Achilles tendon rupture is a sudden onset injury resulting in rupture of the Achilles tendon and a loss of the connection between the calf muscles (gastrocnemius and soleus) to the heel (the calcaneus bone).
Risk Factors
- Sports that stress the Achilles (e.g., basketball, tennis and track athletics)
- Increasing age
- Existing Achilles tendinopathy
- Family history
- Fluoroquinolone antibiotics (e.g., ciprofloxacin and levofloxacin)
- Systemic steroids
TOM TIP: It is worth remembering the association between fluoroquinolone antibiotics and Achilles tendinopathy and rupture. Rupture can occur spontaneously within 48 hours of starting treatment. This knowledge is commonly tested in exams. It is also important to warn patients to look out for any signs of Achilles tendinitis and stop treatment if they occur.
Presentation
The typical presentation is:
- Sudden onset of pain in the Achilles or calf
- A snapping sound and sensation
- Feeling as though something has hit them in the back of the leg
There are often no prior warning signs or Achilles symptoms.
Signs on examination are:
- When relaxed in a dangled position, the affected ankle will rest in a more dorsiflexed position
- Tenderness to the area
- A palpable gap in the Achilles tendon (although swelling might hide this)
- Weakness of plantar flexion of the ankle (dorsiflexion is unaffected)
- Unable to stand on tiptoes on the affected leg alone
- Positive Simmonds’ calf squeeze test
Simmonds’ calf squeeze test is the special test for Achilles tendon rupture. The patient is positioned prone or kneeling with the feet hanging freely off the end of the bench or couch. When squeezing the calf muscle in a leg with an intact Achilles, there will be plantar flexion of the ankle. Squeezing the calf pulls on the Achilles. When the Achilles is ruptured, the connection between the calf and the ankle is lost. Squeezing the calf will not cause plantar flexion of the ankle in a leg with a ruptured Achilles. A lack of plantar flexion is a positive result.
Diagnosis
Ultrasound is the investigation of choice for confirming the diagnosis.
Management
Patients with suspected Achilles rupture should be reviewed by orthopaedics on the same day.
Immediate management involves:
- Rest and immobilisation
- Ice
- Elevation
- Analgesia
Venous thromboembolism prophylaxis needs to be considered while the ankle is immobilised.
There is a debate between non-surgical and surgical management. Healing rates are similar between the two. Non-surgical management avoids the risks associated with surgery (e.g., anaesthetic risks, poor wound healing and infection) but has a higher risk of re-rupture.
Non-surgical management involves applying a specialist boot to immobilise the ankle. The first boot involves full plantar flexion of the ankle. Over time, the boots are altered to gradually move the ankle from full plantar flexion to a neutral position. This process takes 6-12 weeks while the Achilles tendon heals. A long rehabilitation process is required to get back to full pre-injury function.
Surgical management involves surgically reattaching the Achilles. After surgery, a similar process is followed to non-surgical management, with boots that immobilise the ankle initially in a plantar-flexed position, gradually adjusted to a neutral position. This is followed by a long rehabilitation process to get back to full pre-injury function.
Last updated August 2021
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