Achilles Tendon Rupture
e3
BASIC INFORMATION
DEFINITION
Achilles tendon rupture is a disruption of the
continuity of the Achilles tendon that most often
results from the combination of mechanical
stress and intratendinous degeneration.
ICD-10CM CODES
S86.0 Unspecified injury of Achilles
tendon
S86.012 Achilles tendon rupture left
S86.011 Achilles tendon rupture right
M66.871 Non traumatic Achilles tendon
rupture right
M66.872 Non traumatic Achilles tendon
rupture left
EPIDEMIOLOGY &
DEMOGRAPHICS
INCIDENCE: In the general population, Achilles
tendon ruptures occur in 7 per 100,000 indi-
viduals and are the most common large tendon
ruptures, accounting for 20%-35% of all large
tendon injuries in the human body.
PEAK INCIDENCE: 30- to 40-yr age group.
PREDOMINANT AGE: 30- to 55-yr age group.
RISK FACTORS: General risk factors include
recreational athletes, stop-and-go sports
(e.g., basketball, tennis, and soccer), preexist-
ing Achilles tendinopathy, increase in dura-
tion or intensity of running, advanced age,
male gender, and poor running mechanics.
Fluoroquinolone antibiotics have been associ-
ated with Achilles tendon ruptures, with an
incidence of 12 per 100,000. This is more likely
to occur in first-time users of fluoroquinolones
and usually occurs within the first 90 days of
therapy. Other risk factors can be categorized
into intrinsic and extrinsic.
Intrinsic risk factors include Achilles tendi-
nopathy and biomechanics, such as overprona-
tion or underpronation, pes planus, pes cavus,
limb length discrepancy, and foot misalign-
ment. Rheumatologic disorders such as sys-
temic lupus erythematosus, rheumatoid arthri-
tis, and gout can cause collagen degeneration,
inflammation, crystallization, and calcification
of tendons, which causes them to weaken and
predisposes them to rupture.
CLINICAL PRESENTATION
A classic presentation for acute Achilles tendon
rupture is a middle-aged male who participates
in strenuous activities involving sudden pivoting
on a foot or rapid accelerating as in recreational
sports. A snapping/popping sensation of the
tendon may be described by some patients,
followed by an acute onset of severe pain in
the posterior ankle. Patients who also attempt
new strenuous activities without proper training
and stretching or who typically lead a sedentary
lifestyle are more likely to experience some kind
of Achilles tendinopathy, including ruptures. It
is important to note that pain is not always an
initial presenting symptom.
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13.
PHYSICAL FINDINGS
A palpable delve in the posterior distal third of
the Achilles tendon may be appreciated with
increased dorsiflexion of the ankle. Depending
on the severity of the rupture pain, ecchymosis
and diffuse edema may be noted. The patient
may present with an antalgic gait and the
inability to perform a single heel raise on the
injured limb secondary to weakened plantar
flexion power.
ETIOLOGY/MECHANISM OF
INJURY
Indirect trauma is most often associated with
Achilles tendon ruptures, which typically fall
under three categories: mechanical, vascular,
and poor tissue quality.
• Mechanical: Involves variations of a rapid
loading process on an already tensed tendon
such as a sudden dorsiflexion of the ankle
with the knee extended while an eccentric
load is applied.
• Vascular: Located 2 to 6 cm proximal to the
Achilles tendon insertion is a known area of
hypovascularity.
• Poor tissue quality: Tendonitis, which is
inflammation that occurs within the tendon
after an acute injury, and tendonosis, which
is a degeneration process from repetitive
tears related to chronic injuries, are known to
weaken the tendon before it is ruptured. This
often occurs in the form of repetitive micro-
trauma from improper training techniques.
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
• Achilles tendinopathy (tendinosis vs.
tendonitis)
• Retrocalcaneal bursitis
• Ankle sprain
• Calcaneal avulsion fracture
• Partial rupture of gastrocnemius
• Plantaris rupture
• Partial rupture of gastrocnemius
• Os trigonum syndrome
• Calcaneal apophysitis
WORKUP
A thorough history and physical examination,
along with a high clinical suspicion, is key to
distinguishing Achilles tendon ruptures from
other Achilles tendinopathies. The clinical his-
tory in most presentations is very specific, and
the physical examination is usually diagnostic.
The following is a list of specific clinical tests
and imaging modalities.
• Simmonds-Thompson’s test (Fig. E1): Also
known as the “calf squeeze test,” it is an
accurate means of detecting Achilles tendon
ruptures. The patient is placed in a prone
position with the affected limb hanging off
the examination table with the knee flexed.
While squeezing the gastrocnemius, the clini-
cian evaluates for the presence or absence of
ankle plantar flexion. If ankle plantar flexion
is absent, the test is said to be positive and
indicative of Achilles tendon rupture.
• Matles test (knee flexion test): The test is
an additional physical examination finding
utilized to assess Achilles tendon ruptures.
The patient is placed in the prone position
with the knees flexed at 90 degrees. If the
injured foot falls in a neutral or dorsiflexed
position instead of a plantar flexed position
when compared to the contralateral limb, the
test of the injured limb is positive for Achilles
tendon rupture.
IMAGING STUDIES
• Ultrasound imaging may be used to assess
Achilles tendinopathy and is considered
by some the first-line imaging modality.
Ultrasound provides clinicians with a practi-
cal means of evaluating Achilles tendinopa-
thy and ruptures at the bedside.
• MRI (Fig. E2) is often utilized to further evalu-
ate Achilles tendinopathy, especially rup-
tures. Discontinuity of the Achilles tendon
can be seen on T2-weighted images, where
the signal in the tendon is increased at the
area of rupture and the tendon diameter is
increased. MRI provides greater anatomic
detail as well as greater accuracy in detect-
ing partial Achilles tendon tears. MRI has
proved to be superior to ultrasound in defin-
ing ruptures histologically.
TREATMENT
Initial treatment should consist of the PRICE
protocol (protection of the injured limb, rest,
ice, compression to reduce swelling, and eleva-
tion). Adequate analgesics for at-home use
can include acetaminophen and/or nonsteroidal
antiinflammatory drugs.
The typical course of immobilization of the
injured limb ranges from a minimum of 8 to 12
weeks. Over the past few yrs there has been a
trend in nonoperative management of Achilles
tendon ruptures that include accelerated pro-
tocol to rehabilitation. These accelerated pro-
tocols have been shown to improve outcomes
of nonoperative Achilles tendon management.
These protocols have the patient non–weight
bearing in a posterior splint or equinus short
leg cast with crutches for 2 weeks. A controlled
ankle motion walker with special sequential
heel wedges then follows this for the next 4
weeks of non–weight bearing with crutches.
After 4 to 6 weeks the patient may return to
regular shoe gear, with a heel wedge modifi-
cation for an additional 2 months. During this
period it is recommended that patients start
resistance exercises, proprioception and gait
retraining, and sport retraining.
SURGICAL TREATMENT
If surgical intervention is warranted, it should
be done within 7 to 14 days of the injury.
Proper timing of surgical repair is imperative to
postsurgical recovery. The inflammatory phase
of wound healing occurs within the first 7-14
days following an acute Achilles tendon rupture.
During this phase, vascularity to the injured ten-
don increases, aiding in postoperative healing.
 Achilles Tendon Rupture 13.e4

NORMAL RUPTURED
ACHILLES TENDON

Palpation of tendon

No palpable gap Palpable gap

Calf squeeze test

Ankle plantarflexes No movement

Knee flexion test (Matles test)

Ankle >90° Ankle <90°

FIG. E1 Tests for rupture of the Achilles tendon.1All tests are performed with the patient lying prone with
his or her feet extending over the end of the examination table. The patient’s asymptomatic side serves as a control
(for each test, a patient with an intact Achilles tendon is depicted on the left, compared with a patient with a rup-
tured Achilles tendon on the right). (1) Palpable gap in tendon (top): The clinician gently palpates the course of the
tendon, searching for gaps, which if present usually lie between 2 and 6 cm from the calcaneus.2 (2) Calf squeeze
test (Simmonds–Thompson test, middle): The clinician gently squeezes the patient’s calf in its middle third and just
below the place of widest girth, observing the ankle for movement. If the tendon is intact, the ankle should plantarflex.
Absence of movement or minimal movement is a positive response. The normal plantar flexion of the ankle results
from compression of the soleus muscle, which bows the Achilles tendon posteriorly.3 (3) Knee flexion test (Matles test,
bottom): The clinician observes the position of the patient’s ankles as the patient flexes both knees to 90 degrees (the
knees may be flexed individually or simultaneously). The ankle remains slightly plantar flexed if the tendon is intact;
slight dorsiflexion or a neutral position of the ankle is the positive response. Thompson described the calf squeeze
test in 1962,2 pointing out that the test could be performed with the patient prone or kneeling on a chair. Simmonds
described the identical test in 1957.4 Matles described the knee flexion test in 1975.5 (From McGee S. Evidence-
based physical diagnosis, ed 4, Philadelphia, 2017, Elsevier. [1] Maffulli N: The clinical diagnosis of subcutaneous tear
of the Achilles tendon: a prospective study in 174 patients, Am J Sports Med 26[2]:266–270, 1998; [2] Thompson
TC, Doherty JH: Spontaneous rupture of tendon of Achilles: a new clinical diagnostic test, J Trauma 2:126–129, 1962;
[3] Scott BW, Chalabi AA: How the Simmonds–Thompson test works, J Bone Joint Surg Br 74B[2]:314–315, 1992;
[4] Simmonds FA: The diagnosis of the ruptured Achilles tendon, Practitioner 179[1069]:56–58, 1957; [5] Matles AL:
Rupture of the tendon Achilles, Bull Hosp Jt Dis 36[1]:48–51, 1975.)

The primary goal of surgical treatment of decreased operative times and decreased REFERRAL
Achilles tendon rupture is to reestablish ankle postoperative deep infections. Other open Acute and/or complete Achilles tendon rup-
plantar flexion. This is usually achieved when surgical procedures can involve lengthen- tures warrant surgical intervention. Acute
there is an end-to-end apposition of the dam- ing and flap-down methods to bridge the complete Achilles tendon ruptures are more
aged Achilles tendon. Several surgical tech- gap in the tendon. Multiple biologic grafts likely to have better postoperative outcomes
niques exist to repair the ruptured Achilles are available to augment and reinforce the if addressed within 14 days of initial injury.
tendon, which include percutaneous repair rupture site. After surgery, 10 to 12 weeks of Newer studies suggest that acute Achilles
and open operative techniques. Percutaneous immobilization followed by rehabilitation is tendon ruptures surgically managed within
repair has shown to be advantageous, with recommended. 48 hours of injuries tend to have less adverse
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Achilles Tendon Rupture 13.e5

A B C D
FIG. E2 Complete Achilles tendon rupture, managed nonoperatively with 6 weeks of ankle
casting in plantar flexion. A, Transverse T1-weighted magnetic resonance image (MRI). Shown is
severe Achilles tendinopathy (arrow). B, Sagittal short tau inversion recovery (STIR) MRI reveals tendon
fiber discontinuity with fluid-filled gap (arrows). Transverse T1-weighted (C) and sagittal STIR (D) MRIs
obtained in follow-up 18 months after casting show thinning and attenuation of the tendon but reestab-
lished tendon fiber continuity (arrow in C).

events postoperatively than those Achilles ten-
don ruptures that are surgically repaired after
3 days of initial injury. Orthopedic or podiatric
surgical consultation should be obtained for
symptomatic acute or chronic Achilles tendi-
nopathy or ruptures.
continued on a regular basis following Achilles RELATED CONTENT
tendon ruptures and particularly before engag- Achilles Tendon Rupture (Patient Information)
ing in any vigorous exercise.
• The patient should reduce his or her train- AUTHOR: COURTNY JOHNSON, D.P.M., M.S.H.S.
ing intensity during fluoroquinolone use and
anabolic steroid use.

PEARLS &
CONSIDERATIONS
• Patients who experience Achilles tendon rup-
tures may present with or without pain and
may still maintain their ability to ambulate or
flex their ankles. If pain is present, it usually
occurs 2 to 6 cm proximal to the Achilles
tendon insertion on the calcaneus.
• When evaluating Achilles tendinopathy, palpate
the course of the Achilles tendon with particular
attention to any edema, ecchymosis, or pal-
pable delve or discontinuity of the tendon.
• A positive Thompson’s test is an accurate
means for assessing Achilles tendon ruptures.
• Acute Achilles tendon ruptures should be
treated within 14 days. Surgical interven-
tion has been shown to decrease re-rupture
rates as well as restore calf muscle strength
sooner when compared to nonsurgical treat-
ment options.
PREVENTION
• Previous tendinopathy or previous Achilles ten-
don ruptures are known risk factors and are
associated with up to 10% of re-rupture rates.
• Physical therapy as well as physical rehabilita-
tion protocol should be maintained following
both operative and nonoperative therapies.
Eccentric and concentric exercise should be
SUGGESTED READINGS
Dakin SG, et al.: Chronic inflammation is a feature
of Achilles tendinopathy and rupture, Br J Sports
Med 52(6):359–367, 2017.
Deng S, et al.: Surgical treatment versus conserva-
tive management for acute Achilles tendon rup-
ture: a systematic review and meta-analysis of
randomized controlled trials, J Foot Ankle Surg
56:1236–1243, 2017.
Lantto I: A prospective randomized trial comparing
surgical and nonsurgical treatments of acute
Achilles tendon ruptures, Am J Sports Med
44:2406–2414, 2016.
Lim CS, et al.: Functional outcome of acute Achilles
tendon rupture with and without operative treat-
ment using identical functional bracing protocol,
Foot and Ankle Int 1:1–6, 2017.
Magnan B, et al.: The pathogenesis of Achilles ten-
dinopathy: a systematic review, Foot Ankle Surg
20:154–159, 2014.
Suzuki T, et al.: Retrocalcaneal bursitis precedes or
accompanies Achilles tendon enthesitis in early
phase of rheumatoid arthritis, Clin Med Insights
Arthritis Musculoskelet Disord 11:1–4, 2018.
Willits K, et al.: Operative versus nonoperative
treatment of acute Achilles tendon ruptures:
a multicenter randomized trial using acceler-
ated functional rehabilitation, J Bone Surg Am
92:2767–2775, 2010.

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For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.