Synopsis
Identify acute Achilles rupture without being falsely reassured by residual plantar flexion, protect the tendon immediately, distinguish rupture from midportion and insertional tendinopathy, and coordinate functional rehabilitation, thrombosis assessment and selective surgery.
- Acute rupture typically feels like being kicked in the heel, with a pop, weak push-off and inability to perform a normal single-leg heel rise; pain may settle quickly and should not reassure.
- The high-yield bedside tests are a reduced resting plantar-flexion angle and absent or markedly reduced plantar flexion when the calf is squeezed with the patient prone and knees flexed.
- Residual active plantar flexion does not exclude rupture because tibialis posterior, toe flexors and peroneal muscles can still point the foot.
- First-line investigation is a confident clinical examination; ultrasound is used when findings are equivocal or gap and anatomy affect the plan, while routine MRI usually adds delay without changing acute care.
- First-line emergency management is immediate immobilisation in plantar flexion, avoidance of repeated dorsiflexion, urgent specialist pathway referral and documented VTE-risk assessment.
- Both functional non-operative bracing and operative repair can produce good outcomes; select treatment through shared decision using age-independent activity goals, gap, presentation delay, skin, comorbidity and rerupture versus wound risk.
- Achilles tendinopathy is treated first with education, temporary load adjustment and progressive calf loading for at least twelve weeks; insertional disease begins on level ground without forced heel-drop dorsiflexion.
- Do not inject corticosteroid into or around the Achilles tendon routinely because tendon weakening and rupture can outweigh temporary symptom relief.
Key red flags
A sudden acceleration, jump or push-off followed by a pop, weak gait and positive calf-squeeze test is an acute rupture until proved otherwise, even if the patient can still point the foot.
An open posterior-ankle wound over a suspected rupture requires immediate antibiotics, tetanus assessment and orthopaedic washout and repair planning.
Pale or cool foot, altered sensation, severe escalating pain, tense swelling or passive-stretch pain requires emergency neurovascular and compartment assessment.
Calf swelling, pleuritic pain, breathlessness, haemoptysis or unexplained tachycardia during immobilisation requires urgent venous-thromboembolism assessment.
Insertional pain with fever, skin breach, rapidly spreading erythema or systemic illness suggests infection rather than uncomplicated tendinopathy.
Investigation priorities
Confirm functional tendon discontinuity and avoid false reassurance from residual active plantar flexion.
Management branches
An acute event produces weak push-off, abnormal resting angle, palpable gap or positive calf-squeeze test.
- Stop further dorsiflexion testing, document skin and neurovascular status and place the ankle in the approved plantar-flexed boot or backslab.
- Give mobility and weight-bearing instructions that match the local acute rupture protocol and check the device before discharge.
- Assess VTE and bleeding risk, provide thrombosis and pressure-area safety-netting and arrange urgent specialist review.
- Use ultrasound only when examination is equivocal or the specialist pathway needs gap information; do not wait for MRI routinely.