Achilles Tendon Rupture, ABOS Oral Boards Preparation

This is a 42-year-old male attorney who felt a sharp pop in his left heel during a recreational tennis match. He described the classic sensation of being kicked in the back of the leg. He could not push off or continue playing. He is a self-described weekend warrior, plays tennis on weekends but does not exercise regularly otherwise. No prior Achilles problems, no medications, no medical comorbidities.

On exam, after splint removal, there was a palpable gap approximately 4 to 6 centimeters proximal to the calcaneal insertion. Thompson test was positive, no plantarflexion with calf squeeze. He had weak active plantarflexion, which I attributed to the posterior tibial and peroneal tendons. Matles test was positive, with the patient prone and knees flexed to 90 degrees, the affected foot fell into neutral while the contralateral foot stayed in plantarflexion. The diagnosis was clinically clear.

I obtained an ultrasound which confirmed a complete rupture 5 centimeters proximal to the insertion with a 2-centimeter gap at rest that reduced to 5 millimeters with passive plantarflexion. The fact that the gap reduced well with plantarflexion told me the tendon ends would approximate and a primary repair was feasible.

I discussed both options with him. Non-operative management with early functional rehabilitation is a reasonable alternative, the literature shows similar re-rupture rates when a structured protocol is followed. However, given his activity level, his desire to return to tennis, and the potential for improved strength recovery with surgical repair, he elected for operative treatment after understanding both the benefits and the wound-healing risks.

I performed an open primary Achilles repair through a posteromedial approach using a Krackow locking stitch technique.

He was placed in a splint in gravity equinus. At two weeks, I transitioned him to a walking boot with three heel wedges and started early functional rehabilitation, the literature supports early weight-bearing and motion for improved outcomes. I removed one wedge every two weeks. At six weeks, he was in a flat boot, weight-bearing fully. At three months, he was out of the boot, in a shoe with a heel lift, and doing eccentric strengthening exercises. At six months, he had symmetric ankle dorsiflexion and plantarflexion strength was 90% of the contralateral side. He returned to recreational tennis at seven months.

He was satisfied and back to his weekend tennis without significant limitations. Looking back, I would have counseled him more thoroughly about the expected recovery timeline upfront. He was frustrated at the three-month mark when he still had some plantarflexion weakness, and better preoperative expectation-setting would have eased that anxiety. I also think starting the eccentric strengthening protocol a week or two earlier might have accelerated his strength recovery. I watched closely for re-rupture during the return-to-sport phase, and his repair held up well.