Achilles Rupture

An Achilles rupture is a complete tear of the tendon that joins the calf muscle to the heel. It happens in an instant — usually a push-off or a lunge in sport — and it is frequently mistaken for a bad calf strain, because most people can still walk on it. It needs to be diagnosed and treated early: the tendon ends pull apart within days, and the options narrow as the gap widens. If you think you have ruptured your Achilles, see a doctor today rather than waiting for it to settle.

How it happens

The tendon usually tears two to six centimetres above the heel, where its blood supply is poorest. The typical patient is between thirty and fifty, fit but not training every day, and playing a sport with sudden acceleration — basketball, netball, football, tennis, squash. A tendon that has been quietly degenerating is more likely to go, which is why people with Achilles tendinopathy, those who have had a steroid injection near the tendon, and those on certain antibiotics or long-term steroid tablets are at higher risk. Occasionally it tears from a direct blow or a fall.

How to tell

• a sudden sharp pain at the back of the ankle, often with an audible snap or pop

• the feeling of being kicked or hit from behind — many people turn round to see who did it

• difficulty pushing off, going up on tiptoe on that leg, or climbing stairs

• a gap you can feel in the tendon above the heel, with swelling and bruising later

• a flat-footed limp: walking is still possible because other tendons can point the foot down, which is why as many as one in four ruptures is initially missed

The pain often settles surprisingly quickly, which adds to the confusion. Loss of power is the giveaway, not the pain.

What to do now

Get the ankle assessed the same day — your GP, an urgent care clinic or an emergency department. Keep the foot pointed down and the leg elevated in the meantime, and do not try to walk it off. The diagnosis is made by examination: with you lying face down, squeezing the calf normally makes the foot point downward, and with a ruptured tendon it does not. The gap can usually be felt. An ultrasound confirms the tear and measures the distance between the ends; an MRI is occasionally needed when the picture is unclear or the injury is old.

Surgery or a boot?

Both approaches produce good results, and this is the decision worth understanding properly. A ruptured Achilles heals whether or not it is stitched, provided the ends are held close together while it does. Modern non-surgical treatment — a boot with the foot pointed down, early weightbearing and a structured exercise programme — has closed much of the gap that used to exist between the two.

The differences that remain:

• Re-rupture — lower after surgery, though the difference has narrowed with functional rehabilitation.

• Wound problems — a risk of surgery. The skin over the Achilles is thin, and infection or a slow-healing wound is the complication that matters most.

• Tendon length and push-off strength — without surgery the tendon can heal slightly long, which weakens the calf. Stitching the ends together restores the correct tension.

• Nerve injury — a small risk with surgery, causing numbness on the outer foot.

Surgery tends to be recommended for younger and more active people, for those returning to demanding sport, where the gap between the ends is large on ultrasound, and where the injury is more than a couple of weeks old. Non-surgical treatment is often preferred where wound healing is a concern — people who smoke, have diabetes or poor circulation — and for less active patients. Neither is the default; the decision is made with you.

Non-surgical treatment

The leg goes into a boot with wedges under the heel that hold the foot pointed down, so the tendon ends sit together. You start putting weight through the boot within the first fortnight. Over the following six to eight weeks the wedges are removed one at a time, bringing the ankle back to neutral, and physiotherapy begins. The boot comes off at around ten weeks, and strengthening continues for months afterwards. The boot is worn day and night in the early weeks — a stumble without it in the first two months is the commonest cause of re-rupture.

Surgery

The repair brings the torn ends together and stitches them at the correct tension. Dr Janan performs this as day surgery or overnight stay, using a small incision where able. Where the injury is weeks old and the ends have retracted, the gap has to be bridged with tissue from nearby — usually the tendon that bends the big toe — which makes the operation larger and the result less predictable. The operation itself is described on the Achilles repair page.

Recovery

Recovery follows the same staged path whether or not you have surgery, and it is measured in months:

• First two weeks — plaster or boot with the foot pointed down; leg elevated; the wound checked at two weeks if you have had surgery

• Two to six weeks — walking boot with heel wedges, weightbearing as advised, wedges reduced step by step

• Six to twelve weeks — slowly coming out of the boot into supportive shoes; physiotherapy for calf strength and a normal walking pattern

• Three to six months — building strength and control; straight-line running towards the end of this period

• Six to twelve months — return to full sport for most people; calf strength is the last thing to recover and can take a year or more

Driving a manual car, or an automatic with a right-sided injury, is generally possible once you are out of the boot and can brake hard — around ten to twelve weeks.

Risks

Both routes carry risk, and they are not the same risks.

Without surgery. Re-rupture and calf weakness are both more common without surgery. Re-rupture usually happens in the first few months, at the point where the tendon feels better than it is. The weakness comes from the tendon healing in a slightly lengthened position: it shows up later as reduced push-off — difficulty with a single-leg heel raise, on stairs or running. What you avoid is a wound and an anaesthetic.

With surgery. Repair gives a lower re-rupture rate and a stronger calf, but adds risks of its own. The skin over the Achilles is thin, so wound breakdown and infection are the main concern, and this is the reason repair is approached cautiously in smokers and in people with diabetes or poor circulation. The sural nerve runs close to the tendon and can be bruised or caught, leaving numbness along the outer border of the foot. The scar itself can stay tender. There is also the risk of the anaesthetic.

Either way. Both paths carry a risk of stiffness and of a blood clot in the leg — the clot risk is real while the leg is immobilised and is discussed with you before treatment starts. And an old or neglected rupture is harder to treat than a fresh one, whichever route is chosen.

Dr Janan's approach

Dr Janan Chandrananth is a foot and ankle orthopaedic surgeon who completed fellowship training in Bristol and in Tokyo, the latter under a past president of the Japanese Society for Surgery of the Foot. He treats Achilles ruptures both surgically and non-surgically, and both pathways are genuinely available here, so the discussion is about which suits your tendon, your health and your goals.

Early review matters more than which path you take. Acute ruptures are seen quickly — contact the rooms and say what has happened.