Foot & AnkleTrauma & Fractures/Trauma & Fractures

Achilles Tendon Rupture

MD Murat BIRINCI· Umraniye Training and Research Hospital, Department of Ortopaedics and Traumatology, Istanbul
Apr 22, 2026

SUMMARY

Achilles tendon rupture is the most common tendon rupture of the lower extremity, typically occurring after a sudden dorsiflexion force applied to a plantarflexed foot, most often during sporting activities.

Diagnosis is primarily clinical, characterized by weakness of plantarflexion and a positive Thompson test. Imaging is generally unnecessary in acute cases but may be helpful in chronic injuries or equivocal examinations, particularly when surgical planning is required.

Treatment options include nonoperative functional rehabilitation or operative repair, depending on patient age, activity level, comorbidities, and chronicity of the rupture.

EPIDEMIOLOGY

Incidence

  • Approximately 18 per 100,000 per year

  • Missed diagnosis reported in up to 20–25% of cases

Demographics

  • More common in men

  • Peak incidence between 30–40 years

Risk Factors

  • Episodic athletes (“weekend warriors”)

  • Fluoroquinolone antibiotic use

  • Corticosteroid injections

  • Prior intratendinous degeneration

  • Inflammatory arthropathies

ETIOLOGY

Mechanism of Injury

  • Acute traumatic injury, most commonly during sports

  • Sudden violent dorsiflexion of a plantarflexed foot

  • Less commonly with sudden forced plantarflexion

Pathoanatomy

  • Rupture typically occurs 4–6 cm proximal to the calcaneal insertion

  • This region corresponds to a hypovascular zone, predisposing to degeneration and rupture

ANATOMY

  • Achilles tendon is the largest and strongest tendon in the human body

  • Formed by the confluence of:

    • Soleus tendon

    • Medial gastrocnemius tendon

    • Lateral gastrocnemius tendon

  • Primary blood supply from the posterior tibial artery

  • Innervated via the tibial nerve

PRESENTATION

History

  • Sudden onset injury

  • Patients often describe a “pop” or snap

  • Frequently misdiagnosed as ankle sprain or DVT

Symptoms

  • Weakness with push-off

  • Difficulty walking

  • Posterior heel or calf pain

Physical Examination

Inspection

  • Increased resting ankle dorsiflexion with patient prone and knees flexed

  • Calf atrophy in chronic cases

Palpation

  • Palpable gap in the tendon (may be absent)

Motion

  • Weakness of ankle plantarflexion

  • Increased passive dorsiflexion

Provocative Tests

  • Thompson test

    • Squeezing the calf fails to produce plantarflexion

    • Strongly associated with complete rupture

·       • Matles test (Knee Flexion Test)
o Prone position with knees flexed to 90°
o Increased resting ankle dorsiflexion compared with the contralateral side indicates Achilles tendon rupture

 

IMAGING

Radiographs

Indications

  • Rule out associated bony pathology

  • Not diagnostic for tendon rupture

Ultrasound

Indications

  • Differentiation between partial and complete rupture

  • Dynamic assessment

MRI

Indications

  • Equivocal physical exam

  • Chronic ruptures

  • Preoperative planning

Findings

  • Tendon discontinuity

  • Retraction of tendon ends

  • Degenerative changes in chronic cases

TREATMENT

Nonoperative Treatment

Method

  • Functional bracing or casting in resting equinus

  • Early functional rehabilitation preferred

Indications

  • Acute ruptures

  • Sedentary patients

  • Medically frail patients

  • Patient or surgeon preference

Outcomes

  • Equivalent plantarflexion strength compared to surgery

  • Level 1 evidence demonstrates equivalent re-rupture rates when functional rehab is used

  • Lower complication rates than operative treatment

Operative Treatment

Open End-to-End Achilles Tendon Repair

Indications

  • Acute ruptures (< 6 weeks)

  • High-demand or athletic patients

Outcomes

  • Historically lower re-rupture rates

  • No significant difference in strength or re-rupture rates compared to nonoperative treatment when functional rehab protocols are used

  • Increased risk of wound complications

Percutaneous Achilles Tendon Repair

Indications

  • Desire to minimize wound complications

  • Cosmetic concerns

Outcomes

  • Higher risk of sural nerve injury

  • Lower wound complication rates

  • Faster return to work

  • Equivalent functional outcomes at 1 year

Reconstruction with V–Y Advancement

Indications

  • Chronic ruptures with tendon defect < 3 cm

Flexor Hallucis Longus (FHL) Transfer ± V–Y Advancement

Indications

  • Chronic ruptures with defect > 3 cm

  • Requires an intact tibial nerve

Considerations

  • Possible residual hallux plantarflexion weakness

TECHNIQUES

Functional Bracing / Casting

  • Immobilization at ~20° plantarflexion

  • Early functional rehabilitation encouraged

Weeks 0–2

• Immobilization in a cast or functional boot at approximately 20° plantarflexion
• Non–weight bearing or protected touch-down weight bearing with crutches
• Emphasis on:

  • pain control

  • edema reduction
    • No active ankle range of motion

Weeks 2–4

• Transition to a functional walking boot with heel wedges maintaining plantarflexion
• Initiate protected weight bearing as tolerated
• Begin gentle active plantarflexion within the boot
• Avoid dorsiflexion beyond neutral
• No stretching of the Achilles tendon

Weeks 4–6

• Gradual removal of heel wedges to allow progressive dorsiflexion toward neutral
• Progress to full weight bearing in the boot
• Initiate:

  • active ankle range of motion (plantarflexion to neutral)

  • gentle isometric strengthening
    • Continue to avoid forced dorsiflexion

Weeks 6–8

• Discontinue boot as tolerated and transition to supportive footwear with heel lift
• Begin:

  • active dorsiflexion beyond neutral

  • light concentric strengthening of the gastrocnemius–soleus complex
    • Gait training to normalize walking pattern

Weeks 8–12

• Progress strengthening exercises:

  • heel raises (bilateral → unilateral)

  • proprioceptive and balance training
    • Gradual return to low-impact activities
    • Avoid explosive push-off and running

After 12 Weeks

• Advance to:

  • sport-specific training

  • plyometric exercises as tolerated
    • Gradual return to running and high-impact activities
    • Full return to sport typically expected at 4–6 months

Open Repair

  • Medial incision to avoid sural nerve

  • Paratenon incised

  • Repair with heavy non-absorbable sutures

  • Postoperative immobilization in plantarflexion for 4–6 weeks

Percutaneous Repair

  • Multiple small stab incisions

  • Careful protection of sural nerve

V–Y Advancement

  • V-shaped incision at musculotendinous junction

  • Superficial tendon lengthened while preserving muscle fibers

FHL Transfer

  • Degenerative tendon excised

  • FHL harvested at Knot of Henry

  • Tendon transferred through calcaneus

COMPLICATIONS

Re-rupture

  • Historically higher in nonoperative treatment

  • No difference with modern functional rehabilitation

  • Treated with surgical repair

Wound Complications

  • Incidence: 5–10%

  • Risk factors:

    • Smoking (most significant)

    • Steroid use

    • Female sex

    • Open surgical technique

Infection

  • Managed with aggressive debridement

  • Culture-specific antibiotics for 6 weeks

Sural Nerve Injury

  • More common with percutaneous techniques

 

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