45
Achilles Tendon Rupture
John J. Jasko, MD  |  S. Brent Brotzman, MD  |  Charles E. Giangarra, MD
BACKGROUND
The incidence of Achilles tendon rupture has increased dramat-
ically in the past 50 years. The advent and popularity of recre-
ational sports have contributed to this, because 75% of ruptures
are sports related. The peak incidence occurs between 30 and
45 years of age, with a male-to-female ratio of 6:1 (Hansen et al.
2016).
The impact of these injuries in athletes is highlighted by
the report of Parekh et al. in which 10 of 31 professional foot-
ball players with Achilles tendon ruptures were unable to
return to play in the National Football League (Parekh et al.
2009).
Acute ruptures commonly occur when pushing off with
the weightbearing foot while extending the knee, but they also
can be caused by a sudden or violent dorsiflexion of a plantar-
flexed foot (eccentric contracture). Most Achilles tendon rup-
tures occur approximately 2 to 6 cm proximal to its insertion
on the calcaneus, in the so-called “watershed” region of reduced
vascularity. Patients should also be questioned about previous
steroid injection and fluoroquinolone treatment (e.g., Levaquin
or ciprofloxacin) for association with tendon weakening and
increased rupture risk.  zation and weight bearing have been utilized (Willits et al. 2010,
CLINICAL SIGNS AND SYMPTOMS
Sharp pain and a pop heard at the time of complete rupture are
commonly reported. Patients often describe a sensation of being
kicked in the Achilles tendon. Most have an immediate inability
to bear weight or return to activity. A palpable defect may be
present in the tendon initially.
Partial rupture is associated with an acutely tender, localized
swelling that occasionally involves an area of nodularity.
The Thompson test (Fig. 44.2) is positive with complete
Achilles tendon rupture. The patient is placed prone, with both
feet extended off the end of the table. Both calf muscles are
squeezed by the examiner. If the tendon is intact, the foot will
plantar flex when the calf is squeezed. If the tendon is ruptured,
normal plantarflexion will not occur (a positive Thompson
test).
In some patients, an accurate diagnosis of a complete rup-
ture is difficult through physical examination alone. The tendon
defect can be disguised by a large hematoma. A false-negative
Thompson test result can occur because of plantarflexion of the
ankle caused by extrinsic foot flexors when the accessory ankle
flexors are squeezed together with the contents at the superficial
posterior leg compartment. It is important to critically compare
the test with results in the normal side.
Partial ruptures are also difficult to accurately diagnose, and
MRI should be used to confirm the diagnosis.  allow hematoma consolidation. Prolonged immobilization, as
TREATMENT OF ACUTE RUPTURE
OF THE ACHILLES TENDON
Both nonoperative and operative treatment can be used to
restore length and tension to the tendon to optimize strength
and function. Both methods are reasonable, and treatment
should be individualized based on operative candidacy. The
patient’s overall health, vascular status, and activity level are
considered. Traditionally, younger patients and athletes have
been treated with operative repair. A main reason for this is
that studies have shown that operative repair has been associ-
ated with lower rerupture rates, more frequent return to athletic
activities, quicker return to full activity, and greater plantarflex-
ion strength (Heckman et al. 2009, Khan et al. 2005).
Khan et al., in a meta-analysis of randomized trials compar-
ing surgical and conservative management, found rerupture
rates of 3.5% in the operative group and 12.6% in the nonopera-
tive group as well as significant weakness in the nonoperative
group (Khan et al. 2005). However, many of these studies used
prolonged immobilization and limited weight bearing as part
of the nonoperative treatment. More recent studies have found
improved function in both treatment groups when early mobili-
Nilsson-Helander et al. 2010).
In a level 1 study, Nilsson-Helander and Silbernagel’s pro-
tocol included functional bracing rather than casting in both
groups (Nilsson-Helander et al. 2010). They still found a higher
rerupture rate in the nonsurgical group (12% to 4%), but at 12
months the only functional difference was the heel raise in favor
of the surgical group. Other recent studies, such as the random-
ized prospective trial by Willits et al. have shown no significant
functional differences or rerupture rates between operative and
nonoperative groups when early mobilization and weight bear-
ing have been utilized in both treatment groups (Willits et al.
2010, Twaddle and Poon 2007).
Thus, there are still conflicting reports regarding surgery vs. no
surgery, but after that initial decision, there is more of a consen-
sus that accelerated rehab, early ROM, and early weight bearing
are the best approaches. It is important to point out that operative
treatment consistently has higher complication rates. However,
complication rates have decreased with the use of smaller inci-
sions, percutaneous techniques, and better patient selection. 
NONOPERATIVE TREATMENT
OF ACUTE ACHILLES TENDON
RUPTURE
Nonoperative treatment requires temporary immobilization to
299
300 SECTION 4  Foot and Ankle Injuries
mentioned above, is counterproductive to functional healing.
In a meta-analysis of randomized controlled trials, Khan found
that cast immobilization resulted in a rerupture rate of 12%,
compared to 2% with functional bracing (Khan et  al. 2005).
Complications such as adhesions and infection also were more
common in the cast immobilization group (36%) than in the
functional bracing group (10%). Thus we use functional bracing
rather than casting.
Ultrasound serial examinations can be helpful to confirm
that Achilles tendon end apposition occurs with 20 degrees or
less of plantarflexion of the foot. If a significant gap remains
with the leg placed in 20 degrees of plantarflexion, we still favor
operative treatment in young, healthy patients.
After the initial 2-week period of casting in equinus, the
patient is transitioned to an articulating removable cast boot
locked in 20 degrees of plantarflexion. Alternatively, a nonar-
ticulating boot can be used with a 2-cm heel lift that approxi-
mates the 20-degree plantarflexion position. Active dorsiflexion
to neutral with passive plantarflexion is begun. We previously
delayed motion and weight bearing until 4 weeks for nonop-
erative patients. However, with the efficacy and safety shown by
Willits et al. and others using accelerated protocols, we now use
the same protocol for nonoperative and operative treatment of
acute tears after the initial 2 weeks.
See Rehabilitation Protocol 45.1 for nonoperative manage-
ment of an Achilles rupture.  comes with early weight bearing (Suchak et al. 2008).
OPERATIVE TREATMENT FOR ACUTE
ACHILLES TENDON RUPTURE
Various operative techniques have been described for Achilles
tendon repair, ranging from simple end-to-end Bunnell or Kes-
sler suturing to more complex repairs using fascial reinforcement
or tendon grafts, artificial tendon implants, and augmentation
with the plantaris tendon or gastrocnemius (Fig. 45.1). In a
A B C the tensile stress across the repair site. However, Labib et  al.
Fig. 45.1  Reinforcement with plantaris tendon. A, Rupture. B, Achil-
les tendon is repaired, and plantaris tendon is divided and fanned. C,
Plantaris tendon is used to reinforce repair.
prospective randomized study, Pajala et al. found that augmenta-
tion with a gastrocnemius turn-down technique had no advan-
tage over simple end-to-end repair (Pajala et al. 2009).
Percutaneous, endoscopically assisted, and mini-open tech-
niques have been developed to speed recovery and improve cos-
metic results. Most studies have found lower complication rates
with no increase in rerupture rates with percutaneous tech-
niques (Deangelis et al. 2009, Gigante et al. 2008). Percutaneous
repair also has been shown to be less costly than open repair
(Ebinesan et al. 2008). 
REHABILITATION AFTER OPERATIVE
TREATMENT OF ACUTE ACHILLES
TENDON RUPTURE
Historically, patients were immobilized in a rigid cast for at least 4
weeks after operative repair of Achilles tendon rupture; however,
current trends emphasize minimal postoperative immobiliza-
tion and early weight bearing (see Rehabilitation Protocol 45.2).
A number of studies have confirmed that physical activity speeds
tendon healing, and rerupture rates have not been significantly
higher with early weight bearing. A meta-analysis of randomized
trials comparing early weight bearing with cast immobilization
found no difference in rerupture rates and better subjective out-
Early functional treatment protocols, when compared to
postoperative immobilization, led to more excellent rated
subjective responses and no difference in rerupture rated in
Suchak et al.’s meta-analysis.
Strom and Casillas outlined five goals of the rehabilitation
program after repair of Achilles tendon rupture (Strom 2009).
1. Reduce residual pain and swelling. Modalities may include
massage, ice, differential compression, graduated compres-
sion garment, contrast baths, and electrical stimulation.
2. Recover motion while preserving integrity of the repair.
Clinical findings are used to guide the amount of tension
placed on the repair. Warmup, including massage and deep
heat, is done before and during stretching to improve dorsi-
flexion. Isolated stretching of the gastrocnemius muscles and
the soleus–Achilles are done with the knee extended (gas-
trocnemius) or flexed (soleus–Achilles).
3. Strengthen the gastrocnemius–soleus–Achilles motor unit.
This involves a graduated program of resistance strengthen-
ing using elastic bands and closed chain exercises (seated calf
pumps, bipedal calf pumps, single-leg calf pumps, single-leg
calf pumps on a balance board or trampoline).
4. Improve the strength and coordination of the entire lower
extremity. Swimming, water jogging, and exercise cycling are
added to the strengthening program.
5. Provide a safe and competitive return to athletic activity that
avoids rerupture. Cross-training with cycle- and water-based
activities are added to promote aerobic recovery and pro-
mote coordinated motor activity in both lower extremities.
Traditionally, postoperative treatment of surgically repaired
Achilles tendon rupture included prolonged immobilization
with the ankle in plantarflexion. This was thought to decrease
measured the static tension in the Achilles tendon at varying
degrees of plantarflexion before and after surgical repair (with
a number 2 Krakow locking technique reinforced with 4.0
 45  Achilles Tendon Rupture 301

monofilament) (Labib et al. 2007). They found that static ten- phases in rehab is usually prolonged with chronic tears, and
sion in the repaired Achilles tendon was equal to that of the full recovery can take as long as 9 to 12 months (Maffulli and
intact tendon in all positions of plantarflexion. This study sug- Ajis 2008). 
gests that long-term positioning of the ankle in plantarflexion
after secure surgical repair of a ruptured Achilles is probably
not necessary.  RETURN TO SPORTS
RECOMMENDATIONS AFTER
CHRONIC ACHILLES TENDON ACHILLES RUPTURE
RUPTURE Return to competitive and recreational sports is common after
The diagnosis of chronic Achilles tendon rupture is more dif- recovery and rehabilitation of Achilles tendon ruptures. Studies
ficult than diagnosis of an acute rupture. The pain and swelling show ranges of 75% to 100% return to previous level of partici-
often have subsided and the gap between the tendon ends has pation (Jallageas et al. 2013).
filled in with fibrous tissue (Maffulli and Ajis 2008). Time to return averages 5 to 7 months, so patience must be
Weak active plantarflexion may be possible through the stressed to the athlete. The Achilles Tendon Total Rupture Score
action of other muscles, further complicating accurate diagno- (ATRS) at 3 months can predict patients’ ability to return to
sis. A limp often is present, and the calf muscles are typically sport (Hansen 2016).
atrophied. The Thompson squeeze test usually only has a flicker Most strength and functional gains occur between 3 and 6
of plantarflexion on squeezing the calf, which is asymmetric months, but improvement can continue up until one year post
compared to the uninvolved calf. Ultrasonography and MRI are injury, although some slight permanent strength deficit com-
useful to confirm the diagnosis. pared to the normal leg is not uncommon (Carmont et al. 2013).
Chronic Achilles tendon ruptures usually require operative
reconstruction of the soft tissue defect, which may include soft
tissue augmentation, V-Y advancement flaps, or local tendon TABLE Myerson Classification (Chronic Achilles
transfers. The Myerson classification system provides guidelines 45.1 Rupture)
for management (Myerson 1999) (see Table 45.1).
The chronicity and complexity of the reconstruction and Type Defect Management
repair will dictate any changes to the standard functional reha- I ≤1–2 cm End-to-end repair, posterior
bilitation protocol that is used for acute tears. Those requiring compartment fasciotomy
tendon transfers, turndowns, or allograft may require a lon- II 2–5 cm V-Y lengthening, with or without
ger initial period of casting, typically 3 weeks, prior to start- tendon transfer
III >5 cm Tendon transfer, with or with V-Y
ing ROM and weight bearing. Rehabilitation then proceeds advancement
as in acute tears/repairs. Overall progression to subsequent

REHABILITATION PROTOCOL 45.1    Protocol for Nonoperative Management of an Achilles Rupture

Initial evaluation/ Ultrasound or MRI exam showing <5-mm gap with maximal plantarflexion, <10 mm with foot in neutral, or
requirement for >75% tendon apposition with foot in 20 degrees of plantarflexion
inclusion
Initial management Cast with foot in full equinus, NWB with crutches or walker
2–6 weeks Transition to removable cast boot: If hinged, place in 20 degrees plantarflexion; not hinged (flat): 2-cm heel
wedge to approximate 20 degrees plantarflexion
WBAT in boot; use crutches with boot until no pain or limp
Active dorsiflexion to neutral, inversion/eversion below neutral, no resistance
Modalities to control swelling
Hip/knee exercises as appropriate
Hydrotherapy: NWB, adhere to motion restrictions
Wear boot all times except for bathing (NWB) or exercises
6–8 weeks Removable cast boot at neutral; remove heel wedge
Wear boot all times except for bathing or exercises
WBAT in boot, wean off crutches
Dorsiflexion stretching, slowly
Graduated resistance exercises (open and closed kinetic chain as well as functional activities); Dual support
heel raises
During supervised PT, start balance proprioceptive exercises, stationary bike, elliptical trainer in
regular shoe
Hydrotherapy with underwater treadmill
Continued
302 SECTION 4  Foot and Ankle Injuries

REHABILITATION PROTOCOL 45.1    Protocol for Nonoperative Management of an Achilles

Rupture—cont’d
8–12 weeks Remove boot.
1-cm heel lift in shoe
Continue to progress ROM, strength, proprioception
12 weeks Continue to progress ROM, strength, proprioception
Retrain strength, power, endurance
Increase dynamic weightbearing exercise, include plyometric training
Sport-specific retraining

MRI, magnetic resonance imaging; NWB, nonweight bearing; WBAT, weight bearing as tolerated.
Adapted From: Willits K, Ammendola A, Fowler, P et al. Operative vs. Nonoperative Treatment of Acute Achilles Tendon Ruptures, JBJS 92:2767-75,
2010.

REHABILITATION PROTOCOL 45.2    Rehabilitation After Repair of Acute Achilles Tendon Rupture
Initial management Postoperative splint in equinus; NWB with crutches or walker
2–6 weeks Transition to removable cast boot: If hinged, place in 20 degrees plantarflexion; not hinged (flat): 2-cm heel
wedge to approximate 20 degrees plantarflexion
WBAT in boot; use crutches with boot until no pain or limp
Active dorsiflexion to neutral, inversion/eversion below neutral, no resistance
Modalities to control swelling
Hip/knee exercises as appropriate
Hydrotherapy: NWB, adhere to motion restrictions
Wear boot all times except for bathing (NWB) or exercises
6–8 weeks Removable cast boot at neutral; remove heel wedge
Wear boot all times except for bathing or exercises
WBAT in boot, wean off crutches
Dorsiflexion stretching, slowly
Graduated resistance exercises (open and closed kinetic chain as well as functional activities); Dual support heel
raises
During supervised PT, start balance proprioceptive exercises, stationary bike, elliptical trainer in regular shoe
Hydrotherapy with underwater treadmill
8–12 weeks Remove boot.
1-cm heel lift in shoe
Continue to progress ROM, strength, proprioception
12 weeks Continue to progress ROM, strength, proprioception
Retrain strength, power, endurance
Increase dynamic weightbearing exercise, include plyometric training
Sport-specific retraining

MRI, magnetic resonance imaging; NWB, nonweight bearing; WBAT, weight bearing as tolerated.
Adapted From: Willits K, Ammendola A, Fowler, P et al. Operative vs. Nonoperative Treatment of Acute Achilles Tendon Ruptures. JBJS 92:2767-75,
2010.

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A complete reference list is available at https://expertconsult
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FURTHER READING
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