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Achilles tendon rupture
An acute Achilles rupture happens during a sudden push-off, usually in middle age during occasional sport; the Thompson squeeze test diagnoses it, and treatment — functional non-operative care in a boot with the foot pointed down, or surgery — gives similar results when rehabilitation starts early.
Why it matters in the exam
The typical stem describes a man aged 30–50 who played basketball, tennis or squash after a long break, felt as if someone had kicked him in the calf and heard a snap. The diagnosis is often missed, because the patient can still point the foot down using other muscles (the long flexors and peroneals). The key test is the Thompson (or Simmonds) test: with the patient prone, the calf is squeezed, and with a torn tendon the foot does not move down. Other signs: a palpable gap in the tendon about 2–6 cm above the heel, and a resting foot position that is more upright than on the other side. Ultrasound confirms the diagnosis when examination is not clear. Risk factors include fluoroquinolone antibiotics, steroid injections near the tendon and previous tendinopathy. Surgery was once thought superior because of a lower re-rupture rate, but controlled trials showed that non-operative treatment with early functional rehabilitation — a boot with a raised heel, early weight-bearing and gradual reduction of the heel raise — achieves similar re-rupture rates and avoids the wound complications of surgery. Surgery is still considered in professional athletes, in late diagnosis and in rupture at the tendon's insertion into bone. A neglected rupture with a large gap sometimes needs reconstruction with a tendon transfer.
Key points
- Middle age, occasional sport, a feeling of being kicked in the calf.
- Thompson test — the foot does not move when the calf is squeezed.
- The diagnosis is missed because weak plantar flexion is still possible.
- Non-operative care with early rehabilitation and surgery — similar re-rupture rates.
- Risk factors: fluoroquinolones, steroids and tendinopathy.
Summary table
| Aspect | Functional non-operative care | Surgical care |
|---|---|---|
| Principle | Boot with raised heel, foot pointed down, early weight-bearing | Open or limited-incision repair of the tendon |
| Re-rupture | Similar to surgery when rehabilitation is early and structured | Low, similar to non-operative care with early rehabilitation |
| Complications | Venous thrombosis, some tendon lengthening | Infection, wound healing problems, sural nerve injury |
| Suitable candidates | Most patients, especially with diabetes, smoking or vascular disease | Professional athletes, late diagnosis, insertional rupture |
| Rehabilitation | Gradual reduction of the heel raise over about 8–10 weeks | Similar rehabilitation after surgery |
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Sources
- AAOS Clinical Practice Guideline, 2009 (reaffirmed) — Diagnosis and Treatment of Acute Achilles Tendon Rupture
- Campbell's Operative Orthopaedics, 14th ed. (2021) — Disorders of Tendons and Fascia
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.