Achilles Rupture

Original Editors - Sam Verhelpen as part of the Vrije Universiteit Brussel Evidence-based Practice Project

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Introduction

Achilles Tendon Rupture

The Achilles tendon is the strongest tendon in the human body. It serves as the common insertion of the gastrocnemius and soleus into the calcaneus. Achilles tendon rupture typically results from a single high-load event, most commonly involving sudden dorsiflexion or an acceleration-deceleration mechanism during sport. This injury can significantly affect physical function, mental well-being, and quality of life.

Clinically Relevant Anatomy

Anatomy of the calf muscles

The Achilles tendon is composed of tough, fibrous connective tissue. It forms from the aponeuroses of gastrocnemius and soleus and inserts into the calcaneal tuberosity. It is the tendon primarily responsible for transmitting plantarflexion forces generated by the calf muscles at the ankle.

If you would like to learn more about the Achilles tendon anatomy, see: Achilles Tendon

Epidemiology and Aetiology

The incidence of Achilles tendon rupture has risen in recent decades. In the general population, it accounts for 10.7% of all tendon and ligament injuries. In athletes, rupture is frequently associated with high-impact sports that demand quick stops and directional changes, with the highest prevalence reported in athletics (36%), followed by basketball (20%) and football (5%).

Achilles tendon rupture risk factors can be categorised as intrinsic or extrinsic.

Intrinsic factors include:

• tendon properties (composition, vascularity, stiffness)
• degenerative changes (tendinopathy)
• reduced blood flow (hypovascularity in the "watershed area")
• age (typically 30-50 years)
• male gender
• genetics (e.g., collagen synthesis polymorphisms)
• systemic comorbidities, including diabetes, rheumatoid arthritis, lupus, and obesity.

Extrinsic factors include:

• sporting activity and biomechanics (e.g., "weekend warriors," poor technique, or returning to intense activity after inactivity)
• unaccustomed tendon loading, training errors, exercising on hard or uneven surfaces
• medications strongly linked to rupture risk, particularly fluoroquinolone antibiotics and corticosteroid injections

Acute vs Chronic Achilles Tendon Rupture

Acute Achilles Tendon Rupture

An acute Achilles tendon rupture is typically diagnosed based on a patient's history and physical examination. It is characterised by sudden pain and an inability to walk after running or jumping, and is often accompanied by a "pop". Key indicators include difficulty with weight bearing, antalgic gait, and weak plantarflexion. According to the American Academy of Orthopaedic Surgeons guidelines, a definitive diagnosis is established by the presence of two or more of the following: a positive Thompson test, decreased plantarflexion strength, a palpable tendon defect, and increased passive ankle dorsiflexion.

Chronic Achilles Tendon Rupture

Chronic Achilles tendon lesions, defined as those untreated for more than four weeks, typically result from missed acute ruptures or failed prior repairs. Loss of plantarflexion power results in a characteristic calcaneal gait (absent or reduced push-off).

Patients with pre-existing conditions, especially diabetes mellitus, are at risk of delayed diagnosis. Diabetic sensory neuropathy can diminish or mask the severe, acute pain of a rupture, leading patients to underestimate the severity of the injury and delay seeking medical attention.

Chronic rupture signs include a visible or palpable defect. Thompson and Matles tests may be used, but false-negative results are possible if a bridging scar has formed. Because the secondary ankle flexors allow some active plantarflexion, comparing strength with the uninjured side is important for an accurate diagnosis.

Assessment

Observation

Observe the patient in standing, prone and during gait. In standing, note any postural changes, such as flat feet (pes planus). In prone, inspect the tendon for thickening, redness, swelling, and nodules. During gait, observe for gait deviations, such as a lack of plantarflexion, overpronation of the injured ankle, and absent or reduced push-off at the end of stance.

Palpation

Palpation is typically performed with the patient in the prone position, and the foot relaxed in slight dorsiflexion. A healthy tendon should feel smooth, firm, and continuous. A palpable gap, indentation, or defect along the tendon's course is a key clinical finding. Any noticeable absence of the normal taut, cord-like structure warrants further investigation. The size and location of this defect will vary based on the time elapsed since the injury.

Active Range of Motion

The active range of motion assessment should include plantarflexion and dorsiflexion. Plantarflexion is typically weak or absent in people with Achilles tendon rupture, and the patient will be unable to perform a single-leg heel raise.

Special Tests and Measures

Matles test. Affected foot dorsiflexion is a positive sign for Achilles tendon rupture.

The following special tests can help confirm an Achilles tendon rupture:

• Thompson test: The patient lies prone with their feet off the edge of the examination table. The examiner applies a compressive force to the calf muscle.The absence of ankle plantar flexion indicates a positive test result.
• Matles test: The patient lies prone, with their knee actively or passively flexed to 90°. A positive test is indicated when the affected foot stays in a neutral or dorsiflexed position. An intact tendon, or negative result, is indicated when the foot remains in a slightly plantarflexed position.
• Real-time Achilles Ultrasound Thompson (RAUT) test: This test integrates ultrasound imaging with the Thompson manoeuvre, allowing for the real-time visualisation of tendon movement.

Outcome measures for Achilles tendon rupture include:

• Achilles Tendon Total Rupture Score (ATRS)
• Patient-Reported Outcomes Measurement Information System (PROMIS)

Surgical vs Non-Surgical Management of Achilles Tendon Rupture

The American Orthopaedic Foot & Ankle Society (AOFAS) recognises that both nonoperative and surgical approaches are effective in managing acute Achilles tendon rupture and recommends that treatment decisions be made collaboratively with patients, based on individual factors. For healthy and active individuals, surgical repair offers good outcomes with an acceptable risk profile. Surgical options recognised by the AOFAS include both open and minimally invasive repair techniques.

Conservative Management of Acute Achilles Tendon Rupture

General rules in physiotherapy management:

• Treat every Achilles tendon tear as if 100% of the fibres are damaged, regardless of the actual size of the gap or the percentage of the fibres involved.
• See the patient once a week to encourage commitment to early rehabilitation and exercises.
• Avoid Achilles tendon stretches in the earlier stages of rehabilitation. A slightly tight tendon at the end of week 8-10 is preferable to an overlengthened tendon, which cannot generate enough power and puts the patient at risk of re-rupture.
• Complete a follow-up assessment to evaluate the patient's function, return to work, and return to sports.
• There is no consensus on the optimal protocol, including weight-bearing progression, timing of treatment initiation, and type of exercises.

Early Functional Rehabilitation Approach

Early functional rehabilitation is defined as the introduction of weight-bearing and range-of-motion exercises within 2 weeks of injury. While debate continues about the specific details of protocols, evidence supports the following core components of accelerated rehabilitation: strengthening the foot core, plantarflexion strengthening, endurance training, eccentric loading, gait re-education, and fast walking and running when the patient can comfortably perform a single heel raise.

Table 1 describes the time period and general recommendations for early functional rehabilitation protocol in non-operative Achilles tendon rupture.

Table 1. Timeline and general recommendations for early functional rehabilitation protocol in non-operative Achilles tendon rupture.

Time Period	Activities and Exercises Recommendations	Examples of Exercises
Weeks 0-2	Plaster cast or boot in 30 degrees of plantarflexion at all times Non-weight bearing with crutches No physiotherapy
Weeks 2-4	Protected weight bearing (WB) with crutches: Weeks 2-3 25% Weeks 3-4 50% Removing the boot for five minutes every hour or two hours Active plantarflexion Seated stationary bike with the ankle flexed in the boot Hip exercises: Leg lift from prone, sitting, and side-lying Hip extension in supine with feet in plantarflexion on a gym ball or BOSU ball, maintaining ankle flexion	Hip exercises: Prone hip extension
Weeks 4-6	Protected WB to weight bearing as tolerated (WBAT): Weeks 4-5 75% Weeks 5-6 100% Can remove one wedge per week from the boot's inside, until the foot is flat in the boot Continue with previous exercises
Weeks 6-10	Double-leg heel raises on the decline board Quarter squats on a decline board or lunge  with the foot supported at the heel with a wedge to avoid excessive tendon stretch Gait training WBAT in walker boot Endurance/cardio retraining WBAT (e.g., stationary bike)	Double leg raises with decline board or wedge: Squats with decline board or wedges:
Weeks 10-12	Gradual weaning off the boot (usually over 2-5 days) Ankle brace for ankle stability after the boot is removed Gait training without boots, but with crutches or a cane for stability Progressive range of motion, strengthening and proprioceptive exercises with ankle to neutral Endurance exercises: Walking on a treadmill Stationary bicycle Elliptical trainer Balance exercises: Balance board (ankle to neutral only) Calf stretches to neutral in standing Single-heel raises when tolerated keeping the heel at floor level only.	Single heel raises with the heel at the floor level:
Weeks 12-16	Continue to progress range of motion, strength and proprioception exercises No lunges and squats with full WB. Lunges, squats, and step-ups are permitted, maintaining neutral ankle position Maintain caution during activities of daily living, as the tendon is still weak and vulnerable
Weeks 16 and beyond	Dynamic weight-bearing exercises Sport-specific retraining: skipping, jogging, weight training)
Months 6-9	Return to sporting activities, except contact sports, sprinting, jumping,if patient has regained 80% of strength
Months 12 and beyond	Return to full sport activities if patient has regained 100% strength

Post-Surgical Physiotherapy Management of Achilles Tendon Rupture

Post-surgical protocols, which promote early weight-bearing and mobilisation, have been developed by Brumann et al. and Braunstein et al. While these protocols vary in terms of weight-bearing precautions and activity recommendations, Table 2 describes typical time periods and general recommendations for post-surgical management of Achilles tendon rupture.

Note: clinicians should always check the postoperative protocol, precautions, instructions and preferences with their surgeon.

Table 2. Timeline and general recommendations for the post-surgical management of Achilles tendon rupture.

Time Period	Activity and Exercises Recommendation	Example of Exercises
24 Hours to 2 Weeks	The foot is immobilised in a boot or plaster cast in 30° plantarflexion Within 24 hours after surgery, the patient can start to load approximately 5 kg of weight in the boot/cast with an ankle in 30-degree plantarflexion Gait training with a foot in the boot/cast, with crutches and limited weight bearing under the supervision of the physiotherapist Begin quadriceps isometric exercises within 24 hours of surgery to prevent muscle atrophy Introduce muscle pump exercises on the contralateral ankle joint No movements involving ankle dorsiflexion	Quadriceps isometric:
After 2 weeks	Remove the boot for five minutes every one to two hours to do specific exercises Improve plantarflexion mobility and gradually build strength Dorsiflexion stretches and neutral ankle position are not permitted	Active ankle plantarflexion: Plantarflexion isometric:
Week 4-8	Gradually lower the boot wedge until the foot reaches neutral at week 10 Continue with exercises from the previous week Start open-chain hip and knee strengthening exercises
Week 8-12	Gait training with full weight bearing, followed by activity-specific movements Theraband exercises with the lowest resistance to improve ankle strength Exercises begin AFTER achieving neutral at week 10. Examples of exercises are as follows: Ankle active inversion and eversion One leg standing balance exercise Standing heel-rise	One leg standing exercises: Standing heel rise:
Week 12-24	Basic and advanced exercises: Calf stretch Heel raises Single leg balancing on different surfaces Walk on toes with support to start with (if needed) Standing heel-rise is performed with increased weight on the injured leg Heel-rise in a supine position with flexed legs (with increased weight on the injured leg) Leg press with one leg at a time Balance exercises on a trampoline Walk/jog on a trampoline Cross trainer Lunges (only with injured leg in front)	Single leg balancing on different surfaces: Leg press with one leg at a time:
Week 14 Until the End of the Therapy	Running is permitted when the patient achieves: (1) five single-legged heel rises at 90% height of uninjured leg, (2) can walk 5 metres on toes without heel drop, and (3) has clearance from their surgeon. Jogging upwards on stairs if the patient can walk 5 meters on their toes without the heel falling. Eccentric exercise with the patient standing on the step with full body weight on the forefoot of both feet and the knees extended. Next, the patient raises on their toes and lifts the non-injured leg. Their body weight is on the patient's injured leg when the patient slowly lowers the heel. When the patient can perform this exercise without discomfort, they can increase the load by adding books or other weights to a backpack or by performing the exercise with a flexed knee.
End of the Therapy	New assessment of the tendon healing and functions Gradual return to sports Return to sport requires a single-leg heel raise to 90% of the uninjured side height, a calf circumference within 2 cm or <10% of the uninjured side, and sport-specific movement testing. Before participating in contact sports, the patient should wait 6–9 months after the injury. Evidence indicates that up to 50% of patients report residual symptoms 10 years post-rupture, including reduced plantarflexor strength, calf atrophy, and altered gait mechanics. Patients should be counselled that while excellent functional recovery is possible, some degree of permanent deficit may persist. Ongoing strength maintenance programmes may be beneficial.