What is the appropriate treatment for a 30-year-old male with heel pain radiating to the calf and inability to bear weight after hearing an audible pop in his right leg while playing basketball?

Acute Achilles Tendon Rupture

Immediate Clinical Assessment

This patient has sustained an acute Achilles tendon rupture and requires urgent orthopedic evaluation for surgical repair, as the combination of an audible pop during plantarflexion activity, inability to bear weight, and heel pain radiating to the calf in a young active individual strongly indicates complete tendon disruption.

Key Diagnostic Features Present

• Mechanism of injury: Plantarflexion with pivoting during basketball is the classic mechanism for Achilles rupture 1
• Audible "pop": Pathognomonic for complete tendon rupture 2
• Inability to bear weight: Indicates significant structural disruption 1
• Pain distribution: Heel pain radiating to just below the calf localizes to the Achilles tendon insertion and musculotendinous junction 1

Critical Physical Examination Findings to Confirm

Reexamine within 3-5 days if not already done, as excessive swelling and pain can limit examination accuracy within the first 48 hours 3, 1. Specifically assess:

• Palpable gap in the Achilles tendon approximately 2-6 cm proximal to the calcaneal insertion 2
• Thompson test (calf squeeze test): Absence of plantarflexion with calf compression confirms rupture 2
• Increased passive ankle dorsiflexion compared to the contralateral side 2
• Inability to perform single-leg heel raise on the affected side 2

Immediate Management Protocol

Acute Phase (First 24-48 Hours)

Immobilization in equinus position (plantarflexion) is critical to prevent gap widening:

• Apply posterior splint or fixed-ankle walker with heel wedges to maintain 20-30 degrees of plantarflexion 2
• Non-weight bearing status with crutches (already initiated appropriately) 2
• Remove ace wrap and replace with proper immobilization device 2

Pain management:

• NSAIDs for pain control and inflammation reduction 3
• Opioids may be considered for severe pain in the acute phase 3

Diagnostic Imaging

Obtain radiographs immediately to rule out associated calcaneal avulsion fracture or other bony injuries 3, 1. While clinical diagnosis is typically sufficient, imaging serves to:

• Exclude fracture 3
• Document baseline for medicolegal purposes 3
• Identify any calcific tendinopathy or bone spurs 1

MRI is NOT required for diagnosis but may be obtained if clinical examination is equivocal or to assess rupture characteristics for surgical planning 4, 2.

Definitive Treatment Recommendation

Surgical Repair (Strongly Recommended)

For this 30-year-old active patient, surgical repair is the appropriate treatment because:

• Age and activity level: Young patients participating in cutting and pivoting sports have significantly better outcomes with surgical repair 3, 2
• Return to sport: Surgery allows return to pre-injury activity level in athletic individuals 2
• Re-rupture risk: Non-operative treatment carries substantially higher re-rupture rates (up to 4-5 times higher) compared to surgical repair 2
• Functional outcomes: Surgical repair provides superior strength, AOFAS scores, and Achilles Tendon Total Rupture Scores 2, 5

Optimal Surgical Technique

Minimally invasive (mini-open) repair combined with accelerated functional rehabilitation offers the best outcomes 2, 5:

• Mini-open technique advantages: Direct visualization of repair, lower sural nerve injury risk (0% vs 15% with percutaneous), superior functional scores 5
• Timing: Surgery should be performed within 48 hours when possible, though acute repairs up to 2-3 weeks post-injury remain feasible 3, 2
• Accelerated rehabilitation: Early controlled motion protocols reduce complications while maintaining repair integrity 2

Non-Operative Treatment (Not Recommended for This Patient)

Non-operative management with functional bracing and early mobilization is inappropriate for this patient given:

• Young age and high activity demands 2
• Desire to return to basketball (cutting/pivoting sport) 3
• Significantly higher re-rupture rates (12-15% vs 2-5% with surgery) 2
• Risk of chronic weakness and functional limitations 2

Urgent Referral Required

Refer immediately to orthopedic surgery or foot and ankle specialist (within 24-48 hours) 3, 1:

• Surgical repair should occur within 48 hours to optimize outcomes and minimize complications 3
• Delays beyond 2-3 weeks may necessitate more complex reconstruction procedures 2
• Early surgery provides the most effective pain relief 3

Critical Pitfalls to Avoid

• Delaying diagnosis: Do not wait for MRI confirmation when clinical findings are diagnostic 2
• Inadequate immobilization: Neutral or dorsiflexed positioning increases gap size and compromises healing 2
• Weight-bearing too early: Premature loading increases re-rupture risk regardless of treatment method 2
• Dismissing as ankle sprain: The combination of audible pop, inability to bear weight, and heel pain should never be attributed to simple sprain 1
• Attempting conservative management in young athletes: This population has unacceptably high failure rates with non-operative treatment 2