Working Diagnosis:
Left Achilles tendon rupture

Treatment:
The patient was placed in a posterior splint in plantarflexion, made non-weight bearing, and instructed to use ibuprofen for pain. Once MRI confirmed complete Achilles rupture, she was referred to a foot and ankle orthopedic surgeon for operative repair. She underwent surgery two weeks after initial presentation and was subsequently started on aspirin for deep venous thrombosis prophylaxis.

Outcome:
The patient was non-weight bearing for four weeks post-operatively. Her physical exam at two weeks post-op demonstrated an intact Achilles tendon, a mildly swollen ankle, and a healing incision. She transitioned to a walking boot with heel lift and started rehab. At four weeks post-op, she started progressive weight bearing. At the time of this case report, the patient continues with rehab and intermittent follow-up to determine an appropriate timeline for return-to-play.

Author's Comments:
While relatively common in adults, Achilles tendon rupture rarely occurs in children. Research thus far on the optimal management and expected prognosis for this injury among children is limited to a few case reports. Among these cases, direct trauma to the tendon or forced dorsiflexion caused the rupture. In contrast, our patient's mechanism of injury was more classic: preceding rapid acceleration accompanied by a pop. This case highlights the importance of keeping Achilles rupture on the differential in pediatric patients with such a characteristic history. Special attention should also be made to competitive athletes who have a higher reported lifetime incidence of Achilles rupture.

Editor's Comments:
Achilles tendon rupture is an uncommon finding in the pediatric population. When working-up posterior heel pain in the pediatric population, there should be early evaluation for the presence of an open physis. Given the relative increased strength of tendons compared to the growth plate, apophysitis (ie, Sever's disease) is a common diagnosis for the pediatric patient presenting with posterior heel pain and an open growth plate. Achilles tendon rupture can be present with an open physis due to direct trauma (2,3). As seen with this case, a closed physis, or skeletally mature patient, can still be considered a part of the pediatric population resulting in a more typical presentation of achilles tendon rupture.

References:
1. Chorley, Joseph. "Heel Pain in the Active Child or Skeletally Immature Adolescent: Overview of Causes." UpToDate, 16 Aug. 2023, www.uptodate.com/contents/heel-pain-in-the-active-child-or-skeletally-immature-adolescent-overview-of-causes?search=%22achilles%22+and+%22pediatric%22&source=search_result&selectedTitle=1~39&usage_type=default&display_rank=1#H171105229.

2. Vasileff, William Kelton, and Vasilios Moutzouros. "Unrecognized Pediatric Partial Achilles Tendon Injury Followed by Traumatic Completion: A Case Report and Literature Review." The Journal of Foot and Ankle Surgery: Official Publication of the American College of Foot and Ankle Surgeon, U.S. National Library of Medicine, 6 Apr. 2014, pubmed.ncbi.nlm.nih.gov/24713492/.

3. Tudisco, C, and S Bisicchia. "Reconstruction of Neglected Traumatic Achilles Tendon Rupture in a Young Girl." Journal of Orthopaedics and Traumatology : Official Journal of the Italian Society of Orthopaedics and Traumatology, U.S. National Library of Medicine, Sept. 2012, pubmed.ncbi.nlm.nih.gov/22290490/.

4. Boggess, Blake Reid, and Karen L Maughan. "Achilles Tendinopathy and Tendon Rupture." UpToDate, 15 June 2023, www.uptodate.com/contents/achilles-tendinopathy-and-tendon-rupture#H12.

5. Park, Seung-Hwan, et al. "Treatment of Acute Achilles Tendon Rupture." Clinics in Orthopedic Surgery, U.S. National Library of Medicine, Mar. 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7031433/.

6. VanEtten, Lucas, and JJ Kuczynski. "Achilles Tendon Repair Clinical Practice Guideline - the Ohio State ..." The Ohio State University School of Health and Rehabilitation Sciences, 18 May 2015, http://www.wexnermedical.osu.edu/-/media/files/wexnermedical/patient-care/healthcare-services/sports-medicine/education/medical-professionals/knee-ankle-and-foot/achilles-repair-protocol-2019.pdf?la=en&hash=69FC2CFD07F0677199BF20749A5A0C89DAA928C3

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