II. Definitions
- Achilles Tendon Rupture
- Spontaneous heel cord rupture
III. Epidemiology
- More common in men aged 30 to 50 years
- More common with sedentary lifestyle, when sudden or repetitive movement is introduced
- Spontaneous ruptures are related to sports in more than two thirds of cases
- Sports commonly involved
- High Jump
- Basketball
- Football
- Softball
IV. Pathophysiology
- Uncommon injury
- Results from tendon degeneration or excessive force
- Forceful ankle plantar flexion (e.g. forward lunges)
- Rupture site
- Os calcis (2.5 - 5 cm from tendon insertion)
V. Symptoms
- Injury from great stress on tendon (e.g. jumping)
- Patient hears "pop" at heel with injury
- Often with severe sudden acute pain
- Pain may initially be mild
VI. Signs
- Patient walks Flatfooted
- Most plantar flexion lost (esp. in complete ruptures)
- Excessive passive dorsiflexion of foot
- Unable to stand on ball of foot
- Localized tenderness achilles tendon insertion
- Localized Hemorrhage at rupture site
- Sulcus palpable at rupture site
- May be obscured by organizing clot
- Thompson's Test abnormal (no plantar flexion)
VII. Imaging
- Ruptured achilles tendon may be diagnosed clinically without imaging (or with POCUS)
-
Ankle MRI
- Consider when clinical findings are non-diagnostic
- Achilles Tendon Ultrasound (Ankle POCUS)
VIII. Diagnosis
- Exercise high level of suspicion
- Initially missed diagnosis in 20-30% of Achilles Tendon Ruptures
- Missed initial Achilles Tendon Rupture is associated with worse outcomes (and litigation)
IX. Differential Diagnosis
X. Management
- Orthopedic Consultation in all cases
- Best outcomes with early surgical repair (first 48-72 hours)
- Svedman (2018) Am J Sports Med 46(12): 2929-34 [PubMed]
- Surgical repair for young athletes
- Followed by immobilization for 6-8 weeks
- Non-operative Management (Immobilization)
- Indications for non-operative management (immobilization only)
- Older patients or less active (esp. with presentations within 72 hours of injury)
- Efficacy
- Similar outcomes with faster recovery than surgery
- Initial Immobilization for at least 4 weeks (historically 8-12 weeks)
- Short Leg Walking Cast or cam walker
- Foot in mild equinus (plantar flexion)
- Non-weight bearing (Crutches) for at least 2-3 weeks
- Immobilize for 8-12 weeks
- May be as short as 4 weeks in some protocols
- Short Leg Walking Cast or cam walker
- Stabilization and Physical Therapy for 6 weeks
- Stabilization in ankle-foot Orthosis or heel wedges
- Physical therapy
- Adjunctive Measures
- Platelet Rich Plasma Injections
- Indications for non-operative management (immobilization only)
XI. Prognosis
- Recurrent Achilles Tendon Rupture is common
- Protect from excessive activity for 1 year
- Competitive athletes should expect decreased function
- Re-rupture rate
- Immobilization only: 13.4%
- Surgical repair: 1.4%
- Lo (1997) Clin J Sport Med 7:207-11 [PubMed]
XII. References
- Broder (2026) Crit Dec Emerg Med 40(7): 24-6
- Feldsher (2023) Crit Dec Emerg Med 37(3): 20-1
- Greene (2001) Musculoskeletal Care p.420-1
- Mazzone (2002) Am Fam Physician 65(9):1805-10 [PubMed]
- Morancie (2025) Am Fam Physician 112(6): 648-56 [PubMed]
- Yang (2018) Bone Joint Res 7(10):561-69 +PMID: 30464836 [PubMed]