Achilles Tendon Rupture

Overview

This StatPearls review by Shamrock, Dreyer and Varacallo, last updated in August 2023, covers Achilles tendon rupture, the most common tendon rupture in the lower limb. It occurs mostly in the third to fifth decade of life, often in recreational athletes during soccer, racket sports or basketball. Patients typically describe a sudden pain with a snap or pop and a feeling of being kicked in the calf. Incidence has been reported at up to 40 per 100,000 a year, and more than 20% are misdiagnosed, often as an ankle sprain.

Risk factors and mechanism

Risk factors include tendinopathy, fluoroquinolone antibiotics, corticosteroids (including injections), oral bisphosphonates, diabetes, hyperparathyroidism, inflammatory arthritis, end-stage kidney disease and poor conditioning. The tendon usually ruptures 2 to 6 cm above its insertion, where the blood supply is reduced.

Diagnosis

The patient cannot rise onto the toes and may show a palpable gap or bruising. The Thompson test, squeezing the calf with the patient prone, is 96 to 100% sensitive and 93 to 100% specific. Radiographs exclude fracture, and ultrasound or MRI can confirm the diagnosis, but MRI is only needed in ambiguous or chronic cases.

Treatment

Non-operative management (rest, bracing, functional rehabilitation) and repair both give good outcomes, and there is still debate. With modern rehabilitation, the difference in re-rupture rates is small, at a risk difference of 1.6%, whereas surgery carries more complications such as wound problems (5 to 10%) and infection. Surgery gives an earlier return to activity, and athletes are generally advised to have surgery. Minimally invasive repair carries a risk of sural nerve injury. Platelet-rich plasma has given contradictory results, and bone marrow aspirate concentrate has shown some benefit.

Rehabilitation and outcome

Protocols vary and depend on surgical or conservative treatment, with a trend toward earlier weight bearing and accelerated functional rehabilitation. Calf strengthening in the first year is important. Most patients do well, but professional athletes report inferior results, with more than 30% not returning to play in one study. Care is best delivered by an interprofessional team.