Achilles tendon rupture

Achilles tendon rupture

Mitsutoshi Hayashi

Mitsutoshi Hayashi

Doctor of Medicine, specialist in the Japanese Society of Rehabilitation Medicine, specialist in the Japanese Society of Orthopaedic Surgery, specialist in the Japanese Society of Rheumatology, staff to strengthen JOC, and sports physician certified by the Japan Sports Association

Achilles tendon rupture

Disease Overview

Recreational sports have become more active; the incidence of Achilles tendon rupture has increased. Age at injury ranges from the early 20s to the middle-aged and elderly, with a peak in the 40s and 50s. Along with anterior cruciate ligament rupture, Achilles tendon rupture is the most severe sports injury, and it takes about six months to one year to return to competition.

The Achilles tendon is a bundle of muscles in the triceps surae (calf) at the ankle, which becomes the string of the Achilles tendon, which attaches to the calcaneal bone (heel). A rupture of a string near the ankle is called an Achilles tendon tear. Its motor function plays the most important role in sports because it helps raise the heel (calf raises), which is responsible for kicking the toes, dashing, and jumping (the force of ankle plantar flexion). Degenerative changes in the Achilles tendon (due to aging) develop from about age 30 and gradually decrease tendon flexibility. Moreover, weight gain and other causes increased stress on the tendons, the forced bad posture, and muscle weakness. Sports activities account for about 90% of cause of injuries, and the remainder are caused by accidental falls, which are more common in people older than 60. Injuries occur most commonly in tennis (mainly in receiving), followed by badminton (receiving) and then volleyball, which account for 50% of the total. The number of soccer (futsal) injuries has increased recently. In volleyball, the injury rarely occurs with jumping, but mostly it occurs on the foot kicking at the moment to pick up the ball in front, or at the tossing as moving.

Symptoms and Diagnosis

The diagnosis is relatively easy, with a clear recess in the ruptured Achilles tendon (Photo 1), inability to stand on the toes, and a positive Thompson test (immobility of the ankle with a calf grip). Many people were aware of such symptoms as "someone hit to my Achilles tendon" "a ball is hit" or “heard a pop sound”. Note that (1) walking may be possible and (2) it may be painless. Recently, ultrasonography and MRI have enabled easy identification of the rupture (Photo 2).

Depressed tear (left)

Photo 1: Touch the recess

Cause and mechanism of onset

MR imaging for Achilles tendon rupture

Photo 2 Achilles tendon rupture status (arrow) by MRI

Treatment and rehabilitation

Treatment can be generally divided into surgery and conservative treatment (non surgery). Basically, there was no significant difference in the duration of treatment, and I have experienced a case of complete recovery of the Olympic player treated with conservative treatment.
Surgical treatment: The ruptured Achilles tendon is checked with direct vision (Photo 3), the ruptured area is sutured with sutures, and a cast is used to secure the ruptured area after surgery. The cast can immobilize the leg for 4 to 6 weeks with surgery (including a splint) or 6 weeks with conservative treatment. The patient can walk with an orthosis for about 1 month after immobilization with the cast.
Conservative treatment: To make the ruptured tendon closer, a cast immobilizes the leg below the knee in maximal plantar flexion (at least 50 degrees) of the ankle (Photo 4). Loading level would be like touching the floor, and flexion and extension exercises of the lower extremity are allowed even under cast immobilization. Two weeks after the injury, the person is changed to immobilization of the ankle joint at about 30 degrees of plantar flexion, and weight-bearing with mild partial weight-bearing is considered. From the fifth week after the injury, the person should walk with full weight-bearing in a cast with heels in a mild plantar flexion position. An ankle foot orthosis is used for about one month from the seventh week of injury to start automatic ankle exercises. The orthosis is removed from 11 weeks after the injury.
When the orthosis is removed in these treatments, the patient starts toe-to-toe exercises and light jogging. The patient should be most cautious about causes of injuries, such as dashes, and they should be done at the end of the rehabilitation process.
Re-rupture is likely to occur after a cast or orthosis is removed, therefore, precautions against falls must be taken during this time.

Achilles tendon rupture

Photo 3: Achilles tendon rupture at operation (indicated by arrows)

Cast immobilization below the knee

Photo 4: Cast immobilization under the knee during conservative treatment

Toe tip

Photo 5: Exercises for standing on toes for both feet when orthoses are removed

Yoshizumi Iwasaki

Yoshizumi Iwasaki

NATA certified athletic trainers, certified athletic trainers from the Japan Physical Education Association, and chairman of the Japan Core Conditioning Association (JCCA)

Achilles tendon rupture (trainer stitch)


Rupture of the Achilles tendon is a major accident at the sports site. Consulting a specialized sports doctor and receiving appropriate treatment according to the type and level of the sport and age would be recommended rather than hurriedly having the patient transported by ambulance to hospital for surgery.
The idea that a flexible Achilles tendon is less likely to rupture leads to a stretching and balancing menu being prescribed for prophylactic conditioning. The basic stretching of the ankle is dorsiflexion but stretching can be classified into several groups according to the condition of the knee. Stretching with the instruments such as step stretching (see Photos 1 and 2) is also effective. Step stretching, which is characterized by simultaneously doing Achilles tendon stretching and plantar lengthening, may relieve considerably heel and Achilles tendon pain when used correctly.

On-site evaluation and first aid

Rupture of the Achilles tendon occurs suddenly, making the person surprised. It is characterized by kicking (hitting) impact from the back, as described in many text books, but the absence of severe pain, which the person feels such as in sprains, is an "unexpected" feature. The person may not know what happened and may stand up, but then he/she may fall if the Achilles tendon is completely ruptured. Anyone at any level is at risk of Achilles tendon injury when moving suddenly from resting state. Even leading players may be injured in many cases, because other factors, such as the accumulation of fatigue and physical condition, are intricately intertwined. Achilles tendon injuries are often seen among many middle-aged players probably because they forcibly try to move while recalling the past days without realizing weak muscles or tendons.


The starting timing of rehabilitation right after the injury depends on treatment methods: conservative or surgical. Therefore, make sure to follow the instructions given by the physician or physical therapist. Even after you go to the sports scenes, you will be prescribed training that is close to the actual movement while continuing the basic treatment menu. In hospitals, strengthening of the muscles around the body may be done with PNF (proprioceptive neuromuscular facilitation), isokinetic exercises, or other techniques.

A. During fixation

Achilles tendon rupture need to be secured with a cast regardless of, conservative treatment, or a surgery. Originally, this is the period of time when a physical therapist provides a prescription for rehabilitation in a hospital, but there is time to stay on the scene. During this period, the affected side should conduct mainly SLR with a cast and the unaffected side should conduct conditioning such as weight training or reinforcing exercises. If the patient has a doctor’s prescription, he/she can electrically contract the muscles using an EMS in this period. Plantar dorsiflexion of the toes also begins in this period to maintain the activity of the muscles adjacent to the affected area.

B. During wearing a simple cast or walker

For some time after the cast is removed, a patient should wear a simple cast or walker that is removable and stronger than an ankle brace or other sports orthosis. The first 2-3 weeks after the cast has been removed are said to be the time of the greatest risk of re-rupture, and careful recondition is required during this period. Basically, it is recommend to visit the hospital and receive direct guidance from physical therapists. To restore range of joint motion and muscle strength around the ankle, manual resistance exercises using machines such as plantar dorsiflexion, PNF, and isokinetic is prescribed.

C. After walking is allowed

Careful rehabilitation should be carried out under the doctor’s instructions, but a home menu is prescribed when calf raise can be done with hands on a desk. For athletes, walking exercises are performed in water. They may walk at a slow pace, walk on the toes, or walk on the heels. Be careful not to slide on around the swimming pool.
Walking exercises can be performed on land when the patient is able to do calf raise with hands on the walls. In addition to the usual walking, he/she may walk on tiptoe or on the heel. Then he/she gradually increases the length of stride. If he/she is able to do calf raise with getting hands off, shucking is allowed. Shucking is a slow jogging in which one foot is always on the ground.

D. After one-leg calf raise can be performed

Perform an ankle bounce not being away from the floor. An ankle bounce is an in situ jump with the ankle. In the early stages, do it rhythmically while not to leave the floor. As the patient gets used to it, raise the leg gradually.
Starting jogging is encouraged at this stage. Be aware of arm swing and posture, and keep balance as much as possible so that the right and left tempos are the equal. Adjust the speed and distance according to the level of recovery.

E. Hopping with the one leg can be performed

Carry out exercises and reinforcements to restore coordination, by employing instruments such as sliding boards, balance boards and boss systems. In addition to jogging, driving exercises include side-steps, skipping, cross-steps, and back-crossing. As recovery continues, the menu also includes turns and directions, but the most dangerous thing is to suddenly changing in direction from running backwards. It is also recommended to do the China Step at this time.

Return to game

Do not forget to perform a restart test for the basic movement before returning to full game. Careful conditioning and after-care to prevent relapses is absolutely essential for the case of Achilles tendon ruptures, as they have a high rate of relapse.

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