Suspected Tendon Rupture PresentationAPPROACH

MUSCULOSKELETAL AND EXTREMITIES · 19 SECTIONS

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492 items

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Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Shoulder Pain Elbow Pain Wrist Pain Hand Pain Hip Pain Knee Pain Ankle Pain Foot Pain Cast Or Splint Complication Symptoms Wound Check And Suture Related Visits Joint Swelling And Monoarthritis Suspected Septic Joint Presentation Suspected Tendon Rupture Presentation Limp Or Refusal To Bear Weight

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx50

Context and mechanism

›Context and mechanism

›Injury timing

›Activity at time of injury

›Sudden eccentric load

›Direct blow

›Penetrating trauma

›Audible pop or snap

›Immediate loss of function

›Ability to continue activity after event

OPQRST

›OPQRST

›Onset

›Sudden onset during activity

›Gradual onset with acute worsening

›Provocation and palliation

›Worse with active contraction

›Worse with passive stretch

›Relief with immobilization

›Quality

›Sharp pain at moment of injury

›Weakness without severe pain

›Region and radiation

›Focal tendon location pain

›Proximal radiation to muscle belly

›Severity

›Pain intensity

›Functional loss severity

›Timing

›Persistent weakness

›Progressive swelling

›Delayed bruising

Associated symptoms

›Associated symptoms

›Swelling

›Bruising

›Deformity

›Mechanical symptoms

›Giving way

›Buckling

›Neurovascular symptoms

›Numbness

›Tingling

›Coldness

›Systemic symptoms

›Fever

›Chills

Prior tendon history and baseline

›Prior tendon history and baseline

›Prior tendinopathy at same site

›Prior rupture or repair

›Prior corticosteroid injection near tendon

›Baseline function and mobility

›Athletic or occupational requirements

02Alarm Features/alarm33

Immediate limb threats

›Immediate limb threats

›Open laceration over tendon

›Gross contamination

›Active hemorrhage

›Expanding hematoma

›Neurovascular compromise

›Absent distal pulses

›Capillary refill delayed

›Cool pale limb

›New motor deficit

›Compartment syndrome concern

›Pain out of proportion

›Pain with passive stretch

›Tense compartments

›Progressive sensory change

High risk mechanisms and populations

›High risk mechanisms and populations

›High energy trauma

›Fall from height

›Crush injury

›Penetrating injury near major vessels

›Anticoagulation or bleeding disorder

›Immunocompromised state

›Diabetes with foot wound concern

Vital sign danger thresholds

›Vital sign danger thresholds

›Systolic blood pressure less than 90 mmHg

›Heart rate greater than 130 per minute

›Respiratory rate greater than 30 per minute

›Oxygen saturation less than 92 percent

›Temperature 38.0 C or higher

Escalation triggers

›Escalation triggers

›If open injury then immediate antibiotics and urgent surgical consult

›If absent pulses then emergent reduction if dislocation suspected and vascular surgery consult

›If compartment syndrome concern then emergent ortho consult and avoid delays for imaging

03Medications/meds21

Medication exposures linked to rupture risk

›Medication exposures linked to rupture risk

›Systemic corticosteroids

›Recent fluoroquinolone exposure

›Local corticosteroid injection near tendon

›Anabolic androgenic steroids

Bleeding and procedural considerations

›Bleeding and procedural considerations

›Anticoagulants

›Warfarin

›Direct oral anticoagulants

›Low molecular weight heparin

›Antiplatelets

›Aspirin

›Clopidogrel

›NSAID use pattern

Analgesic history and contraindications

›Analgesic history and contraindications

›Acetaminophen use in last 24 hours

›NSAID contraindications

›Chronic kidney disease

›Peptic ulcer disease

›Anticoagulation

›Opioid tolerance or use disorder risk

04Diet/diet10

Recent intake and hydration

›Recent intake and hydration

›Last oral intake timing

›Dehydration indicators

›Poor oral intake

›Vomiting

›Diarrhea

Nutrition factors affecting healing

›Nutrition factors affecting healing

›Protein malnutrition concern

›Eating disorder concern

›Alcohol use affecting nutrition

05Review of Systems/ros16

Musculoskeletal

›Musculoskeletal

›Pain in adjacent joints

›Prior joint instability

›Prior overuse symptoms

Skin and soft tissue

›Skin and soft tissue

›Wound or abrasion

›Rapidly progressive swelling

›Skin color change

Neurologic and vascular

›Neurologic and vascular

›Weakness distal to injury

›Sensory loss

›Claudication history

Infectious and inflammatory

›Infectious and inflammatory

›Fever

›Recent infection

›New hot swollen joint elsewhere

06Collateral History and Family History/chafh9

Collateral source and function baseline

›Collateral source and function baseline

›Witness description of injury

›Baseline mobility and independence

›Baseline hand dominance and job requirements

Family and genetic risk

›Family and genetic risk

›Connective tissue disorder history

›Ehlers Danlos syndrome

›Marfan syndrome

›Early severe tendon injury history in family

07Risk Factors/rf17

Patient factors

›Patient factors

›Age over 40 years

›Male sex

›Obesity

›Smoking

›Diabetes mellitus

›Chronic kidney disease

Systemic disease associations

›Systemic disease associations

›Rheumatoid arthritis

›Gout

›Hyperparathyroidism

›Dyslipidemia

Exposure and activity factors

›Exposure and activity factors

›Sudden increase in training volume

›High impact sports participation

›Recent fluoroquinolone exposure

›Systemic corticosteroid exposure

08Differential Diagnosis/ddx46

Life threatening

›Life threatening

›Compartment syndrome

›Severe escalating pain

›Pain with passive stretch

›Tense compartments

›Acute arterial injury

›Absent distal pulses

›Cool pale limb

›Open fracture or open joint injury

›Laceration with exposed tissue

›Contamination

›Necrotizing soft tissue infection

›Pain out of proportion

›Rapid progression

Common

›Common

›Achilles tendon rupture or tear injury of Achilles tendon (S86.0)

›Sudden pop

›Weak plantarflexion

›Quadriceps tendon rupture injury of quadriceps muscle fascia and tendon (S76.1)

›Inability to extend knee

›Suprapatellar gap

›Patellar tendon rupture

›Inability to extend knee

›Patella alta

›Distal biceps tendon rupture

›Supination weakness

›Antecubital fossa pain

›Rotator cuff tear or rupture not specified as traumatic (M75.1)

›Weak abduction

›Night pain

›Tendon laceration wrist and hand level injury codes (S66 category)

›Loss of active extension or flexion

›Open wound

Less common

›Less common

›Avulsion fracture at tendon insertion

›Bony tenderness

›Visible fragment on imaging

›Muscle belly tear

›Pain proximal to tendon

›Preserved tendon continuity on ultrasound

›Peripheral nerve injury

›Sensory loss pattern

›Motor deficit out of proportion

›Deep vein thrombosis after calf injury

›Calf swelling disproportionate

›Risk factors for thrombosis

09Past Medical History/pmh16

Relevant comorbidities

›Relevant comorbidities

›Diabetes mellitus complications

›Peripheral vascular disease

›Chronic kidney disease

›Inflammatory arthritis

›Prior venous thromboembolism

Prior procedures and injuries

›Prior procedures and injuries

›Prior tendon repair

›Prior fracture near current site

›Prior joint surgery

›Implanted hardware near site

Baseline functional status

›Baseline functional status

›Baseline walking tolerance

›Baseline stair use

›Baseline overhead function

›Baseline grip and pinch function

10Physical Exam/exam45

General and vitals

›General and vitals

›Appearance

›Distress level

›Toxic appearance

›Vitals pattern

›Fever

›Tachycardia

›Hypotension

Inspection and palpation

›Inspection and palpation

›Swelling distribution

›Ecchymosis pattern

›Visible deformity

›Open wound

›Palpable tendon gap

Range of motion and strength

›Range of motion and strength

›Active range of motion deficit

›Passive range of motion pain

›Strength testing limited by pain vs true weakness

Neurovascular and compartment assessment

›Neurovascular and compartment assessment

›Distal pulses

›Capillary refill

›Sensation

›Motor function distal to injury

›Compartment firmness

Region focused tendon patterns

›Region focused tendon patterns

›Achilles tendon

›Thompson test

›Matles test

›Single leg heel raise inability

›Knee extensor mechanism

›Straight leg raise inability

›Extensor lag

›Patella position

›Distal biceps

›Hook test

›Supination strength loss

›Shoulder rotator cuff

›Drop arm test

›External rotation lag sign

›Belly press test

›Hand and finger tendons

›Finger cascade abnormality

›Tenodesis effect abnormality

›Isolated DIP flexion loss

›Isolated DIP extension loss

11Lab Studies/labs13

Not routine for isolated closed rupture

›Not routine for isolated closed rupture

›Normal vitals and closed injury

›No systemic symptoms

Preoperative and high risk labs

›Preoperative and high risk labs

›CBC for anemia or infection

›Electrolytes and creatinine for operative planning

›Coagulation studies if anticoagulated or liver disease

Infection and inflammatory evaluation

›Infection and inflammatory evaluation

›CRP and ESR if fever or septic joint concern

›Blood cultures if febrile and systemic toxicity

Rhabdomyolysis and crush injury

›Rhabdomyolysis and crush injury

›CK if prolonged compression

›Urinalysis for heme without RBC

12Imaging/img29

Scoring Systems

›Decision rules for associated fracture screening

›Ottawa ankle rules for ankle and midfoot trauma

›Ottawa knee rules for acute knee trauma

MRI

›MRI use cases

›Equivocal exam and ultrasound

›Suspected partial thickness tear requiring operative planning

›Rotator cuff tear characterization and retraction assessment

›Distal biceps tendon assessment when exam uncertain

›Contraindications

›Non MRI compatible implants

›Unable to tolerate supine due to pain

›CT use cases

›Suspected occult fracture at tendon insertion

›Complex periarticular fracture pattern

›CT angiography if hard signs of vascular injury

›Absent pulses

›Expanding hematoma

›Bruit or thrill

Ultrasound

›Ultrasound and POCUS

›Achilles tendon rupture diagnosis

›Sensitivity 94.8 percent for complete rupture

›Specificity 98.7 percent for complete rupture

›Positive likelihood ratio 74.0

›Negative likelihood ratio 0.05

›Tendon discontinuity and hematoma identification

›Dynamic assessment with plantarflexion or joint motion

›Pitfalls

›Partial tears can be missed

›Anisotropy causing false hypoechoic appearance

13Special Tests/spec40

Achilles tendon bedside tests

›Achilles tendon bedside tests

›Thompson test

›Sensitivity 96 to 100 percent for complete rupture

›Specificity 93 to 100 percent for complete rupture

›False negatives with partial tear or intact plantaris

›Matles test

›Sensitivity 88 percent

›Specificity 85 percent

›Palpation gap test

›Sensitivity lower than Thompson in awake patients

›Increased false negatives early swelling

Knee extensor mechanism tests

›Knee extensor mechanism tests

›Straight leg raise

›Inability suggests extensor mechanism disruption

›Pain limited effort as mimic

›Extensor lag

›Partial tear possible with preserved lag

›Compare contralateral side

Distal biceps tests

›Distal biceps tests

›Hook test

›Sensitivity 78 percent for all tears

›Sensitivity 83 percent for complete tears

›Sensitivity lower for partial tears

›Supination strength testing

›Marked weakness with distal rupture

›Pain inhibition as pitfall

Shoulder rotator cuff tests

›Shoulder rotator cuff tests

›Drop arm test

›Suggests full thickness supraspinatus tear

›Pain can mimic weakness

›External rotation lag sign

›Suggests infraspinatus tear

›Limited by pain and stiffness

Hand tendon screening

›Hand tendon screening

›Tenodesis effect

›Passive wrist extension normally flexes fingers

›Absent effect suggests flexor tendon disruption

›Isolated tendon testing

›FDP test for jersey finger

›Terminal extensor test for mallet finger

14ECG/ecg8

When ECG is relevant

›When ECG is relevant

›Older patient with syncope preceding injury

›Chest pain or dyspnea with collapse

›Significant electrolyte abnormality on labs

Peri sedation and operative screening

›Peri sedation and operative screening

›Planned procedural sedation

›Known cardiac disease with tachycardia

›Significant anemia concern

15Assessment/ax30

Working diagnosis by region

›Working diagnosis by region

›Achilles tendon rupture suspected

›Positive Thompson test

›Weak plantarflexion

›POCUS tendon discontinuity

›Knee extensor mechanism rupture suspected

›Inability to straight leg raise

›Extensor lag

›Patellar malposition

›Distal biceps tendon rupture suspected

›Positive hook test

›Supination weakness

›Rotator cuff tear suspected

›Weak abduction

›Positive lag signs

›Hand tendon laceration suspected

›Open wound

›Loss of isolated tendon function

Severity and complexity stratification

›Severity and complexity stratification

›Open vs closed injury

›Neurovascular compromise present

›Complete vs partial tear suspected

›Time since injury

›High demand athlete or manual labor

Complications to exclude

›Complications to exclude

›Associated fracture

›Joint dislocation

›Compartment syndrome

›Infection with open injury

›DVT risk after calf injury and immobilization

16Plan/plan56

First 5 minutes

›First 5 minutes

›Monitoring

›Cardiac monitor if syncope or high risk comorbidity

›Pulse oximetry if respiratory symptoms or sedation planned

›Access

›IV access if severe pain requiring parenteral analgesia

›IV access if open injury or anticipated transfer

›Immediate escalation

›If neurovascular compromise then emergent consult

›If open tendon injury then antibiotics within 60 minutes local protocol dependent

Analgesia and symptom control

›Analgesia and symptom control

›Acetaminophen 1000 mg PO once

›Ibuprofen 400 mg PO once

›Naproxen 500 mg PO once

›Ketorolac 15 mg IV once

›Morphine 0.05 mg per kg IV once

›Hydromorphone 0.5 mg IV once

›Fentanyl 25 mcg IV once

›Antiemetic options

›Ondansetron 4 mg PO once

›Ondansetron 4 mg IV once

Immobilization and protection

›Immobilization and protection

›Achilles tendon suspected rupture

›Posterior short leg splint in plantarflexion

›Non weight bearing until specialist follow up

›Knee extensor mechanism suspected rupture

›Knee immobilizer in full extension

›Weight bearing status per ortho guidance

›Distal biceps suspected rupture

›Sling or posterior long arm splint at 90 degrees

›Forearm supination as tolerated

›Hand tendon laceration

›Irrigation and sterile dressing

›Splint position per zone and tendon involved

Diagnostic sequencing

›Diagnostic sequencing

›X ray for suspected avulsion fracture or joint injury

›POCUS for rapid confirmation when available

›MRI when results change operative planning

›CT angiography if vascular hard signs

Consultation and timing

›Consultation and timing

›Immediate orthopedic consultation

›Open tendon injury

›Neurovascular compromise

›Extensor mechanism rupture

›Early outpatient orthopedic follow up

›Closed Achilles rupture without limb threat

›Suspected distal biceps rupture

›Suspected rotator cuff tear with preserved perfusion

›Hand surgery consultation

›Any suspected flexor tendon laceration

›Any tendon injury with neurovascular deficit

Reassessment loop

›Reassessment loop

›Pain reassessment within 30 to 60 minutes after analgesia

›Neurovascular reassessment after splinting

›Skin pressure point check after immobilization

›If worsening pain or numbness then remove or loosen splint and reassess compartments

17Disposition/dispo26

ICU and resuscitation indications

›ICU and resuscitation indications

›Hemodynamic instability

›Sepsis concern with open wound and systemic toxicity

›Polytrauma

Inpatient admission indications

›Inpatient admission indications

›Open tendon injury requiring operative washout

›Compartment syndrome concern

›Vascular injury requiring intervention

›Uncontrolled pain despite ED management

Observation pathway

›Observation pathway

›Diagnostic uncertainty requiring MRI

›High risk social situation preventing safe discharge

›Recurrent neurovascular checks after tight swelling

Discharge criteria

›Discharge criteria

›Closed injury

›Intact distal perfusion and sensation after immobilization

›Pain controlled with oral regimen

›Ambulation plan established

›Reliable follow up within appropriate timeframe

Follow up timing

›Follow up timing

›Achilles rupture suspected

›Ortho or sports medicine within 3 to 7 days

›Distal biceps rupture suspected

›Ortho within 3 to 7 days

›Hand tendon laceration suspected

›Hand surgery within 24 hours

18Discharge Instructions/di18

Copy discharge instructions

›Copy discharge instructions

›You were seen for a suspected tendon tear

›Your limb was immobilized to protect the injury

›Keep the splint clean and dry

›Do not put weight on the injured limb unless you were told it is allowed

›Pain control options

›Acetaminophen as directed on the label

›Ibuprofen as directed on the label if safe for you

›Return to the emergency department now for

›Increasing severe pain not relieved by medication

›New numbness or tingling

›Fingers or toes becoming cold or pale

›Increasing swelling with tight splint pressure

›Fever

›Drainage or redness spreading from a wound

›Follow up

›Orthopedic or hand specialist follow up as arranged

›Bring your imaging reports if you go to a different facility

19References/r9

Key sources

›Key sources

›Aminlari A 2021 Diagnosing Achilles tendon rupture with ultrasound in the emergency department systematic review and meta analysis

›Shamrock AG 2023 Achilles tendon rupture StatPearls NCBI Bookshelf

›Kou J 2010 AAOS clinical practice guideline acute Achilles tendon rupture

›AOFAS 2024 Position statement management of acute Achilles tendon ruptures

›Maffulli N 1998 Clinical diagnosis of subcutaneous tear of the Achilles tendon

›Luokkala T 2019 Distal biceps hook test sensitivity in acute and chronic tears

›ODriscoll SW 2007 Hook test for distal biceps tendon avulsion

›AAOS 2025 Management of rotator cuff injuries clinical practice guideline update

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.