The Achilles tendon is a crucial structure that connects the calf muscle to the heel bone and allows for movement of your foot an ankle.
Although it’s the largest, thickest, and strongest tendon in the body, the Achilles can succumb to injury—namely, partial or full-thickness tears. These injuries can require treatment with nonoperative or surgical methods.
What Is a Ruptured Achilles?
“When it ruptures, the Achilles tendon can tear near the heel bone, or it can tear near where the tendon meets the calf muscle,” says Cleveland Clinic orthopedic surgeon Anthony Egger, MD, who is fellowship trained in sports medicine and pediatric orthopedic surgery. A ruptured Achilles can be partial or complete. “In orthopedics, we use rupture and tear to mean the same thing,” he explains.
Achilles Tendon Rupture Causes and Risk Factors
Common causes of a ruptured Achilles tendon are sports injuries and accidents. Achilles rupture is more common in those who are older, male, and who have a more active lifestyle. Fluoroquinolone antibiotics and previous injections into the tendon have been shown to increase the risk of Achilles tendon rupture.
Moreover, suddenly resuming intense physical activity after a long time off can be a risk factor for an Achilles tendon tear. This injury has become more common recently, and Dr. Egger explains there was a spike after the inactivity many people experienced during the COVID-19 pandemic.
“Achilles ruptures most commonly happen with an explosive movement,” he says. “The force then goes through the tendon, and it can tear the tendon. Some risk factors for rupture are not being warmed up, having a tight Achilles, playing cutting-type sports, or even just some bad luck.”
Achilles Tendon Rupture Symptoms
Classic symptoms of a ruptured Achilles are a pop or snap followed by immediate pain.
“People will say that they feel like somebody kicked them in the back of the calf or ankle, and oftentimes they’ll look around and no one’s around them,” Dr. Egger says. “It is a sharp, acute pain, especially a full-thickness rupture where it happens suddenly.”
In a complete tear, the calf muscle can become disconnected and move up the leg. Usually, the pain is so bad and alarming that people go to the emergency room or urgent care. If you are concerned about an Achilles rupture, seek medical attention immediately or within a few days.
Achilles Tendon Tear Diagnosis
Most of the time a healthcare provider can make the diagnosis in the office based on clinical exams. “Often, you can feel a palpable defect in the back of the ankle,” Dr. Egger says.
A physician might use a Thompson test, in which you lie on your belly and the provider squeezes your calf. Squeezing the calf on an intact Achilles will automatically flex the foot, whereas this motion will be absent in a torn Achilles. A magnetic resonance imaging (MRI) scan can help show the severity and exact location of the tear, which in certain cases can aid in determining the treatment approach.
Achilles Tendon Rupture Treatment Options
Nonsurgical treatments are an option for both partial or full-thickness Achilles tears and may be the preferred option for tears closer to the calf muscle, where it is more difficult to repair surgically. The nonsurgical approach gives time for that tendon to scar in and heal, Dr. Egger explains.
Nonsurgical Achilles tendon treatment starts with a splint, with the foot in a flexed down position. You will avoid weight-bearing on the affected foot and ankle for about two weeks and then wear a walking boot with some wedges to keep your foot in that flexed position. The wedges are gradually removed over four to six weeks to get the foot into a normal walking position. Physical therapy will help work on range of motion and strengthening.
The two main approaches to Achilles tendon surgery are an open technique and a minimally invasive procedure. The open technique involves an approximately 3-inch incision on the back of the ankle at the level of the Achilles tendon. The surgeon often repairs the torn tendon with sutures. Open surgery remains the gold standard for treatment, and people usually recover well afterward.
More recently, surgeons have developed minimally invasive techniques to bring the tendon back together with very small incisions. Minimally invasive surgery carries a slightly increased risk of nerve injury but a lower risk of wound complications, compared with open techniques. After surgery, the approach to splinting and healing is similar to the nonsurgical approach.
A Norwegian study published in 2022 in the New England Journal of Medicine compared open and minimally invasive surgery with nonsurgical treatments in 554 people, ages 18 to 60, presenting with an Achilles rupture. At one year, the researchers found no significant differences in measures of recovery, physical activity, and symptoms among the study groups. However, the risk of tendon re-rupture was higher in the nonoperative group, compared with their surgical counterparts, while the risk of nerve injuries was higher in those treated with minimally invasive surgery, the study found.
“Foot and ankle surgeons who do this surgery a lot are doing the more minimally invasive techniques, especially in a healthy person,” Dr. Egger explains.
The risk of re-rupture with not fixing the Achilles tendon surgically is especially increased in a more active person, but “in an older or more sedentary person, you absolutely do not need to do surgery,” Dr. Egger says. “Having an informed conversation with your surgeon can determine whether surgery is right for you. People still can have really good outcomes with or without surgery, depending on their tear pattern and what their goals are.”
Achilles Tendon Rupture Recovery Time and Rehabilitation
Typically, recovery entails refraining from putting weight on the affected foot and ankle for two weeks, followed by four to six weeks of wearing a walking boot and gradually returning the foot to a normal position. Taking part in physical therapy can help improve strength and range of motion in your foot and ankle.
Regardless of the treatment approach, a full return to activity and playing sports typically does not happen until nine months after the injury or surgery.
Achilles Tendon Rupture Complications
The main risks with surgery are nerve injuries, repeat rupture of the tendon, and surgical complications, such as infection and risks from anesthesia.
Matching the treatment approach to your individual characteristics, age, and lifestyle can help minimize complications. For instance, a person at risk for wound complications, such as someone with diabetes, might be a better candidate for nonoperative treatment.
To minimize the risk of re-rupture, follow your surgeon’s advice for activity restrictions and caring for surgical wounds.
Prevention Tips
You can’t fully prevent a ruptured Achilles, but Dr. Egger recommends stretching the Achilles tendon and calves before intense activity to reduce your risk.
“Make sure that your calf is nice and stretched before you go,” he says. “Especially if you’re a little bit older, warm up before you just get out there.”e
