Episode Overview

Podcast: The AOFAS Orthopod-Cast
Episode Title: Achilles Injuries – What Is the Ideal Treatment?
Date: December 31, 2025
Host: AOFAS Podcast Committee (Dr. Matt Conti)
Guests:

• Dr. Martin O’Malley (HSS; Brooklyn Nets, Giants, Devils)
• Dr. Joe Park (University of Virginia)

Theme:
A deep dive into the current trends, causes, and controversies surrounding Achilles tendon rupture management, especially in both elite athletes (with a focus on the NBA) and increasingly among the general population. The panel explores the rising incidence, risk factors, treatment choices (operative vs. nonoperative), surgical techniques, rehabilitation protocols, complications, and patient expectations.

Key Discussion Points & Insights

1. Why Are Achilles Ruptures Increasing?

• Recent NBA Trends:

  • Dr. O’Malley highlights a record eight Achilles ruptures in the NBA this year—a significant outlier both for frequency and for affecting star players. Visibility due to televised events has heightened public awareness.
  • “This year was definitely a huge outlier... six of the eight were starting players and also they did it in front of national TV.” — Dr. O’Malley [02:03]

• Investigated Causes:

  • Shoe Type: No data supports high-top vs. low-top shoes as a factor.
  • Player Attributes: No change in size, speed, or minutes played compared to prior years.
  • Season Format: More frequent games due to in-season tournaments considered, but rupture timing was varied.
  • Athletic Movements: The “step-back move” is common, but rupture occurs during routine maneuvers.
  • Prior Injuries: Some players had prior gastroc injuries, but the link remains speculative.
  • Bottom Line: Multiple theories, but “no one knows... it may just be bad luck.” — Dr. O’Malley [04:55]

2. Risk Factors in Younger & Everyday Athletes

• Intensifying Youth Training:

  • Increase in early, heavy weightlifting among youth athletes may be making tendons more vulnerable relative to rapidly developing muscle mass. — Dr. Park [05:14]
  • The trend toward specialization in a single sport likely increases rupture risk due to repetitive, unvaried movement patterns.
  • “The single sport player is the one that's mostly at risk because they just never get a break...” — Dr. O’Malley [07:04]

• Aging Weekend Warriors & Pickleballers:

  • Dramatic rise in Achilles ruptures among older recreational athletes, especially in sports like pickleball and tennis—a “start-stop” dynamic without proper warmup.
  • “Pickleball is a start-stop sport. I mean, you look at these people playing... No one's warmed up. It is ripe for Achilles tendons. I mean that's like an annuity. Pickleball for Achilles tendon surgeons.” — Dr. O’Malley [09:06]

3. Operative vs. Nonoperative Treatment Outcomes

• Patient Demands:

  • Older, active patients often request surgery to return to sport quickly, even when nonoperative is a reasonable option. — Dr. Park [10:22]

• Re-rupture Rates:

  • Surgery significantly reduces re-rupture risk compared to nonoperative management.
  • “The re rupture rate is significantly higher with nonoperative treatment... almost a tenfold increase in re-ruptures.” — Dr. O’Malley [11:20]

• Nonoperative Caveats:

  • Works particularly if patients are treated quickly (<48 hours) with appropriate plantar flexion casting.
  • “As long as I get them quickly... you'll have a good result from a nonoperative treatment.” — Dr. O’Malley [11:44]
  • Concern over tendon “stretch-out” and some patients remaining unhappy with outcome despite being technically “functional.” — Dr. Conti [12:27]

• Shared Clinical Experience:

  • Surgeons often feel post-op that some patients would have done fine nonoperatively, but motivation and expectation often guide the decision.

4. Surgical Techniques: Why Dr. O’Malley Favors Open Repair

• Mini-Open/ Docking Techniques (e.g., PARS, SpeedBridge):

  • Open technique provides better tensioning and lower complication rates in Dr. O’Malley’s experience.
  • Cites multiple complications and re-ruptures with minimally invasive approaches, including open dehiscence and severe infection.
  • “I had a 28-year-old dentist had an open re rupture through the skin because the skin gets macerated... So I said, okay, I'm never doing the parts again.” — Dr. O’Malley [16:40]
  • “Subsequent to that, I've seen now five professional athletes who re-ruptured after pars technique...” [17:42]

• Anchors/SpeedBridge Concerns:

  • Avoids suture anchors in healthy tendon repairs except avulsions; notes heel pain and infection risk.
  • “I'm very wary of putting anchors in people's heel. And I don't know whether because we make it too tight when we put the Achilles back and distressed at the anchor or just the anchor itself in that cancellous bone is not very good.” [19:36]

• Preference for Open Repair:

  • Allows for more precise tensioning, ability to “over-tighten” to prevent later stretch-out, and easier management of tendon twists and complex anatomy.
  • “If you start out equal, you're going to be stretched out. So I want you tighter...” [13:29]

5. Imaging and Surgical Planning

• Imaging Modalities:

  • Office ultrasound is preferred for immediate assessment; MRI in older patients or those with signs of extensive degeneration.
  • “Everyone gets an ultrasound in the office for an Achilles. If you're over 50, any prodrome, you're getting an MRI...” — Dr. O’Malley [20:37]

• Surgical Augmentation:

  • For cases with significant degenerative change, may use FHL transfer or hamstring graft augmentation.

6. Rehabilitation Protocols

• Elite Athlete vs. Regular Patient Rehab:

  • Fast-tracked, highly supervised rehab for pro athletes (start working the day after surgery).
  • For others: Boot and Theraband exercise at week 1, partial weightbearing at 2 weeks, increasing activity over months, with no neutral position until 8 weeks.
  • “At eight weeks, I'll let them walk around in their boot and then they come out of their boot at home. At 10 weeks... at three months, they're working out, but they're not... doing any sort of ballistic motions.” — Dr. O’Malley [27:10]

• Philosophy:

  • Early plantar flexion loading to minimize calf atrophy and promote tendon healing.
  • “Working in plantar flexion early on really decreases the amount of calf atrophy.” [28:49]

• Single Heel Rise & Return to Sport Timing:

  • First single-leg rise (assisted) by 10 weeks; unaided often not until 3–4 months.
  • Athletes resume sport-specific drills at 4–5 months; return to competition at 6 months.
  • “The predictors of heel height after Achilles are... age and tightness to repair. Can’t do anything about the age, but make the repair tighter.” [29:41]

Notable Quotes & Memorable Moments

• On the spike in NBA ruptures:
  “Now, if the player has some injury before on the ipsilateral lower extremity, you could think that it's a risk... But he passed all the tests and his imaging looked fine. So did it have anything to do with it? We don't know... The bottom line is no one knows.” — Dr. O’Malley [03:51]

• On sport specialization:
  “For my gut, I think it's the single sport player... because they just never get a break and they're doing repetitive movements the whole time.” — Dr. O’Malley [07:09]

• On pickleball and rising ruptures:
  “Pickleball for Achilles tendon surgeons [is] like an annuity.” — Dr. O’Malley [09:06]

• On open vs. minimally invasive repair:
  “I've seen now five professional athletes who re-ruptured after pars technique... the thing pops.” — Dr. O’Malley [17:42]

• On tensioning:
  “If you start out equal [to the uninjured side], you're going to be stretched out. I want you tighter... That's my rationale: fix it tight and rehab them faster.” — Dr. O’Malley [13:29]

Important Timestamps

• NBA Rupture Rates and Theories: [01:26–05:14]
• Younger Athletes and Single-Sport Risk: [05:14–08:06]
• Pickleball and Weekend Warriors: [08:52–10:11]
• Operative vs. Nonoperative—Re-rupture Rates: [10:59–13:07]
• Complications & Techniques: Mini-Open vs. Open: [15:12–20:04]
• Imaging for Surgical Planning: [20:04–22:06]
• Surgical Rehab Protocols: [25:12–31:40]
• Heel-Rise Milestones & Return to Sport: [30:03–31:32]

Conclusion

This episode provides an expert, nuanced perspective on the complexities of Achilles rupture management, blending epidemiology, surgical decision-making, technical pearls, and modern rehabilitation wisdom. Dr. O’Malley’s experience—particularly at the elite athlete and high-volume level—offers listeners both the confidence of data-driven decision-making and the humility to recognize ongoing unknowns.

Memorable sign-off:
“Well, I learned today that if I tear my Achilles, I'm going to have you fix it. I'm going to come live with you every day.” — Dr. Matt Conti [31:43]