE SAME (No Improvement)

This represents failure of initial conservative treatment at 4 weeks, requiring escalation:

Immediate interventions:

• Continue boot for another 2-4 weeks 4
• Refer to physical therapy for supervised rehabilitation including:
  • Eccentric strengthening exercises (most effective for tendinopathy) 4, 5
  • Range of motion exercises 4
  • Neuromuscular facilitation 3
• Consider custom orthotic devices with heel lifts to reduce Achilles tension 4, 6
• Open-backed shoes when out of boot to reduce posterior heel pressure 4
• Continue NSAIDs 6
• Ice therapy through wet towel for 10-minute periods 4

Reassess at 6-8 weeks total from injury (2-4 weeks from now):

• If improving, continue conservative management 1
• If no improvement at 6-8 weeks, refer to podiatric foot and ankle surgeon 1, 4, 3

If Symptoms Are WORSE (Increasing Pain or New Symptoms)

Obtain advanced imaging immediately:

• MRI without contrast is the preferred modality for persistent pain >1 week with negative radiographs 1, 3
• Evaluates for:
  • Achilles tendon partial rupture 6, 7
  • Progression of peritendinitis 6
  • Occult stress fracture 1
  • Deltoid ligament complete tear 8, 9

Refer immediately to podiatric foot and ankle surgeon if:

• Constant pain at rest (suggests infection or nerve compression) 4
• Increasing swelling/redness (infection concern) 4
• Inability to bear weight despite 4 weeks of immobilization 3
• MRI shows complete or high-grade partial tendon tear 6, 7
• MRI shows complete deltoid ligament tear (causes severe ankle instability) 9

Critical Pitfalls to Avoid

Do not inject corticosteroids near the Achilles tendon - this increases risk of tendon rupture 4, 3

Do not completely immobilize indefinitely - functional rehabilitation prevents muscular atrophy and deconditioning 3

Do not miss stress fracture - calcaneal compression test is essential, and symptoms often precede radiographic findings requiring bone scan or MRI 1

Do not delay referral beyond 6-8 weeks if conservative treatment fails, as chronic symptoms become harder to treat 1, 4

Specific Referral Indications

Refer to podiatric foot and ankle surgery when:

• No improvement after 6-8 weeks of appropriate conservative treatment 1, 4, 3
• Need for advanced imaging (MRI) or diagnostic testing 1, 3
• Consideration of surgical intervention 1, 3
• Complete deltoid ligament tear on imaging (requires augmented repair) 9
• Partial Achilles tendon rupture that is chronic 7

Do NOT refer to orthopedic surgery for routine ankle sprains or tendinitis - podiatric foot and ankle surgeons are the appropriate specialists 1, 4, 3

Expected Timeline

Most patients respond to conservative treatment within 6-8 weeks 4

Surgical intervention is required in approximately 25% of athletes with Achilles tendon overuse injuries, with frequency increasing with duration of symptoms 7

About 70-90% of athletes successfully return to activity after Achilles tendon injury 7