Torn or Ruptured Achilles Tendon: Symptoms, the First Days, and Whether You Need Surgery

What is an Achilles tendon rupture?

When the Achilles tendon tears suddenly (an acute rupture), people realise it is urgent, because they are not able to walk or push off.

A sudden rupture is a different condition from long-standing Achilles pain (Achilles tendinopathy), from bursitis at the back of the heel (retrocalcaneal bursitis) and from pinching at the back of the ankle (posterior ankle impingement). Telling these apart is what makes the right treatment possible. Long-standing Achilles pain is covered on my Achilles tendon pain page, and pinching at the back of the ankle on my hindfoot endoscopy page.

The first days: what not to do, and when to be seen

In my experience, the wrong thing people do is to move the ankle as much as possible. Moving it, especially pulling the foot upwards, draws the torn ends of the tendon further apart and can widen the gap between them.

A rupture is quite often mistaken for a sprain, because a sprained ankle can also pop and leave you feeling unable to walk, run or jump. When to be seen urgently, before and after treatment, is set out under When to see a specialist urgently.

If an operation turns out to be needed, it does not have to be done on the day you are first seen, or the next day. So the operation itself is planned rather than done as an emergency, but being seen early still matters. The timing of the operation is described in more detail on my Achilles tendon repair page.

How it is diagnosed

The American Academy of Orthopaedic Surgeons (AAOS) guideline recommends a detailed history and physical examination, including two or more of four clinical tests ^[1]. The four are the calf-squeeze (Thompson or Simmonds) test, reduced strength when pointing the foot down, a gap that can be felt in the tendon, and the foot bending upwards further than normal when the examiner moves it ^[1]. This is a consensus recommendation, based on expert agreement rather than on research evidence ^[1].

One study measured how well three of these tests pick up a complete tear ^[2]. It was a prospective study of 174 people with a complete rupture of the tendon and 28 people suspected of one who did not have a tear ^[2]. In that study, the calf-squeeze (Thompson) test picked up 96 in 100 of the tears, and correctly showed no tear in 93 in 100 of the people without one ^[2]. The Matles test picked up 88 in 100 of the tears and correctly showed no tear in 85 in 100 ^[2]. A gap felt in the tendon picked up 73 in 100 of the tears and correctly showed no tear in 89 in 100 ^[2]. The 73 in 100 for the felt gap was with the patient awake; under anaesthesia it was 81 in 100 ^[2]. No confidence intervals are given in the report available ^[2]. These figures describe that study’s patients with a complete rupture, not every Achilles injury ^[2].

In my experience, the most disabling sign people notice is that they cannot push off as they walk, or that they feel as if they will lose their balance or fall. In my practice, the gap between the torn ends can be measured on an MRI or an ultrasound scan of the ankle and foot, and that gap is one of the three things that decide how I manage the rupture.

Surgery or not: how the decision is made

In my practice, three things decide the treatment of an Achilles rupture: the size of the gap in the tendon, the person’s age and what they need from their leg, and other health conditions, such as diabetes or long-term steroid use. In a fresh tear, a gap of up to 1.5 or 2 cm can be brought together by placing the ankle in certain positions. That figure is from my own practice and is about bringing the ends together; it is not a research cut-off for surgery.

For a younger person who wants to get back to an active life, I suggest a repair. For someone with many other health problems, such as diabetes and steroid use, I would choose treatment without surgery, although I still offer both options.

In my practice, a competitive athlete’s treatment differs, because the athlete needs the Achilles not only to walk but to jump, land and store energy, as a high jumper does when pushing off, so an athlete’s demands are greater and different. What a person needs the leg for, whether sport or daily activity, changes how I carry out the operation, and whether the rehabilitation is accelerated or given more emphasis.

The AAOS guideline states that surgery is an option, but that it should be approached more cautiously in some people ^[1]. These are people with diabetes, neuropathy (nerve damage), immunocompromised states (a weakened immune system), age over 65, tobacco use, a sedentary (inactive) lifestyle, obesity (a body mass index over 30), peripheral vascular disease (poor blood circulation, usually in the legs), or local or systemic dermatologic disorders (skin conditions, local or general) ^[1]. This, too, is a consensus recommendation ^[1].

Research on the size of the gap gives mixed answers ^{[3] [4]}. One prospective study followed people treated without surgery ^[3]. In it, a larger gap, measured on ultrasound with the foot pointed down, was only weakly linked to a lower patient-reported score of Achilles function (ATRS) (r = −0.30, p = 0.008; 82 of 131 people analysed) ^[3]. In that study, the average score was lower for gaps over 5 mm than for gaps of 5 mm or less (73 [SD 21] against 82 [SD 16], p = 0.031) ^[3]. For gaps over 10 mm it was 70 (SD 23) ^[3]. The number of people in each group and the confidence intervals are not given in the report available ^[3]. A second study, a prospective series of 56 people treated without surgery, found no statistically significant link between the first gap measured on ultrasound and the score at one year ^[4]. A link of this kind does not show that the gap causes the result, and neither study sets a gap size at which surgery is needed ^{[3] [4]}.

What the research shows: surgery compared with treatment without surgery

A 2022 randomised trial found that the tendon tore again more often without surgery, while people’s own scores of function at one year did not differ significantly between the groups ^[5]. The trial included 554 people (526 in the full analysis) ^[5]. The tendon tore again (re-rupture) in 11 of 178 people treated without surgery (6.2%), 1 of 176 after open repair (0.6%) and 1 of 172 after minimally invasive repair (0.6%) ^[5]. The risk difference was 5.6 percentage points (95% CI 1.9 to 10.2 against open repair, and 1.8 to 10.2 against minimally invasive repair); this is a difference in risk, not a relative risk ^[5]. A 95% confidence interval (95% CI) is the range within which the true figure is likely to lie. The trial’s main measure, a patient-reported function score (ATRS) at 12 months, did not differ significantly between the three groups (p = 0.57) ^[5]. That does not show the three treatments are equivalent ^[5]. The trial also compared the groups two at a time; the authors report that these comparisons, which were not tested for statistical significance, provided no evidence of differences between the groups ^[5].

An earlier randomised trial of 144 people, published in 2010, counted re-ruptures and complications after each treatment ^[6]. Both groups had accelerated rehabilitation, and re-rupture occurred in 2 of 72 people after surgery and 3 of 72 without surgery ^[6]. There were 13 complications in the surgery group and 6 in the group without surgery, with more complications involving the skin and soft tissues after surgery ^[6].

A 2025 systematic review and meta-analysis that pooled 33 studies of mixed design found surgery associated with fewer re-ruptures, but with more infections and nerve injuries ^[7]. It included 14 prospective and 19 retrospective studies, each with at least 6 months of follow-up ^[7]. In the 23 studies that reported re-rupture, it occurred in 3.6% (81 of 2,267) after surgery and 7.0% (136 of 1,918) after treatment without surgery ^[7]. Pooled, surgery was associated with a lower risk (relative risk 0.44, 95% CI 0.34 to 0.57) ^[7]. This is an association in pooled data from studies of mixed design, and no confidence interval was established for the absolute difference ^[7]. On this page, the review is not counted as separate evidence alongside the trials it includes.

The same review found surgery associated with a higher rate of return to sport (relative risk 1.32, 95% CI 1.03 to 1.69; 4 studies, 379 people), but no statistically significant difference in the ATRS function score (mean difference 7.02 points, 95% CI −1.35 to 15.38; 3 studies, 908 people) ^[7]. Both results come from small subsets of the review’s studies, and the ATRS result does not show that the treatments are equivalent ^[7].

The same review found surgery associated with higher relative risks of deep infection (RR 1.91, 95% CI 1.15 to 3.16), superficial infection (RR 4.89, 95% CI 1.57 to 15.24) and nerve injury (RR 3.67, 95% CI 1.34 to 10.06) ^[7]. These came from smaller groups of 8, 5 and 6 studies ^[7]. These are relative risks, not the chance of each complication, and the numbers of events were not established ^[7]. The review’s abstract also reports nerve injury 3.33 percentage points and infection 0.53 percentage points less frequent after treatment without surgery ^[7]. No confidence intervals are given for these absolute differences, and the infection figure is not assigned to deep or superficial infection ^[7].

A 2012 meta-analysis of randomised trials looked at re-rupture separately for rehabilitation with and without early movement of the ankle ^[8]. Where rehabilitation began early movement of the ankle, re-rupture did not differ significantly between surgery and treatment without surgery (risk difference 1.7%, p = 0.45) ^[8]. That does not show the two are equivalent, and it applies only to early-movement rehabilitation ^[8]. When early range-of-motion rehabilitation was not employed, the same meta-analysis found that surgery reduced the absolute risk of re-rupture by 8.8 percentage points (p = 0.001) ^[8].

Treatment without surgery

For someone with many other health problems, such as uncontrolled diabetes, or with a tear that has only a short gap, I offer treatment without surgery as an option, alongside surgery. In that treatment I hold the foot in a set position, and the person walks in an air boot. An air boot is one kind of functional brace. In my experience, how well it works depends on the two tendon ends lying as close together as possible. As the tendon heals, a lot of physiotherapy is needed to get back to the level of function you had before.

A review of the management of Achilles injuries describes the foot being placed at first fully pointed down (full equinus), to help restore and keep contact between the tendon ends ^[9]. Treatment regimens vary, and this description is not a universal or mandatory protocol ^[9].

For people treated without surgery, one randomised trial (UKSTAR) compared a plaster cast with a functional brace ^[10]. The cast was not superior to the brace for a patient-reported function score at 9 months (adjusted mean difference −1.38, 95% CI −4.9 to 2.1, p = 0.44; 244 cast and 259 brace patients analysed) ^[10]. This does not show that the two are equivalent, and it compares two kinds of treatment without surgery only ^[10].

If you have an operation

If an operation is needed, it is planned as described under The first days. The operation itself is described on its own page, keyhole-assisted (arthroscopic) repair of a torn Achilles tendon. The complications that pooled studies have linked with surgery are set out in the research section above ^[7].

When to see a specialist urgently

Before treatment, see a specialist at the earliest if you have difficulty pushing off, or feel that you may lose your balance or fall when you walk.

If you have sudden difficulty breathing, go to the nearest hospital emergency department straight away. Warning signs after the operation are set out on my Achilles tendon repair page.

To contact us: Dr. Kini, +91 99208 61187, or the clinic, +91 98207 89797.

Questions about your own injury

At a first visit, I hear the whole story and examine you in detail, so bring all your previous imaging (X-ray, ultrasound, MRI or CT), any blood tests and earlier consultation notes. Bring what you have to hand; do not delay being seen to look for old records.

Common questions