Achilles Tendon Rupture: Symptoms, Treatment, and Recovery Time for an Achilles Tendon Rupture

The Achilles tendon (tendinum calcaneum) is the thickest and strongest tendon in the human body. It connects part of the leg’s flexor muscles to part of the foot’s skeleton. 

The tendon originates from the triceps surae muscle, the calf muscle. Extending from this muscle, it runs steeply upward and becomes significantly thinner. Its narrowest point is located about four centimeters from its origin. It then widens again and ultimately attaches to the heel bone.

In total, the Achilles tendon is between 15 and 20 centimeters long.

Its most important function is plantar flexion—that is, bending the foot or toes toward the sole of the foot. It also enables the foot to be lowered at the ankle joint.

The Achilles tendon therefore plays a crucial role, especially in walking and running.

An Achilles tendon tear (ICD code: S86.0) is also known as an Achilles tendon rupture. It refers to a complete or partial tear of the Achilles tendon.

Such a rupture is rarely caused by external force. Rather, the tear results from chronic overuse, such as excessive or improper athletic training. The tear often occurs a few centimeters above the heel bone, where the tendon is most vulnerable.

The tendon often tears at its narrowest point, but ruptures can occasionally occur at the tendon’s insertion as well.

The location of the Achilles tendon at the back of the foot and an illustration of an Achilles tendon rupture © Henrie / Fotolia

After an Achilles tendon rupture, the ankle joint is no longer fully functional, leading to restricted movement.

Depending on the type of injury, an Achilles tendon rupture can be treated conservatively or surgically. 

An Achilles tendon rupture is a common sports injury. The tendon usually tears due to a sudden and intense strain. In particular, fast sprints involving abrupt stops and frequent sudden changes in direction place significant stress on the ankle joint. Sports that pose a risk to the Achilles tendon include, for example,

• tennis,
• soccer,
• skiing, or
• running.

In untrained individuals, the Achilles tendon can tear even under relatively light stress.

Quick changes of direction during sports are usually the cause of an Achilles tendon rupture © pavel1964 / Fotolia

As a general rule, however, a healthy Achilles tendon does not tear. In most cases, damage to the tendon tissue is already present before the actual tear occurs.

For example, inflammation caused by tiny tears can compromise the tendon’s structural integrity. Conditions such as Achilles tendinopathy or Haglund’s deformity fall into this category.

Such tendon damage occurs particularly frequently in conditions such as

• osteoarthritis,
• gout, or
• diabetes mellitus

. However, prolonged high levels of stress can also cause lasting damage to the tendon tissue.

In addition to intense sports involving sudden movements, there are other risk factors for an Achilles tendon rupture. These include

• congenital or acquired foot deformities (such as flat feet),
• inappropriate footwear, or
• shortened calf muscles.

A previous partial Achilles tendon tear also increases the likelihood of a second, usually complete, rupture.

The risks for an Achilles tendon rupture include both active patients with high training loads and older patients with pre-existing damage to the tendon tissue.

The Achilles tendon can be affected by various conditions © bilderzwerg / Fotolia

An Achilles tendon rupture may be preceded by

• chronic Achilles tendon irritation (Achillodynia) or
• inflammation of the tendon

, manifesting as pain when the calf muscles are tensed or stretched. Prolonged strain on the ankle joint can also cause pain.

The Achilles tendon rupture itself is accompanied by a loud, whip-like sound. This so-called “whip crack” is particularly audible in cases of rupture resulting from very intense strain or a sudden movement.

Immediately after the snap, those affected feel severe, stabbing pain above the heel. Due to the specific nature of the pain, the injured person may initially mistake the rupture for a kick to the calf or heel.

Shortly after the rupture, indentations and/or bruises become visible and palpable in the area above the heel. The back of the ankle and the calf appear swollen.

Due to the injury, the tip of the foot can no longer be lowered toward the sole of the foot. Running is completely impossible in most cases; walking is occasionally possible but accompanied by severe pain. However, the foot can no longer roll forward under any circumstances.

The doctor usually recognizes an Achilles tendon rupture based on the characteristic signs on the foot. To confirm his suspicion of an Achilles tendon rupture, he asks the patient to describe the exact circumstances of the accident (medical history).

During the physical examination, the doctor pays particular attention to visible or palpable indentations in the area of the Achilles tendon, as well as to bruising.

The Thompson test provides further clues. In this test, the patient lies on their stomach with the injured foot hanging freely off the examination table. The doctor then compresses the calf muscles with his hands. If the Achilles tendon is intact, the toes reflexively move toward the sole of the foot. In this case, the Thompson test is negative.

If the Thompson test is positive, the reflex does not occur. This is a clear indication of an Achilles tendon rupture.

Additionally, imaging techniques can be used to make a diagnosis. An orthopedic surgeon can rule out a bony avulsion using an X-ray. In this type of injury, not only would the Achilles tendon be affected, but also parts of the bone.

Using an ultrasound examination (sonography), the doctor examines the site of the tear more closely. This allows the doctor to assess how far apart the ends of the tendon are. This is particularly important for selecting the appropriate treatment.

If the ultrasound examination does not provide clear results, magnetic resonance imaging (MRI) can provide further details.

Treatment for an Achilles tendon rupture depends on the severity of the tear. It can be managed either through conservative treatment or through surgery. The goal of treatment is to restore full function and load-bearing capacity to the tendon and ankle. 

Conservative Treatment of an Achilles Tendon Rupture

Surgery is not always necessary to treat an Achilles tendon rupture. In some cases, conservative treatment may be sufficient:

• in the case of a partial tear,
• in patients who are not very active in sports,
• when there is a higher risk of complications from surgery, such as due to pre-existing conditions.

For conservative management, patients are fitted with a lower-leg cast. The treatment involves immobilizing the foot. The foot is immobilized in a pointed-toe position for two weeks. Afterward, the cast is replaced with shoe or boot orthoses that are raised in the heel area. This pointed-toe position allows the tendon ends to heal together more easily.

Over the course of conservative treatment, the orthopedic surgeon gradually adjusts these orthoses to better match the foot’s natural position.

To monitor the success of the treatment, the doctor also performs ultrasound examinations at regular intervals.

After treatment, the patient must keep the affected foot at rest for some time © sunnychicka / Fotolia

However, conservative treatment is only possible if the tendon ends can still come into contact with one another. If the tendon ends are very far apart, they can no longer fuse together and must be reconnected surgically.

Surgical Treatment of an Achilles Tendon Rupture

Surgery is primarily performed on young athletes or in cases of severe tears. The advantage of surgery is that, compared to conservative treatment, the Achilles tendon is less likely to tear a second time. However, as with any other surgery, complications can occur during the procedure.

During the procedure, the surgeon sutures the ends of the tendon back together. To do this, the surgeon makes an incision directly over the Achilles tendon and opens the tendon sheath that surrounds it. In most cases, a special suture material is used to suture the tendon, which dissolves on its own after a few weeks.

To promote the healing process, patients are fitted with a cast for a few days following the surgery.

With both conservative and surgical treatment, it is important to put weight on the foot again as soon as possible. Limited physical therapy may be beneficial in this regard. However, athletic activities are not possible again until several months later.

The course of the condition, the healing time, and the prognosis depend primarily on the treatment. Appropriate, early treatment with supervised follow-up care by a physical therapist is of the utmost importance. In many cases, this allows for the restoration of ankle function and the tendon’s load-bearing capacity.

Follow-up care usually begins after six weeks and lasts a total of about 6 to 8 weeks. The recovery time can vary from patient to patient; it often takes several months after an Achilles tendon rupture to regain full strength. After about six months, most patients can resume sports without pain or even participate in competitions.

Competitive athletes, however, rarely return to their previous level of performance after an Achilles tendon rupture. In many cases, they must end their careers.

Early medical treatment is important to prevent complications. As recovery progresses, physical therapy should begin to specifically rebuild mobility and strength in the ankle joint.

1. How does an Achilles tendon rupture occur?
An Achilles tendon rupture is usually caused by a sudden, intense strain—such as during sports or due to abrupt movements of the ankle joint. The tendon often ruptures a few centimeters above the heel bone, where it is most vulnerable.

2. What are the signs of a rupture?
Typical signs include a loud popping sound, sharp pain, and swelling above the heel. Those affected can no longer actively lower their foot or stand on their tiptoes. A visible indentation on the back of the ankle may also indicate a torn tendon.

3. How is the diagnosis made?
In addition to a physical examination and the Thompson test, imaging techniques such as ultrasound or MRI are used. This allows the orthopedic surgeon to assess the severity of the Achilles tendon tear and determine whether surgical treatment is necessary.

4. How long does it take to heal after an Achilles tendon rupture?
The recovery time depends on the type of treatment. After conservative treatment with a cast or a special shoe, gradual weight-bearing usually begins after six weeks. Overall, recovery takes about six to eight weeks until patients can walk normally again—athletic activities are not recommended until several months have passed.