Achilles Tendon Rupture — ABOS Oral Boards Preparation
What examiners expect and how to prepare
Clinical Scenario
A 42-year-old right-hand-dominant male attorney presents to the emergency department after feeling a sharp pop in his left heel during a recreational tennis match. He describes the sensation of being kicked in the back of the leg. He was unable to push off or continue playing. He has no prior Achilles problems but admits to being a weekend warrior with minimal regular exercise. He takes no medications and has no medical comorbidities. On exam, he is in a splint applied at an urgent care center. After splint removal, there is a palpable gap approximately 4-6 cm proximal to the calcaneal insertion. The Thompson test is positive — no plantarflexion with calf squeeze. He has weak active plantarflexion, likely through the posterior tibial and peroneal tendons. Simmonds test is positive. Matles test shows the left foot falls into neutral with the patient prone and knees flexed, while the right foot remains in plantarflexion. Neurovascular exam is intact.
Ultrasound confirms a complete rupture of the Achilles tendon 5 cm proximal to the calcaneal insertion with a 2 cm gap at rest that reduces to 5 mm with passive plantarflexion. The plantaris tendon is intact.
After discussing operative and non-operative options, the patient opted for surgical repair. You performed an open primary repair through a posteromedial approach using a Krackow locking stitch technique with #2 non-absorbable suture. Tension was set with the ankle in 20 degrees of plantarflexion. The paratenon was closed over the repair. The patient was placed in a splint in gravity equinus, transitioned to a walking boot at 2 weeks with heel wedges, and began early functional rehabilitation with progressive dorsiflexion.
What Examiners Look For
- Data gathering: Age, activity level, and patient goals are central — a weekend athlete versus an elite competitor may warrant different approaches.
- Diagnosis: Describe the Thompson test, Matles test, and the palpable gap — clinical diagnosis should be confident before imaging.
- Treatment plan: Discuss the operative versus non-operative debate — what does the evidence show regarding re-rupture rates and functional outcomes with early functional rehabilitation?
- Technical skill: Describe the Krackow stitch, suture material, and how you set tension. What is the posteromedial approach and why is it preferred?
- Complications: Wound healing problems, sural nerve injury, re-rupture, and deep vein thrombosis — how do you counsel and mitigate?
- Applied knowledge: How has the evidence on non-operative management with functional bracing changed the discussion? What protocols do you follow?
Common Pitfalls
- Stating that all Achilles ruptures require surgery — non-operative management with early functional rehabilitation is a valid option with comparable outcomes in select patients.
- Not knowing the sural nerve anatomy — it crosses the operative field and is at risk with the posterolateral approach.
- Forgetting DVT prophylaxis — the Achilles rupture population has an elevated thrombotic risk.
- Setting tension too tight — over-tensioning is worse than slight laxity and limits dorsiflexion recovery.
- Dismissing non-operative management without acknowledging the literature — examiners want balanced, evidence-informed answers.
Key Classifications
Related Scenarios
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