Achilles Tendon Injury

Overview

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The Achilles tendon is the largest and strongest tendon in the body, connecting the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). It plays a critical role in walking, running, jumping, and pushing off the foot. An Achilles tendon rupture occurs when the tendon partially or completely tears, typically during sudden acceleration, jumping, or abrupt changes in direction.

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Most ruptures occur approximately 2–6 cm above the tendon’s insertion into the heel bone, an area with relatively limited blood supply. Patients often report a sudden popping sensation or feeling as though they were kicked in the back of the ankle, followed by pain, swelling, and difficulty pushing off the affected foot. Achilles tendon ruptures require prompt evaluation to determine whether surgical repair or nonsurgical treatment is most appropriate.

Signs & Symptoms

An Achilles tendon rupture typically causes sudden pain and loss of function in the back of the ankle or lower leg. Common signs and symptoms include:

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• Sudden Pain: Sharp pain in the back of the ankle or calf, often occurring during running, jumping, or pushing off.

• Popping Sensation: An audible pop or snap at the time of injury, frequently described as feeling like being kicked in the back of the leg.

• Swelling & Bruising: Swelling and discoloration along the Achilles tendon, which may extend toward the heel.

• Difficulty Walking: Weakness or inability to push off the affected foot, resulting in an altered gait.

• Inability to Stand on Tiptoes: Difficulty or inability to perform a single-leg heel raise on the injured side.

• Palpable Gap: A noticeable indentation or defect along the tendon where the rupture occurred.

• Reduced Plantarflexion Strength: Significant weakness when attempting to point the foot downward.

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Important: Some patients with a complete Achilles tendon rupture can still walk or move their ankle. The ability to walk does not rule out a serious tendon injury.

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Evaluation & Diagnosis

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Diagnosis of an Achilles tendon rupture begins with a thorough medical history and physical examination to assess the extent of the injury. We will evaluate swelling, tenderness, tendon continuity, and ankle strength. The Thompson test, which involves squeezing the calf muscle to assess plantarflexion of the foot, is commonly performed to identify a complete tendon rupture.

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Diagnostic imaging may be used to confirm the diagnosis and determine the severity of the injury. Ultrasound can identify partial or complete tendon tears and evaluate tendon separation, while MRI provides detailed visualization of the tendon and surrounding soft tissues when the diagnosis or injury pattern is unclear. X-rays may also be obtained to evaluate for associated fractures or bony avulsion injuries.

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​Treatment for Achilles Injury

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Treatment of an Achilles tendon rupture depends on the severity of the injury, degree of tendon separation, patient activity level, and overall health. Both surgical and nonsurgical approaches aim to restore tendon continuity, strength, and ankle function.

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Nonsurgical Treatment: Selected Achilles tendon ruptures can be managed with immobilization in a cast or walking boot, typically with the foot positioned downward (plantarflexed) to approximate the torn tendon ends. This is followed by a structured rehabilitation program. Although effective in appropriately selected patients, nonsurgical treatment has historically been associated with higher rates of tendon re-rupture compared to surgical repair.

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Surgical Repair: Surgery involves directly reconnecting the torn tendon ends using specialized suturing techniques. Repair may be performed through an open or minimally invasive approach. Surgical treatment generally provides a lower risk of re-rupture, particularly in active individuals, but carries risks including infection, wound complications, and nerve injury.

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Re-Rupture Risk: A 2022 randomized clinical trial published in the New England Journal of Medicine reported re-rupture rates of 6.2% with nonsurgical treatment compared to 0.6% with surgical repair. 

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Regardless of the treatment approach, physical therapy and progressive strengthening are essential for restoring function. Treatment decisions are individualized based on your long-term goals.