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Acute lower leg injuries: complete rupture of Achilles tendon

By Torbjorn Grontvedt

The Achilles tendon is the thickest and strongest tendon in the human body. It plays a very important role in most sport activities and is particularly vulnerable to overloading from repetitive running and jumping. The Achilles tendon forms a joint distal tendon for the gastrocnemius and the soleus muscles. These muscles combine to form the triceps surae muscle (figure 13.5). Athletes who sustain Achilles tendon ruptures most frequently are those who participate in ball sports that demand rapid changes of direction and quick, reactive jumps (e.g., tennis, squash, badminton, and soccer), in addition to runners and jumpers in track and field. Sometimes a patient with a ruptured tendon has a history of long-term pain localized to the tendon, but more often the rupture occurs without warning. Such ruptures are often caused by degenerative changes in the tendon (tendinosis), usually in the segment of the tendon that has the worst blood supply. This segment extends from 2 to 6 cm proximal to the insertion of the tendon onto the calcaneus.

Achilles tendon ruptures may be divided into full thickness ("total") and partial thickness ruptures. Total ruptures usually occur in formerly active athletes (average age 40) who resume sport activity after having been away from it for some time. In these cases, degenerative changes have weakened the tendon so much that sudden, forceful loading of the tendon causes it to tear. To some extent, these changes in the tendon could have been prevented by regular physical activity. In most cases, the injury mechanism is a strong activation of the posterior lower leg musculature, eccentrically overloading the tendon. A typical mechanism of injury involves pushing off hard with the weight-bearing foot while the knee is extended (e.g., running uphill) or sudden, unexpected dorsal extension of the ankle with reflex contraction of the calf musculature (e.g., falling down into a hole).

Symptoms and signs: The athlete experiences acute, intense pain corresponding to the Achilles tendon, often accompanied by an audible "snap." The athlete often spins around to see "who kicked her." She cannot walk on tiptoe, nor can she walk with a normal stride.

Diagnosis: During the clinical examination, the patient will have significantly reduced ankle plantar flexion strength on the involved side. When the tendon is palpated with one finger on either side, the tendon can be followed from the calcaneus to where it "disappears" in the area of the rupture and to where it then returns 2 to 3 cm proximal to the rupture. If the injury is recent, the patient indicates that her pain is localized at the site of the rupture. The defect eventually fills with blood and edema and the skin over the area becomes ecchymotic. The Thompson test is positive (figure 13.5).

Supplemental examinations: If the diagnosis is uncertain, ultrasound or MRI can be used to further evaluate the regional anatomy.

Treatment by physician: All patients who are active in sport at a relatively high level should undergo operative repair of the ruptured tendon as quickly as possible. Postoperatively, the ankle should be immobilized in an orthosis or cast for 2 weeks, with the foot in a slightly equinus position.

Treatment by physical therapist: After 2 weeks the cast or orthosis is removed. Then the patient’s ankle is mobilized in a range-of-motion walking orthosis permitting free plantar flexion and gradually increasing dorsiflexion (beginning from a zero position) over the next 4 weeks. Beginning 6 weeks after surgery, the patient gradually increases the intensity of strength and flexibility training. This treatment plan usually allows the athlete to return to full sport activity after about 3 months. Several studies have shown that early mobilization and loading of a sutured tendon increases collagen formation, remodeling, and strength in the repaired tendon. The risk of recurrent rupture is 1% to 2%, whereas the risk of perioperative infection is between 5% and 10%.

Some authors have recommended conservative treatment for total Achilles tendon ruptures. The recommended treatment consists of cast immobilization of the ankle with the foot in a mild equinus position for 4 weeks, after which the ankle is casted in slight plantar flexion for another 4 weeks. When the cast is removed at 8 weeks, the patient uses a buildup (of about 2 cm) under the heel for another 4 weeks, followed by careful strength and flexibility training. This treatment usually results in healing with a lengthened tendon, which reduces jumping ability. In addition, the risk of a recurrent rupture following conservative treatment is between 10% and 30%. Therefore, this method of treatment is not recommended for athletes.

Total Achilles tendon ruptures are frequently overlooked. The patient who sustains this injury will complain of weak calf musculature, and he will not be able to maintain his normal stride. It is impossible for the patient to stand on his toes on the involved side, and plantar flexion is limited. These patients require surgery to resect the scar tissue interposed in the rupture cleft, to mobilize the tendon and muscle proximally, and to suture end to end using either the tendon of the long plantar muscle or a fascia/tendon flap from the proximal part of the Achilles tendon for strength. Rehabilitation is the same as that used after acute repair, except that the progression of activities is somewhat slower and more cautious. The result with respect to strength and jumping ability is often somewhat worse in patients who undergo delayed repair than in those who undergo acute surgical repair.


This is an excerpt from Clinical Guide to Sports Injuries, edited by Roald Bahr and Sverre Maehlum and illustrated by Tommy Bolic.

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