Review Question - QID 214654

This patient is presenting after exertion with sudden pain over his Achilles as well as weakness of plantar flexion and a radiograph demonstrating Achilles tendon injury (edema), which is concerning for an Achilles tendon rupture. The most appropriate next step in management is splinting in plantar flexion for appropriate healing.

Achilles tendon ruptures are common in "weekend warriors" or older men who attempt to engage in vigorous athletics without proper conditioning. The classic history is a sudden pop and pain over the Achilles tendon with weakness on plantar flexion (strain or partial rupture) or absent plantar flexion (complete rupture). The initial step in management for all patients is splinting in plantar flexion. An MRI can confirm the diagnosis if there is any uncertainty. A radiograph could be performed to rule out a fracture and may demonstrate edema. Surgical repair is recommended for younger or highly functional patients; however, many patients have good outcomes (albeit with slower healing) with splinting in plantar flexion to allow the Achilles tendon to heal (in particular with partial tears).

Figure/Illustration A is an ankle radiograph without any fractures demonstrating an Achilles tendon rupture (red arrow pointing at edema/swelling) in the setting of this patient’s history/exam.

Incorrect Answers:
Answer 1: Activity as tolerated, ice, elevation, and compression are the appropriate management of a muscle strain, which presents with pain worsened with palpation/stretching without any neurological or range of motion deficits. This diagnosis can be made clinically and does not require any diagnostic modalities.

Answer 2: Closed reduction and splinting are indicated in the management of a minimally displaced fracture. Traction can be placed on the extremity, and the bones can be realigned and splinted.

Answer 3: MRI would be the most accurate diagnostic test to confirm an Achilles tendon rupture; however, it is clear that this patient has an Achilles tendon rupture and an MRI is not needed given this patient’s symptoms (as the diagnosis can be made clinically). Also, given the patient’s age and medical comorbidities, he would be a poor surgical candidate (if considering an MRI for surgical planning).

Answer 5: Surgical repair is not preferred in this elderly patient (poor surgical candidate). More appropriate management would include splinting the patient’s foot in plantar flexion to allow for healing and reassessment at a later time to monitor progress.

Bullet Summary:
The acute management of an Achilles tendon rupture (in particular in a patient who is not a good surgical candidate) is splinting in plantar flexion.