Achilles tendon rupture
A complete or partial tear of the Achilles tendon, usually occurring suddenly during sport. Patients typically describe being kicked in the back of the leg, followed by an inability to push off the foot. Requires prompt assessment and a decision between surgical and non-surgical treatment.
📊 Achilles tendon ruptures affect approximately 1 in 12,000 people per year in the UK, with rates rising in recent decades as participation in middle-aged recreational sport has increased. Around 80% occur during sport.
What is an Achilles tendon rupture?
The Achilles tendon is the largest and strongest tendon in the body, joining the calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). It transmits enormous forces during walking, running, and jumping. A rupture is a complete or partial tear of the tendon, usually occurring 2-6cm above where it attaches to the heel - the area with the poorest blood supply.
Ruptures usually happen suddenly during an explosive push-off movement - jumping, sprinting, or quickly changing direction. Patients classically describe feeling a sudden blow or kick to the back of the leg, sometimes hearing an audible pop, followed by an inability to push off the foot. The pain often settles surprisingly quickly, leading some patients to underestimate the injury.
Modern treatment offers two main pathways. Non-surgical treatment in a walking boot with functional rehabilitation gives outcomes very similar to surgery, with the main difference being a slightly higher re-rupture rate (around 6-12% non-surgical vs 2-5% surgical) balanced against the risks of surgery itself. The choice is increasingly patient-centred, taking into account age, activity demands, and personal preference.
Common mechanisms
- Sudden explosive push-off during sport (jumping, sprinting, racquet sports)
- Direct trauma to a tensioned tendon
- Underlying degenerative changes in the tendon (often present)
- Quinolone antibiotics (a recognised risk factor)
- Steroid injections directly into the Achilles tendon
- Sudden return to sport after a period of inactivity
Who is at risk? Male sex (around 5 times more common), age 30-50 years, occasional or weekend sport participation, fluoroquinolone antibiotic use, oral steroids, and underlying inflammatory conditions all increase risk. Previous Achilles tendinopathy is also a risk factor.
Symptoms
Symptoms typically begin at the time of injury and can vary depending on the severity:
- Sudden sharp pain in the back of the leg or ankle - often described as being kicked or hit
- Audible pop or snap at the time of injury
- Inability to push off the foot or rise onto tiptoes on the affected side
- Bruising and swelling in the back of the lower leg
- Palpable gap in the tendon a few centimetres above the heel (in complete ruptures)
- Pain may improve quickly, which can be misleading
When to seek help: Attend A&E or an urgent care service on the same day if you suspect an Achilles rupture. Delay in diagnosis (beyond 2 weeks) makes treatment significantly more difficult. The Simmonds-Thompson calf squeeze test is highly sensitive for complete rupture.
How is it diagnosed?
Your foot and ankle specialist will take a detailed history and examine the foot. The following investigations may be arranged to confirm the diagnosis:
- Clinical examination - palpable gap in the tendon and positive Simmonds-Thompson test (no plantarflexion on calf squeeze)
- Ultrasound - the imaging of choice. Confirms diagnosis, locates the rupture, and assesses the gap between the torn ends
- MRI - reserved for complex cases or when ultrasound is inconclusive
- X-ray - normal in most cases but may show a small avulsion fracture at the heel insertion
Up to 25% of Achilles ruptures are missed at the first medical contact, because pain often settles quickly and some plantarflexion is preserved by other tendons. Any patient with a sudden snapping sensation in the calf followed by difficulty walking warrants a Simmonds-Thompson test and ultrasound.
Treatment pathway
Treatment depends on the severity of the injury, your age, and your activity demands. Many injuries can be managed without surgery; others require surgical fixation.
Equinus cast or boot
The foot is held in a pointed-down (equinus) position immediately to bring the torn ends together. This applies whether surgery or non-surgical treatment is chosen, and is best applied within the first 1-2 weeks.
Functional rehabilitation in a walking boot
A structured programme using a walking boot with adjustable heel wedges. Heel wedges are gradually removed over 8-10 weeks, bringing the foot back towards a neutral position. Early weight-bearing is encouraged. Modern outcomes are very similar to surgery for most patients.
Open or percutaneous repair
The torn tendon ends are surgically reconnected. Open repair gives a robust repair through a larger incision; percutaneous repair uses small stab incisions and specialised instruments. Both have re-rupture rates of 2-5%. Recovery in a boot follows the same protocol as non-surgical treatment.
Reconstruction with tendon transfer
For ruptures presenting more than 4-6 weeks after injury, the torn ends have retracted and cannot be directly repaired. Reconstruction usually involves tendon transfer (most commonly flexor hallucis longus) to bridge the gap. More complex surgery with a longer recovery.
Recovery
Recovery takes 6-12 months whether surgery or non-surgical treatment is chosen. Both pathways require the same boot protocol and physiotherapy. Most patients are walking comfortably by 3-4 months and running by 6 months. Calf strength typically reaches 90-95% of the unaffected side by one year, with a small residual loss of explosive push-off being common.
- Boot or cast in equinus: 0-2 weeks
- Boot with progressive heel wedge reduction: 2-10 weeks
- Out of boot, into normal shoes: 10-12 weeks
- Walking comfortably: 3-4 months
- Return to running and sport: 6-12 months
What results can I expect?
Outcomes are generally good with either approach. Patient satisfaction is around 85-90%. Risk of DVT is increased after Achilles rupture - prophylactic injections are commonly prescribed for 4-6 weeks. Re-rupture risk is around 6-12% with non-surgical treatment and 2-5% with surgery.
In numbers
When can I…?
Typical activity timelines for this condition. These are approximate and vary considerably between patients. Always follow the specific guidance given by your surgeon and physiotherapist.
| Activity | Typical timeline | Notes |
|---|---|---|
| Boot, plantarflexed | From day of diagnosis | The foot is held pointing slightly downward in a boot. This applies to both surgical and non-surgical pathways.[2] |
| Bear weight in the boot | Usually from week 1-2 | Most UK protocols allow early weight-bearing in the boot, with crutches initially for confidence.[2] |
| Drive | 8-10 weeks (right foot) | When you are out of the boot and can perform an emergency stop confidently. Left-foot rupture with automatic car may be earlier.[4] |
| Walk in normal shoes | 8-10 weeks | Out of the boot, often with a small heel raise for the first few weeks.[2] |
| Return to gentle exercise | 3-4 months | Cycling and swimming first; gradual return to load and impact.[1] |
| Return to running | 5-6 months | Once calf strength is well-recovered. Often slower than patients expect.[1] |
| Return to sport | 6-12 months | Full return to cutting and jumping sports often takes a year. Calf strength rarely fully returns to the uninjured side.[1] |
Is this normal?
Common concerns from patients with this condition or recovering from treatment, and whether they are expected or worth mentioning to your team.
Preparing for surgery?
Read our step-by-step guide: what to expect before, during, and after your procedure.
Related injuries & conditions
Your questions, answered
Plain-English answers to the things people most often ask, grounded in published guidance. Tap a question to open it.
About thisHow do I know the tendon has ruptured?
A rupture usually comes with a sudden sharp pain, a snap, or a feeling of being kicked or shot in the back of the leg, followed by difficulty pushing off and standing on tiptoe.
A gap may be felt in the tendon. It often happens during sport in middle age.
Your choiceShould I have surgery or not?
A large randomised trial found similar function at twelve months whether the tendon was repaired surgically or treated non-surgically. Surgery lowers the chance of re-rupture, to under one percent versus around six percent, but adds risks such as nerve injury and wound problems.
Many people, especially those who are not high-level athletes, do very well without an operation.
Your choiceIf treated non-surgically, cast or brace?
The UK UKSTAR trial found that a functional brace allowing early weight-bearing gave similar outcomes to a traditional plaster cast, with re-rupture around five to six percent either way.
A brace lets you get moving sooner and is often preferred where available.
Getting backHow long is recovery?
Expect a boot for roughly eight to ten weeks with the foot position adjusted in stages, then a prolonged rehabilitation programme.
Return to sport is often around six to twelve months.
WellbeingWill my calf be weaker afterwards?
Some lasting reduction in calf strength is common after an Achilles rupture, whichever treatment you have.
Consistent rehabilitation gives you the best final result.
UrgentWhat are the warning signs to act on?
Because the leg is immobilised, there is a raised risk of a blood clot. Calf pain, swelling or redness, or breathlessness, need urgent help.
Follow any clot-prevention advice your team gives you.
References & further reading
- 1.British Orthopaedic Foot & Ankle Society: Achilles tendon rupture patient information
- 2.UK Achilles Tendon Rupture: Patient pathway (UKSTAR trial)
- 3.NHS: Achilles tendon rupture
- 4.Royal College of Surgeons of England: Driving after surgery guidance
References are to UK clinical guidance and patient information from recognised organisations. This page is for general information and does not replace personalised advice from your own clinical team.