Original Editors - Sam Verhelpen as part of the Vrije Universiteit Brussel Evidence-based Practice Project
- 1 Introduction
- 2 Clinically relevant anatomy
- 3 Epidemiology
- 4 Aetiology
- 5 Characteristics/Clinical Presentation
- 6 Differential Diagnosis
- 7 Classification
- 8 Outcome Measures
- 9 Examination
- 10 Management
- 11 Surgical management
- 12 Conservative management
- 13 Physiotherapy management
- 14 References
The achilles tendon is the strong fibrous band that attaches the calf muscles to the calcaneus bone. A rupture of the achilles tendon (ATR) is a common pathology and it is the most commonly ruptured tendon in the human body. The main causes of a rupture can be overstretching of the heel during recreational sports, a forceful plantar flexion of the heel or a fall from an important height. .
Clinically relevant anatomy
The incidence is 7 per 100 000 per year but goes up to 15 to 25 per 100 000 per year for (recreational) athletes, with a peak incidence at the age of 30 to 50 years. ‘ It affects mostly 'middle-aged weekend warriors' but this aetiology accounts for only about 70% of such injuries.
An achilles tendon rupture occurs more frequently among men than women.
In the situation of an acute rupture, patients are usually engaged in athletic activities, accounting for 68 % of injuries. It is common in stop-and-go sports such as badminton, soccer, volleyball, basketball, tennis, racquetball, squash as eccentric movement puts an enormous amount of stress on the tendon.
There are some conditions that predispose to rupture, research suggests that injuries in this patient population are more likely to be missed on first examination, these include:
- The natural ageing process
- Use of some commonly prescribed medications such as fluoroquinolone and steroids
- Poor running mechanics
- Altered biomechanics such as flat foot (pes planus), high foot arch (pes cavus),and leg length discrepancy
Three categories of indirect injury that may result in rupture are:
- Pushing off with a weight bearing forefoot while also extending the knee, as occurs at the beginning of a sprint, running, and some forms of jumping
- Sudden and unexpected dorsiflexion of the ankle, which may occur when a person slips off a chair or a ladder, when stumbling into a hole, or suddenly falling forward
- Violent dorsiflexion of a plantar-flexed foot when one falls from a height.
A complete rupture of the achilles tendon will show the following characteristics:
- At the moment of rupture a sharp pain will be felt, as if the patient was stabbed in the heel with a dagger.
- Often the rupture will coincide with a loud crack or pop sound.
- When palpating the tendon, a gap may be felt.
- The back of the heel will be swollen.
- Decreased active plantar flexion of the ankle.
- Increased passive dorsoflexion
- inability to heel raise
- Impaired gait
- A positive outcome of the calf muscle squeeze test or Thompson Test.
- Some patients will have a history of tendinopathy in the heel or a prior cortisone injection.
In most of the available literature, an achilles tendon rupture is described as chronic if it occurs at least 4 to 6 weeks after injury. The symptoms of chronic achilles tendon rupture include pain, decreased strength, fatigue, and ankle stiffness. A correct distinction needs to be made, because the treatments differ.
Differential diagnosis includes:
- Acute achilles tendon peritendinitis
- Gastrocnemius tear
- Calf muscle strain or rupture
- Posterior tibialis stress syndrome
- Posterior tibialis tendon injuries
- Peroneal injuries
Achilles tendon tears may be grouped into 4 types, according to severity of the tear and degree of retraction:
- type I: partial ruptures ≤50% - typically treated with conservative management
- type II: complete rupture with tendinous gap ≤3 cm - typically treated with end-end anastomosis
- type III: complete rupture with tendinous gap 3 to 6 cm - often requires tendon/synthetic graft
- type IV: complete rupture with defect of >6 cm (neglected ruptures) - often requires tendon/synthetic graft and gastrocnemius recession
The outcome measures used to evaluate functional results following an ATR can be broadly divided into two types: objective measures and patient-reported measures. The former are parameters directly registered by the physiotherapist, such as ankle range of motion (ROM) or calf muscle strength measurements. These objective data, derived from the patient’s physical examination, have traditionally formed the basis of functional assessment following an ATR. However, over the past two decades, it has become increasingly recognized that the patient’s own appraisal of outcome is of the most important when judging the results of a treatment.
The best choice of outcome tools for reporting the results of treatment in patients with foot and ankle disorders remains uncertain and controversial. Nevertheless, on the basis of the available evidence, a patient treated for an ATR should be assessed with a disease-specific measure, such as the ATRS in combination with a generic measure, such as the SF-36 . The 36-item Short Form (SF-36) is a commonly used instrument for measuring the Health Related Quality of Life, it is a valid and reliable tool. The SF-36 has been proven useful in monitoring population health, estimating the burdens of different diseases, monitoring outcome in clinical practice, and evaluating medical treatment effects. . These patient-reported outcome scales focus on the patient’s perception of his/her health status, which has to be considered as the most important indicator of the success of a treatment. Patient-reported outcome scales should be complemented by objective indicators of function, such as muscle strength , calf muscle endurance  and return to previous activity level, in order to obtain a complete picture of the effect of the treatment.
For the inspection of an ATR, the therapist may observe the patient in several positions:
- Standing - to look for fallen arches (flat feet) and other postural complications.
- Laying - usually on the front. This can be used to observe the tendon more closely for thickening, redness, swelling and nodules.
- Walking and running - to look for overpronation.
- Swelling: a swollen ankle can point to a rupture of the achilles tendon.
- On palpation: The achilles tendon is easily palpable. When palpating along the entire length of the tendon, a gap may be present.
In this part of the examination the therapist asks the patient to fulfil some active movements which can aid in the diagnosis of a tendon rupture.
There are several active movements:
- Observing the gait pattern can be an important indication for a possible rupture. A patient with an ATR can possibly not make a plantar flexion of his ankle. So if the plantar flexion movement in the walking phase is hindered and painful, it can be an indication of an achilles rupture. A patient with a achilles rupture will show an overpronation of the injured ankle. The patient will also show a lack of push-off at the end of the stance phase as a result of the dysfunction of the Gastrocnemius and Soleus muscles.
- Instructing the patient to stand on his/her toes for making a plantar flexion. This will be impossible if the patient has an ATR.
- Ask the patient to actively plantar flex the ankle.
- Every active movement containing a plantar flexion of the heel will be almost, if totally not impossible.
There exist several special tests for the observation of an ATR:
- Thompson Test - this test is especially useful for diagnosing complete achilles tendon ruptures and less useful for the diagnosis of partial ATR.
- Matles Test - the patient lies in prone position and is asked to actively flex the knee through 90 degrees. The therapist observes the feet and ankles throughout the movement. The test is negative when the foot displays slight plantar flexion; the test is positive if the foot falls into the neutral position or the movement results in dorsiflexion. Maffulli reports a sensitivity of 0.88. 
- Achilles Tendon Total Rupture (ATR-score) - the ATR-score is an important questionnaire that refers to the limitations/difficulties a patient with a tendon rupture will face. 
- Realtime achilles ultrasound thompson test - his test is exactly similar to the thompson test, but under ultrasound visualisation. It can be used by surgeons with minimal training in ultrasonography. It provides improved diagnostic characteristics compared with static ultrasound. 
There is still considerable controversy as the most optimal treatment plan. Debate about nonoperative vs surgical repair for acute ruptures, minimally invasive vs traditional open repair, and early functional rehabilitation protocols instead of a more traditional rehabilitation program are only a few of the arguments that continue to exist in the realm of treatment.
Historically, intervention has been dependent on personal factors such as age, desire to return to sport and individual preference. Operative repair by sewing the torn ends of the injured achilles tendon together was considered to reduce risk of a future re-rupture but wound infection presented a possible complication such as scar adhesions, loss of sensation, DVT, and infection. Therefore younger persons were recommended to choose for the operative repair and elderly and less active patients were recommended for a conservative approach with immobilisation in cast.
Post surgically, early weight bearing and early ankle mobilisation is now widely accepted. However more recently, it has been demonstrated that a conservative and accelerated functional rehabilitation approach is more effective than a surgical approach. Wu et al showed that when functional rehabilitation was used, the effect of non-surgical intervention was similar to surgical treatment regarding the incidence of range of motion, a future chance of re-rupture, calf circumference and functional outcomes and also the incidence of other complications was reduced. Willits et al found all measured outcomes of nonoperative treatment with a functional rehabilitation protocol were acceptable and were clinically similar to those for operative treatment, in addition, this study suggests that the application of an accelerated-rehabilitation nonoperative protocol avoids serious complications related to surgical management. Non-surgical intervention significantly increased the re-rupture rate if a functional rehabilitation approach is not available.
There are a variety of approaches to the surgical management of this injury and contention exists over the surgical approach (open or percutaneous). There is a difference between surgery for chronic and acute ATR.
By evaluating the presence or absence of achilles tendon stumps and the gap length of the rupture, different surgical options (V-Y advancement, gastrocnemius fascial turndown flap, or flexor hallucis longus tendon transfer) can be selected for tendon repair.
Due to a high complication rate after open surgical repair, including wound infection, abnormal sensation, adhesion and thrombosis new technics which require much smaller incisions have been developed. Minimal invasive technics and percutaneous repair become more and more common because they reduce complications and have both a good outcome.
The aim of non-operative means of treatment is to restore and maintain contact between the two ends of the ruptured Achilles tendon to facilitate healing. Conservative treatment regimens vary greatly but commonly involve immobilisation with rigid casting or functional bracing. Gulati et al describe the conservative approach to be this, "the foot is initially placed in full equinus (30° namely full plantarflexion). The foot is then brought into neutral sequentially over a period of 8-12 wk. Once ankle position permits it, weight bearing is allowed. There is currently no clinical consensus on whether the cast should extend above the knee or if a below knee cast is sufficient".
Accelerated functional rehabilitation approach
Despite the increasing supported for accelerated rehabilitation regimes both in surgical and non-surgical situations, there is still no consensus regarding the most preferable protocol. Post surgical protocols which promote early weight bearing and mobilisation have been developed by Brumann et al(level of evidence: 1a) and Braunstein et al.(level of evidence: 2a)
See the following protocols:
Rehabilitation depends on the initial management approach taken - surgical or non-surgical. However, the patient will normally wear a plaster cast for immobilisation or a below-knee dorsal brace which allows the ankle to make a plantar flexion to start early mobilisation. After the cast or brace is removed rehabilitation is mainly focused on firstly improving the range of movement of the ankle, later it is focussed on increasing the muscle strength and muscle coordination. A return to activities should be expected at 4-6 months of therapy, but the rate of rehabilitation greatly depends on the quality of the treatment and the motivation of the patient.
In general physical therapy can start immediately with general exercises for the affected lower limb:
- Hip abduction
- Straight leg raise
- Standing hamstring curl
- Core exercises such as Plank
Once the cast or brace is removed start with gentle passive mobilisation of the ankle and the subtalar joints and active ROM exercises. After two weeks of physiotherapy, progressive resistance exercises are added. Possible exercises for the patient are
- Active flexion/extension of the ankle
- Ankle circles (clockwise and counterclockwise)
- Hip abduction
- Straight leg raise
- Standing hamstring curl
- Cycling on a stationary bicycle
8-12 weeks after surgery
Gait training exercises can be started, followed by activity specific movements. The patient can start with theraband exercises by starting from the lowest resistance and work up from there for regaining strength. The patient should also continue with the previous exercises.
- Ankle range of motion : plantar flexion and dorsiflexion to 90° : 2 x 8 repetitions
- Ankle range of motion : inversion and eversion
- Ankle range of motion : pronation and supination : 2 x 8 repetitions
- One leg standing balance exercise : 3 × 30 seconds
- Standing heel-rise (2 × 3 seconds tempo) : 3 × 10 repetitions
12-24 weeks after surgery
The first set of exercises can now be executed with ankle weights. The following exercises can be added to the training program, but also basic exercises (described above) should still be executed :
- Calf stretch
- Heel raises
- Single leg balancing
- Walk on toes with support to start with (if needed) : 2 × 5 meters
- Standing heel-rise is performed with increased weight on injured leg : 5 × 10 repetitions
- Heel-rise in supine position with flexed legs (with increased weight on injured leg) : 2 × 15 repetition
- Leg press with one leg at a time (10 repetitions maximum) : 2 × 10 repetitions
- Balance exercises on a trampoline : 2 × 45 seconds
- Walk/jog on a trampoline : 2 × 45 seconds
- Cross trainer : 1 min and 45 seconds
- Lunges (only with injured leg in front) : 2 × 10 repetitions
Starting from week 14 until the end of the therapy
The patient is able to run approximately 14 weeks after the injury or surgery.
- Running on even ground is allowed when the patient can perform 5 single-legged heel-rises with approximately 90% of the height of the uninjured leg.
- Jogging upwards on stairs is allowed if the patient can walk 5 meters on their toes without the heel falling down.
The last step after surgery is eccentric exercise. During the eccentric part (lowering the heel), the patient has full weight on the injured foot, and during the concentric part (raising on tiptoe) only the non-injured foot is used .(Level of evidence: 2a)
- Patient takes places on a step, standing with full bodyweight on the forefoot of both feet, the knees are extended. Then he is asked to go stand on his/her toes and to raise the non-injured leg so that his/her bodyweight is on his injured leg. Now the patient slowly lowers the heel. In this way the calf muscle eccentrically guides the motion and is eccentrically trained.
- When the patient can perform this exercise without discomfort, he/she can increase the load by adding books or other weight to a backpack, or to perform the exercise with a flexed knee.
When treated with an eccentric training program, the patient is more likely to be able to return faster to sport. The eccentric exercises should reduce pain and tendon thickness and should improve function of the tendon (and muscles). The eccentric calf-muscle exercises, as described below, should be executed twice daily for 12 weeks. The exercise program consists of 1-3sets of 15 repetitions per exercise, according to the improvement of the patient.(Level of evidence: 2a)
But not all patients benefit equally from an eccentric exercise program. It’s also proven that these exercises are less effective in sedentary people in comparison to athletes.(Level of evidence: 2)
End of the therapy :
After completing the rehabilitation program, new examination of the tendon healing and functions is required. If needed, a new referral for further physiotherapy sessions can be provided to the patient. Gradual return to sports is recommended. For example before participating to contact sports, the patient should wait at least 6–9 months after the injury(Level of evidence: 2)(Level of evidence: 1b).
- Nicola Maffulli*1, Umile Giuseppe Longo2, Nikolaos Gougoulias1 and Vincenzo Denaro2. fckLRIpsilateral free semitendinosus tendon graft transfer for reconstruction of chronic tears of the Achilles tendon. 2008 (level of evidence: 1)
- Flint, James H., et al. "Defining the Terms Acute and Chronic in Orthopaedic Sports Injuries. A Systematic Review." The fckLRAmerican journal of sports medicine42.1 (2014): 235-241. (level of evidence: 1A)
- American college of foot and ankle surgeons/ foot health artikel. Achilles Tendon Rupture (2016 ) https://www.foothealthfacts.org/conditions/achilles-tendon-rupture (level of evidence: 2)
- Vosseller JT, Ellis SJ, Levine DS, Kennedy JG, Elliott AJ, Deland JT, Roberts MM, O’Malley MJ. Achilles tendon rupture in women. Foot & ankle international. 2013 Jan;34(1):49-53. (level of evidence: 2)
- Raikin SM, Garras DN, Krapchev PV. Achilles tendon injuries in a United States Population. Foot Ankle Int. 2013;34:475–480. doi: 10.1177/1071100713477621.(level of evidence: 2A)
- Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am. Jul 1999;81(7):1019-36. (level of evidence: 2A)
- Saglimbeni A, Fulmer C. Achilles tendon injuries and tendonitis. Medscape 2009 [accessed 2014 May 29]. fckLRhttp://emedicine.medscape.com/article/309393-overview (level of evidence: 2)
- Jacobs B, Lin D, Schwartz E. Achilles tendon rupture. Medscape 2009 [accessed 2014 May 29] fckLRhttp://emedicine.medscape.com/article/85024-overview (level of evidence: 2)
- Gravlee J, Hatch R. Achilles tendon rupture: a challenging diagnosis. J Am Board Fam Med. 2000;13(5) fckLRhttp://www.medscape.com/viewarticle/405807 (level of evidence: 2)
- 2016 Mar;23(10):34-6; quiz p 37. doi: 10.7748/en.23.10.34.s24. Achilles tendon rupture in atypical patient populations. fckLRKingsley P1. 1South East Coast Ambulance Service NHS Foundation Trust, Surrey (level of evidence: 2)
- Berkson E. Achilles tendon rupture. Quincy medical center (level of evidence: 2)
- AchillesTendon.com (2004-2016) : http://achillestendon.com/physiology/ (level of evidence: 3)
- Metzl et al. The ruptured Achilles tendon: operative and non-operative treatment options. Curr Rev Musculoskelet Med (2008) 1:161–164 (level of evidence: 1)
- Lewis N, Quitkin HM. Strength analysis and comparison of the Teno fix tendon repair system with the two-strand modified Kessler repair in the Achilles tendon. Foot Ankle Int. 2003;24(11):857–60 (level of evidence: 2)
- Lansdaal JR, et al. The results of 163 Achilles tendon ruptures treated by a minimally invasive surgical technique and functional aftertreatment. Injury. 2007;38(7):839–44. (level of evidence: 2)
- Brumann M, Baumbach SF, Mutschler W, Polzer H. Accelerated rehabilitation following Achilles tendon repair after acute rupture–Development of an evidence-based treatment protocol. Injury. 2014 Nov 30;45(11):1782-90. (level of evidence: 1)
- Wu Y, Lin L, Li H, Zhao Y, Liu L, Jia Z, Wang D, He Q, Ruan D. Is surgical intervention more effective than non-surgical treatment for acute Achilles tendon rupture? A systematic review of overlapping meta-analyses. International Journal of Surgery. 2016 Nov 10. (level of evidence: 1)
- Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. JBJS. 2010 Dec 1;92(17):2767-75. (level of evidence: 1b)
- Gulati V, Jaggard M, Al-Nammari SS, Uzoigwe C, Gulati P, Ismail N, Gibbons C, Gupte C. Management of achilles tendon injury: a current concepts systematic review. World journal of orthopedics. 2015 May 18;6(4):380. (level of evidence: 1)
- Brumann, M., Baumbach, S. F., Mutschler, W., & Polzer, H. Accelerated rehabilitation following Achilles tendon repair after acute rupture-Development of an evidence-based treatment protocol. Injury. 2014 (level of evidence: 1a)
- Braunstein M, Baumbach SF, Boecker W, Carmont MR, Polzer H. Development of an accelerated functional rehabilitation protocol following minimal invasive Achilles tendon repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2015:1-8. (level of evidence: 2a)