Achilles tendon rupture

Anatomy and function of the Achilles tendon

The Achilles tendon connects the calf muscles (gastrocnemius and soleus muscles) with the heel bone (calcaneus). It transmits high forces and enables push-off when walking, climbing stairs and running. In the hindfoot it runs directly behind the ankle joint, surrounded by gliding tissue and close to the sural nerve.

• The body's highest tendon pulling forces, especially during sprints and jumps
• Relatively low blood flow in the middle third of the tendon (common tear zone)
• Neighborhood: retrocalcaneal bursa and Haglund exostosis can promote irritation

What is an Achilles tendon rupture?

An Achilles tendon rupture is a partial or complete separation of the tendon fibers. It typically occurs 2-6 cm above the heel bone (middle third). More rarely, bony parts tear away (avulsion) or there is a tear (partial rupture).

• Acute tear: a sudden event, often with a popping sound and loss of strength
• Chronic rupture: delayed detection; Tendon ends retract and the gap fills with scar tissue
• Partial rupture: painful, but occasionally initially resilient

Causes and risk factors

A combination of previous damage to the tendon and sudden stress is often the deciding factor. Microtrauma and degenerative changes reduce resilience.

• Sudden acceleration/deceleration (sprints, changes of direction, jumps)
• Previous Achilles tendon problems (tendinopathy, Haglund exostosis, bursitis)
• Inappropriate footwear or hard training surfaces
• Medications: Fluoroquinolone antibiotics, systemic or local corticosteroids
• Risk factors: older age, diabetes, smoking, obesity, muscular imbalances

Symptoms: How do I recognize an Achilles tendon rupture?

• Sudden, stabbing sensation or “whip crack” in hindfoot/calf
• Inability to stand on tiptoes or roll vigorously
• Swelling, bruising, palpable gap along the tendon
• Pain that may decrease after the event, loss of strength remains
• Walking is often still possible, but unsteady and without active standing on the toes

Warning signs: an audible pop, immediate loss of strength and a positive test result (e.g. Thompson test) strongly suggest a rupture.

Diagnostics: Examination and imaging

The diagnosis is based on clinical examination and is confirmed by imaging techniques. An early diagnosis is important in order to initiate the appropriate therapy.

• Clinic: Inspection, palpation (tendon gap), functional test
• Thompson Test: Compression of the calf does not induce plantar flexion in the event of a complete rupture
• Matles test: in the prone position the foot shows increased dorsiflexion in the event of a rupture
• Ultrasound: dynamically measurable, gap size (diastasis) and fiber path
• MRI: for unclear findings, partial tears, degenerative changes or surgical planning
• X-ray: if bony avulsions or accompanying pathologies are suspected

The gap size in defined positions (e.g. plantar flexion) helps justify conservative vs. surgical strategies. Comorbidities and activity goals will be included.

Differential diagnoses in the hindfoot area

Not every episode of hindfoot pain is a tendon tear. The following diseases can cause similar symptoms and are taken into account in the differential diagnosis:

• Retrocalcaneal bursitis (bursitis behind the heel)
• Haglund exostosis (bony prominence on the heel bone with friction)
• Tibialis posterior insufficiency (medial foot pain, arched arches)
• Peroneal tendinopathy or subluxation (lateral pain/instability)
• Nerve constriction in the tarsal tunnel or Baxter neuropathy (neuropathic pain, numbness/tingling)

Therapy: think conservatively first, operate in a targeted manner

The goal is a stable, functional tendon with the lowest possible re-rupture rate and quick, safe recovery from everyday life and sport. Conservative and surgical treatment can achieve comparable results – with appropriate indications and modern functional follow-up treatment.

• Conservatively suitable for: recent rupture, low diastasis in functional position, good tendon quality, low desire for surgery
• Consider surgery for: large diastasis, degenerative tendon structure, high performance demands in sports, avulsion, interposition, chronic/old diagnosed rupture
• Decision made individually based on clinic, imaging, activity profile and comorbidities

Conservative treatment

Conservative therapy relies on early functional immobilization in a protective position and gradual mobilization. It requires consistent cooperation and close control.

• Regular ultrasound checks check tendon adaptation
• No forced stretching in dorsiflexion in the first few weeks
• Eccentric strengthening is used in a phase-adapted manner
• Address risk factors: smoking, blood sugar, footwear, training control

Operational options

Operations aim at a safe adaptation of the tendon ends with sufficient sutures and low-tension reconstruction. The procedure depends on the type of crack, its height and the quality of the fabric.

• Percutaneous/minimally invasive tendon suturing: small accesses, suture systems; Be aware of the risk of sural nerve irritation
• Open tendon suture: for complex tears or poor tendon quality; if necessary with seam reinforcement
• Augmentation/tendon transfer (e.g. FHL transfer) for chronic rupture, re-rupture or severe degeneration
• Accompanying measures: debridement of degenerative tissue, treatment of bony spurs (e.g. Haglund) if indicated

Follow-up treatment follows a functional protocol similar to conservative therapy, often with stable full weight-bearing under protection slightly earlier. Careful wound control is essential.

Follow-up treatment and rehabilitation

A clearly structured rehabilitation program is crucial – regardless of whether the treatment is conservative or surgical. Strength, coordination and tendon quality build up over months.

• Orthosis management: gradually reduce heel wedges, check your gait regularly
• Physiotherapy: phase-appropriate mobilization, strengthening, proprioceptive training
• Return-to-Run: after passing functional tests (one-legged heel stand, symmetry of calf circumferences, pain-free hop tests)
• Return to Sport: depending on sport; Jump and change of direction only after sufficient load tolerance and force symmetry

Orientative time windows (very variable from individual to individual): everyday resilience usually after 8-12 weeks, hobby sports from approx. 4-6 months, intensive pivot or jumping sports often only after 9-12 months.

Possible complications and risks

• Re-rupture or elongation (increase in length) with strength deficit
• Wound healing disorders, infection (especially in open operations)
• Suralis nerve irritation or lesion (lateral numbness/paresthesia)
• Risk of thrombosis/embolism during immobilization
• Persistent pain with accompanying pathologies (e.g. bursitis, bony prominences) or tendinopathy

Careful indication, close follow-up care and risk factor management reduce the risk of complications.

Regenerative processes: realistic classification

In the case of acute Achilles tendon tears, the focus is on mechanical healing through adequate adaptation and functional follow-up treatment. Complementary procedures such as PRP are being discussed; the evidence for their superiority over standard therapies is currently heterogeneous.

• PRP/blood products: if necessary as a supplement in selected situations; Benefits, risks and costs should be weighed individually
• Shock wave therapy: more established in chronic tendinopathy than in recent ruptures
• No therapy replaces structured rehabilitation and load control

Everyday life, work and sport: What is realistic?

Returning to everyday life and work depends on the activity and the healing process. Over- or under-challenging in the first few weeks can have a negative impact on the course.

• Office/desk: often possible after 2-4 weeks (with orthosis, breaks in elevation)
• Standing/walking activities: often after 6-12 weeks, depending on the stress profile
• Physically heavy work/ladder work: more likely after 3-4 months or later
• Sports: first cycling/swimming (without fins) followed by running build-up; Jump/pivot sport in late phase according to test criteria

Self-help and prevention

• Warm up and progressive increase in load during training
• Eccentric calf muscle training for tendon conditioning
• Footwear with sufficient cushioning and heel support; If necessary, temporary heel wedges
• Reduce risk factors: abstain from nicotine, control blood sugar, adequate amount of training
• Early diagnosis of persistent Achilles tendon pain to prevent rupture

When should I seek medical attention?

• Immediately after a sudden popping sensation in the hindfoot with loss of strength
• When you can no longer stand on tiptoes
• If there is severe swelling/bruising and a palpable gap
• If you experience numbness, increasing pain or signs of infection
• If the course is unclear despite rest and painkillers

Until the examination: relieve pressure, elevate, cool, immobilize. Please no forced stretching.

Your appointment in Hamburg-Winterhude

Our orthopedic foot and ankle consultation is located at Dorotheenstrasse 48, 22301 Hamburg. We will promptly clarify your suspicion of an Achilles tendon rupture, discuss conservative and surgical options and accompany the rehabilitation with a transparent step-by-step plan.

Make an appointment conveniently online via Doctolib or by email. Bring any existing findings and, if necessary, sports/shoe information with you.