REBEL Core Cast 116.0 – Achilles Tendon Rupture

Take Home Points

  • Achilles tendon rupture is a clinical diagnosis. The Thompson Test should be applied in all suspected cases.
  • Remember to brace or splint a rupture, even if suspected, in the resting equinus position for optimal healing and prevention of further injury.
  • Schedule follow up with orthopedics within 1 week for discussion of operative management vs early rehab protocols.

REBEL Core Cast 116.0 – Achilles Tendon Rupture

Achilles Tendon Rupture Exam (

Physical Exam

  • May have palpable gap or deformity in region of tendon.
  • Weakness with plantar flexion.
  • Increased resting ankle dorsiflexion on affected side in prone position with knees bent .
  • Usually in absence of bony tenderness unless accompanied by other injury
  • Thompson Test (video)
    • Place the patient in the prone position, with feet hanging over the end of a stretcher or table. If patient is not able to lay down/there are no stretchers, the patient can kneel on a stool or chair
    • Squeeze the calf of the normal limb. You will notice the squeeze will cause the ankle to plantarflex appropriately
    • Squeeze the calf of the limb with the suspected Achilles tendon rupture.  You will notice the squeeze will cause no motion if there is a full rupture/tear, and diminished motion if there is a partial tear
    • Performance Characteristics (Garras 2012)



(+) LR

(-) LR






  • X-Rays
    • Used to rule out other or concurrent pathology
    • May show soft tissue swelling and destruction of pre-Achilles fat pad (Kager’s Fat Pad)
    • Findings are non-specific as tear of tendon unable to be visualized
  • Ultrasound
    • Ultrasound is helpful if obvious findings present and to distinguish between partial vs complete tears, however only around 50% sensitive for detecting only partial tears (Kayser 2005)
  • MRI
    • Gold-standard imaging modality
    • Rarely, if ever, necessary in the ED
    • Used for equivocal physical exam/alternate imaging findings or for assessing the severity of the tear for possible operative management
    • Findings
      • A full-thickness tear often shows a tendinous gap filled with edema or blood
      • Complete rupture shows retraction of tendon ends

ED Management

    • Provide analgesia
    • Tendon stabilization in an optimal healing position
      • Functional bracing/splinting in resting equinus/talipus equinus
      • AO splint/brace in 20 degrees of plantar flexion for 4-6 weeks (may use tall CAM boot with 20 degrees wedge inserts)
      • All patients should be non-weightbearing
        • Any weight-bearing can convert a partial tear to a complete tear
        • Maintain non-weightbearing status until see orthopedics (within 1 week)
        • After evaluation by orthopedics, early weight-bearing and early ROM exercises yield better outcomes (can be as early as 2 weeks)
  • Referral to rehab warranted to improve plantar flexion and decrease risk of re-rupture
    • ED Ortho consultation: patients with open wounds in the area of trauma, or with concomitant fractures
    • Operative Management is usually reserved for acute ruptures (approximately <6 weeks) of full thickness with large tendon gaps, failed conservative treatment of partial thickness tears, or high performance athletes
      • These cases will be determined during follow up with orthopedics and may warrant outpatient MRI to assess severity of tear


    • For conservative management, there is no significant difference in plantar flexion strength (Willits, 2010)
    • Some increased risk of re-rupture compared to operative management, although review of evidence shows that this may not be significant if patients used structured, accelerated rehab protocol.
      • Protocol includes initially non-weightbearing cast with the foot in equinus position as described above, then transitioned to a pneumatic walker with elevated heels (elevation gradually reduced biweekly), and physical therapy to improve gait, strength, and mobility. (Wallace 2011)
    • If addressed early and appropriately, most patients have good self-reported long-term outcomes regardless of the treatment modality


Orthobullets: Achilles Tendon Rupture


  • Sheth U et al. The epidemiology and trends in management of acute Achilles tendon ruptures in Ontario, Canada: a population-based study of 27,607 patients. Bone Joint J. 2017; 99-B(1): 78-86. PMID: 28053261
  • Chiodo CP, Wilson MG. Current Concepts Review: Acute Ruptures of the Achilles Tendon. Foot Ankle Int 2006; 27(4): 305-13. PMID: 16624224
  • Leppilahti J, Orava S. Total Achilles tendon rupture. A review. Sports Med. 1998; 25(2): 79-100. PMID: 9519398 
  • Kayser R et al. Partial rupture of the proximal Achilles tendon: a differential diagnostic problem in ultrasound imaging. Br J Sports Med. 2005; 39(11): 838-42. PMID: 16244194
  • Margetic P et al. Comparison of ultrasonographic and intraoperative findings in Achilles tendon rupture. Coll Antropol. 2007; 31:279-284. PMID: 17598414
  • Garras DN et al.  MRI is Unnecessary for Diagnosing Acute Achilles Tendon Ruptures: Clinical Diagnostic Criteria. Clin Orthop Relat Res 2012; 470(8): 2268-2273. PMID: 22538958
  • Willits K et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation .J Bone Joint Surg Am. 2010; 92(17): 2767-75. PMID: 21037028
  • Wallace RG et al. The non-operative functional management of patients with a rupture of the tendo Achillis leads to low rates of re-rupture. J Bone Joint Surg Br 2011; 93(10):1362-6. PMID: 21969435
  • Erickson BJ. Is Operative Treatment of Achilles Tendon Ruptures Superior to Nonoperative Treatment? Orthop J Sports Med. 2015; 3(4): PMID: 26665055

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie)

Cite this article as: Anand Swaminathan, "REBEL Core Cast 116.0 – Achilles Tendon Rupture", REBEL EM blog, January 24, 2024. Available at:

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