Skip to main content
Symptom
dx.
Menu
Clinical Reference
Approaches
I have a symptom
Management
I know the diagnosis
Orthopedic Injuries
Fractures & dislocations
Medications
Drug reference
Calculators
Clinical calculators
OHIP Billing
Billing code lookup
Practical Skills
ECG
Interpretation guide
POCUS
Bedside ultrasound
Procedures
Step-by-step guides
Resuscitation
ACLS / PALS / NRP
Learn
Blog
Articles & updates
Deep Dive
In-depth clinical reviews
About
Our mission
Symptom
dx.
Clinical Reference
Approaches
I have a symptom
Management
I know the diagnosis
Orthopedic Injuries
Fractures & dislocations
Medications
Drug reference
Calculators
Clinical calculators
OHIP Billing
Billing code lookup
Practical Skills
ECG
Interpretation guide
POCUS
Bedside ultrasound
Procedures
Step-by-step guides
Resuscitation
ACLS / PALS / NRP
Learn
Blog
Articles & updates
Deep Dive
In-depth clinical reviews
About
Our mission
Get Started
Menu
Clinical Reference
Approaches
I have a symptom
Management
I know the diagnosis
Orthopedic Injuries
Fractures & dislocations
Medications
Drug reference
Calculators
Clinical calculators
OHIP Billing
Billing code lookup
Practical Skills
ECG
Interpretation guide
POCUS
Bedside ultrasound
Procedures
Step-by-step guides
Resuscitation
ACLS / PALS / NRP
Learn
Blog
Articles & updates
Deep Dive
In-depth clinical reviews
About
Our mission
Loading...
Achilles tendon rupture
Cardiovascular Presentations
Abdominal aortic aneurysm
Acute coronary syndrome (NSTEMI)
Acute coronary syndrome (STEMI)
Acute decompensated heart failure
Acute limb ischemia
Acute mesenteric ischemia
Aortic dissection
Aortic stenosis
Atrial fibrillation and flutter
Bradyarrhythmia and heart block
Cardiac arrest
Deep vein thrombosis
Myocarditis
Pericarditis
Pulmonary embolism
Stable angina
Superficial thrombophlebitis
Superior vena cava syndrome
Supraventricular tachycardia
Syncope (cardiogenic)
Unstable angina
Ventricular tachycardia
Respiratory Presentations
Acute bronchitis
Acute respiratory failure
Aspiration pneumonia
Asthma exacerbation
Bronchiolitis
Community-acquired pneumonia
COVID-19 pneumonia
COPD exacerbation
Croup
Croup (laryngotracheobronchitis)
Epiglottitis
Hemothorax
Hospital-acquired pneumonia
Pleural effusion
Pneumothorax (traumatic)
Pulmonary contusion
Spontaneous pneumothorax
Neurological Presentations
Bell's palsy
Benign paroxysmal positional vertigo
Brain abscess
Cauda equina syndrome
Cervical radiculopathy
Concussion (mild traumatic brain injury)
Encephalitis
Guillain-Barré syndrome
Hemorrhagic stroke (intracerebral)
Ischemic stroke
Lumbar radiculopathy
Malignant spinal cord compression
Migraine
Peripheral neuropathy (acute)
Retropharyngeal abscess
Schizophrenia (acute exacerbation)
Seizure (breakthrough:known epilepsy)
Seizure (first-time)
Spinal cord injury
Status epilepticus
Subarachnoid hemorrhage
Tension headache
Transient ischemic attack
Traumatic brain injury (moderate-severe)
Vestibular neuritis
Viral meningitis
Gastrointestinal Presentations
Acute appendicitis
Acute cholecystitis
Acute diverticulitis
Acute pancreatitis
Anal fissure
Choledocholithiasis and cholangitis
Clostridioides difficile colitis
Gastritis
Gastroenteritis (viral and bacterial)
Gastroesophageal reflux disease
Incarcerated or strangulated hernia
Inflammatory bowel disease flare
Large bowel obstruction
Lower GI hemorrhage
Peptic ulcer disease
Perforated viscus
Small bowel obstruction
Upper GI hemorrhage
Genitourinary and Reproductive Presentations
Acute prostatitis
Acute urinary retention
Ectopic pregnancy
Epididymitis
Orchitis
Ovarian torsion
Paraphimosis
Pelvic inflammatory disease
Priapism
Pyelonephritis
Renal laceration
Ruptured ovarian cyst
Testicular torsion
Tubo-ovarian abscess
Urinary tract infection (uncomplicated)
Urolithiasis (renal colic)
Vaginal bleeding (non-pregnant)
Infectious Disease Presentations
Acute sinusitis
Acute tonsillitis
Acute upper respiratory infection
Animal bite
Bacterial meningitis
Cellulitis
Conjunctivitis (bacterial)
Dental abscess
Endocarditis
Febrile neutropenia
Fournier gangrene
Hand-foot-mouth disease
Hepatitis (acute)
Herpes zoster
HIV-related illness
Human bite
Impetigo
Infected diabetic foot ulcer
Infectious mononucleosis
Influenza
Necrotizing fasciitis
Osteomyelitis
Otitis externa
Parasitic infection
Periorbital cellulitis
Peritonsillar abscess
Scabies
Sepsis
Septic arthritis
Spontaneous bacterial peritonitis
Tick-borne illness (Lyme disease)
Tinea infection
Tuberculosis
Viral exanthem
Wound infection
Trauma Presentations
Achilles tendon rupture
ACL and mceniscus tear
Ankle fracture
Ankle sprain
Burn
Calcaneus fracture
Cervical spine fracture
Clavicle fracture
Dental avulsion
Distal radius fracture
Drowning
Elbow fracture and dislocation
Electrical injury
Facial bone fracture
Facial laceration
Femur fracture
Fingertip amputation
Forearm fracture (radius and ulna)
Frostbite
Hand:finger laceration
Heat exhaustion
Heat stroke
Hip fracture
Humeral shaft fracture
Knee dislocation
Knee sprain
Lightning injury
Mandible fracture
Metacarpal fracture
Metatarsal fracture
Muscle strain
Nasal fracture
Non-accidental trauma
Orbital fracture
Patella fracture
Phalanx fracture (finger)
Proximal humerus fracture
Pulmonary contusion
Rib fracture
Rotator cuff tear (acute traumatic)
Scalp laceration
Scaphoid fracture
Shoulder dislocation
Skull fracture
Splenic laceration
Sternal fracture
Supracondylar pediatric fracture
Tendon laceration (hand:wrist)
Thoracic and lumbar spine fracture
Tibia:fibula fracture
Tibial plateau fracture
Toe fracture
Traumatic epistaxis
Traumatic hyphema
Toxicologic Presentations
Acetaminophen toxicity
Alcohol intoxication
Alcohol withdrawal
Anticholinergic toxicity
Anticoagulant overdose
Benzodiazepine overdose
Benzodiazepine:sedative overdose
Beta-blocker and calcium channel blocker toxicity
Carbon monoxide poisoning
Caustic ingestion
Digoxin toxicity
Drug eruption
Foreign body ingestion
Opioid intoxication
Opioid overdose
Opioid withdrawal
Organophosphate
Salicylate toxicity
Serotonin syndrome
Stimulant intoxication (cocaine, methamphetamine)
Tricyclic antidepressant overdose
Psychiatric Presentations
Acute anxiety
Acute psychosis
Agitation:behavioral emergency
Bipolar disorder
Conversion disorder
Major depressive episode
Neuroleptic malignant syndrome
Suicidal ideation and attempt
Musculoskeletal and Rheumatologic Presentations
Acute low back pain (mechanical)
Bursitis
Cervical radiculopathy
Costochondritis
Gout (acute)
Lumbar radiculopathy
Pseudogout
Tendinitis
Dermatology Presentations
Acute eczema (Eczema acute flare)
Allergic contact dermatitis
Erythema multiforme
Henoch-Schönlein purpura
Pressure injury
Psoriasis (acute flare)
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Urticaria (acute)
Environmental and Exposure Presentations
Envenomation (snake, spider, insect)
High-altitude illness
Hypothermia
Hematologic and Oncologic Presentations
Acute chest syndrome
Coagulopathy
Hyperviscosity syndrome
Sickle cell crisis (vaso-occlusive)
Symptomatic anemia
Thrombocytopenia (severe)
Tumor lysis syndrome
Pediatric-Specific Presentations
Bronchiolitis
Croup
Emergency delivery
Febrile seizure
Kawasaki disease
Neonatal jaundice
Neonatal sepsis
Nursemaid's elbow
Pediatric fever 0 to 28 days
Pediatric fever 29 to 60 days
Pediatric fever 61 to 90 days
Pyloric stenosis
Slipped capital femoral epiphysis
Intussusception
Endocrine and Metabolic Presentations
Adrenal crisis
Diabetic ketoacidosis
Hypercalcemia
Hyperosmolar hyperglycemic state
Hypertensive emergency
Hypertensive urgency
Hypoglycemia
Myasthenia gravis crisis
Myxedema coma
Severe hyperkalemia
Severe hyponatremia
Thyroid storm
ENT and Maxillofacial Presentations
Acute laryngitis
Acute otitis media
Acute pharyngitis
Cerumen impaction
Epistaxis (anterior)
Nasal foreign body
Otitis externa
Tympanic membrane perforation
Ophthalmologic Presentations
Acute angle-closure glaucoma
Central retinal artery occlusion
Chemical eye injury
Corneal abrasion
Corneal ulcer
Globe rupture
Ocular foreign body
Orbital cellulitis
Retinal detachment
Obstetric Presentations
Hyperemesis gravidarum
Painful vaginal bleeding in pregnancy
Placenta previa
Placental abruption
Preeclampsia:eclampsia
Preterm labor
Threatened:inevitable:incomplete abortion
Systemic and Miscellaneous Presentations
Anaphylaxis
Angioedema
Cannabis-induced hyperemesis
Achilles tendon rupture
POCUS
Procedures
Medications
Calculators
Resuscitation
ECG Guide
Back
Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate priorities
Stability and limb risk screen
▶
Hemodynamic instability
▶
If shock or syncope, alternate diagnosis pathway
Open posterior ankle wound
▶
If open injury, immediate ortho consult
Neurovascular compromise
▶
If absent pulses, emergent reduction of splinting tension and vascular consult
Severe pain out of proportion
▶
If concern for compartment syndrome, emergent ortho consult
Inability to comply with non weight bearing
▶
If unsafe ambulation, admit or arrange mobility support
Pain control and immobilization early
Early protection
▶
Posterior splint or boot in plantarflexion
▶
Resting equinus position
Non weight bearing until specialist plan
▶
Crutches or walker training
Key concepts
Time sensitive treatment decisions
▶
Early functional rehab pathway selection
▶
Operative vs nonoperative shared decision
Early immobilization in plantarflexion
▶
Prevention of tendon gap retraction
History
Presentation pattern
Typical history
▶
Sudden posterior ankle pain
▶
Pop or snap sensation
Sudden loss of push off
▶
Difficulty walking upstairs
Misdiagnosis risk
▶
Partial tears with preserved plantarflexion
Mechanism and context
Injury context
▶
Acceleration or jumping sport
▶
Basketball
Volleyball
Sudden forced dorsiflexion
▶
Tripping off a curb
Direct trauma
▶
Laceration
Risk factors
Predisposition
▶
Age 30 to 60
▶
Male sex higher incidence
Prior tendinopathy
▶
Chronic heel pain
Recent fluoroquinolone exposure
▶
Tendinopathy history
Systemic corticosteroids
▶
Oral or injection exposure
Inflammatory arthropathy
▶
Rheumatoid arthritis
Metabolic disease
▶
Diabetes
Smoking
▶
Poor wound healing risk for surgery
Physical Exam
Inspection and palpation
Posterior ankle findings
▶
Swelling and ecchymosis
▶
Often mild early
Palpable tendon gap
▶
2 to 6 cm proximal to calcaneal insertion
Resting ankle position
▶
Increased dorsiflexion compared with contralateral
Active plantarflexion
▶
Possible via long toe flexors in complete rupture
Functional tests
Achilles rupture bedside tests
▶
Thompson test
▶
Absent plantarflexion with calf squeeze
Sensitivity about 96%
Specificity about 93%
Matles test
▶
Prone knee flexed 90 degrees
Increased dorsiflexion on injured side
Single leg heel raise
▶
Unable on affected side
Neurovascular and associated injury screen
Limb status
▶
Dorsalis pedis and posterior tibial pulses
▶
Compare bilaterally
Sensation
▶
Sural nerve distribution
Skin integrity
▶
Posterior laceration or puncture
Differential Diagnosis
Posterior ankle pain mimics
Musculotendinous injuries
▶
Gastrocnemius tear
▶
Medial calf pain with intact Thompson test
Plantaris rupture
▶
Calf pain with preserved plantarflexion
Soleus strain
▶
Deep calf tenderness
Osseous and joint pathology
Foot and ankle injury
▶
Ankle sprain
▶
Lateral ligament tenderness
Calcaneal fracture
▶
Heel squeeze pain
Posterior malleolus fracture
▶
Bony tenderness with swelling
Calcaneal tuberosity avulsion
▶
Older adult with weak bone
Vascular and infectious
Non traumatic causes
▶
Deep vein thrombosis
▶
Calf swelling with risk factors
Cellulitis
▶
Erythema and warmth
Septic arthritis
▶
Fever and joint effusion
Coding aligned terminology
Diagnostic codes
▶
ICD-10 S86.0 injury of Achilles tendon
▶
Laterality and encounter specific extensions required
SNOMED CT Achilles tendon rupture
▶
Use local SNOMED mapping table
Laboratory Tests
Baseline labs when surgery or comorbidity risk
Preoperative screening context
▶
Complete blood count for anemia or infection concern
▶
Leukocytosis interpretation limited in acute injury
Basic metabolic panel for renal function before NSAIDs
▶
Creatinine for NSAID safety
Coagulation studies if anticoagulant use or liver disease
▶
INR for procedural planning
Pregnancy test for reproductive age with imaging or surgery planning
▶
Medication safety implications
Thrombosis risk assessment support
VTE evaluation context
▶
D dimer only if low risk DVT pathway selected
▶
Immobilization increases false positives
No routine thrombophilia testing
▶
Not ED indicated
Diagnostic Tests
Scoring Systems
Clinical diagnostic framework
▶
Thompson test
▶
Absent plantarflexion with calf squeeze
Sensitivity about 96%
Specificity about 93%
LR plus about 13
LR minus about 0.04
Palpable gap
▶
Supports complete rupture
Less reliable with swelling
Matles test
▶
Increased dorsiflexion with knee flexed 90 degrees
Helpful when Thompson equivocal
Achilles Tendon Total Rupture Score
▶
Baseline function tracking
Not a diagnostic rule
MRI
MRI use cases
▶
Equivocal exam with suspected partial tear
▶
Persistent weakness with normal Thompson test
Preoperative planning when complex injury suspected
▶
Insertional rupture or large gap
High sensitivity for tendon discontinuity
▶
Limited ED utility due to access delay
Contraindications
▶
Non MRI compatible implant
CT
CT role
▶
Suspicion of bony avulsion or fracture
▶
Calcaneal tuberosity avulsion
Not preferred for isolated tendon rupture
▶
Soft tissue detail inferior to MRI and ultrasound
Ultrasound (or US)
Ultrasound diagnosis
▶
Complete rupture findings
▶
Tendon discontinuity
Hematoma and gap
Dynamic assessment
▶
Gap changes with plantarflexion
Diagnostic accuracy for complete rupture
▶
Sensitivity 94.8%
Specificity 98.7%
LR plus 74
LR minus 0.05
Pitfalls
▶
Partial tear interpretation variability
Anisotropy artifact mimicking tear
Disposition
Ortho referral timing and level of care
Outpatient ortho pathway
▶
Follow up within 1 week
▶
Earlier if high performance athlete or uncertain diagnosis
Shared decision discussion
▶
Operative vs nonoperative functional rehab
Physical therapy pathway initiation
▶
Boot and wedge protocol if nonoperative selected
ED discharge criteria
Copy
Safe discharge prerequisites
▶
Pain controlled on oral regimen
▶
No escalating analgesic requirement
Immobilization in plantarflexion completed
▶
Splint integrity confirmed
Non weight bearing demonstrated
▶
Crutch safety verified
Neurovascularly intact after splint
▶
Pulses and sensation documented
Admission or urgent transfer triggers
Higher acuity indications
▶
Open rupture or laceration
▶
IV antibiotics and urgent repair planning
Skin compromise over posterior heel
▶
Threatened skin necrosis
Calcaneal tuberosity avulsion
▶
Urgent ortho management
Inability to mobilize safely
▶
Frailty or unsafe home environment
Suspected concomitant fracture dislocation
▶
Imaging and immobilization escalation
Treatment
Immobilization and protection
Initial immobilization strategy
▶
Posterior splint in plantarflexion
▶
20 to 30 degrees plantarflexion typical
Knee flexion position optional for comfort
Walking boot with heel wedges
▶
Useful for early functional rehab pathway
Wedges maintain equinus
Non weight bearing initially
▶
Progression per ortho or rehab protocol
Analgesia and symptom control
Multimodal pain regimen
▶
Acetaminophen PO
▶
1000 mg every 6 to 8 hours
▶
Maximum 3000 mg per day for most adults
Ibuprofen PO
▶
400 mg every 6 to 8 hours as needed
▶
Maximum 2400 mg per day
Avoid if CKD or GI bleed risk
▶
Alternative analgesia plan
Naproxen PO
▶
250 mg every 12 hours as needed
▶
Maximum 1000 mg per day
Opioid for severe pain only
▶
Lowest dose shortest duration
▶
Reassessment for alternate diagnosis if persistent severe pain
Surgical vs nonoperative decision support
Shared decision elements
▶
Operative management benefits
▶
Lower rerupture rates in many studies
Earlier return to high demand sport in some cohorts
Operative management risks
▶
Wound complications
Infection
Sural nerve injury
Nonoperative functional rehab benefits
▶
Avoids surgical wound risks
Comparable functional outcomes in many modern protocols
Nonoperative functional rehab requirements
▶
Early immobilization in plantarflexion
High adherence to boot and wedge protocol
VTE considerations
Thrombosis risk management
▶
Immobilization related VTE risk
▶
Individual risk assessment needed
Pharmacologic prophylaxis decision
▶
If high VTE risk and low bleeding risk, coordinate with ortho
Mechanical prevention
▶
Early safe mobilization of non injured limb
Hydration and avoidance of prolonged immobility
Open injury pathway
Open rupture management
▶
IV antibiotics
▶
Cefazolin IV 2 g
▶
Redose per institutional protocol
If severe beta lactam allergy, clindamycin IV 600 mg
▶
Alternative per local antibiogram
Tetanus prophylaxis per immunization status
▶
Vaccine and immune globulin per wound risk
Urgent ortho consult
▶
Operative irrigation and repair planning
Special Populations
Pregnancy
Pregnancy considerations
▶
VTE risk increased
▶
Lower threshold for prophylaxis discussion with obstetrics and ortho
Analgesia safety
▶
Acetaminophen preferred
Avoid NSAIDs especially later gestation
Imaging selection
▶
Ultrasound preferred over CT when tendon diagnosis needed
Geriatric
Older adult considerations
▶
Higher risk of insertional rupture or avulsion
▶
Lower threshold for x ray or CT for bony injury
Frailty and fall risk with non weight bearing
▶
Walker or knee scooter planning
Surgical risk stratification
▶
Diabetes and vascular disease increase wound complication risk
Pediatrics
Pediatric considerations
▶
True rupture uncommon
▶
Alternate diagnoses common
Differential emphasis
▶
Calcaneal apophysitis
Ankle sprain
Posterior malleolus injury
Imaging thresholds
▶
Lower threshold for x ray with bony tenderness
Weight based analgesia
▶
Acetaminophen 15 mg per kg per dose
Ibuprofen 10 mg per kg per dose
Background
Epidemiology
Population patterns
▶
Common in middle aged recreational athletes
▶
Higher incidence in males
Typical rupture location
▶
2 to 6 cm proximal to calcaneal insertion
Misdiagnosis rate
▶
About 20% initially missed
Pathophysiology
Mechanism of failure
▶
Sudden eccentric loading of plantarflexors
▶
Forced dorsiflexion against contraction
Watershed hypovascular zone
▶
Mid substance vulnerability
Degenerative tendon changes
▶
Collagen disorganization predisposes rupture
Therapeutic Considerations
Treatment principles
▶
Tendon end apposition
▶
Plantarflexion reduces gap
Early functional rehabilitation
▶
Weight bearing and ROM within 2 weeks in many protocols
Operative vs nonoperative outcomes
▶
Functional outcomes often similar with modern protocols
Surgery associated with wound complication risk
Imaging strategy
▶
Clinical diagnosis primary
Ultrasound useful when exam equivocal
Patient Discharge Instructions
copy discharge instructions
Copy
Discharge instructions
▶
Diagnosis explanation
▶
Achilles tendon rupture suspected or confirmed
Immobilization care
▶
Keep splint or boot on continuously
Keep ankle pointed down
Keep splint dry
Weight bearing
▶
No weight on the injured leg until orthopedics says otherwise
Elevation and swelling control
▶
Elevate above heart level when resting
Ice around splint if possible
Pain control plan
▶
Use acetaminophen and ibuprofen as directed if safe
Follow up
▶
Orthopedics appointment within 7 days
Return earlier if appointment not arranged
Return to ED now if
▶
New numbness or toes turning blue or cold
Severe increasing pain or tight swelling
Splint feels too tight
Fever or spreading redness
New chest pain or shortness of breath
New calf swelling on either leg
Fall or new injury to the splinted leg
References
Guidelines and key evidence
Evidence sources
▶
Aminlari A et al. meta analysis diagnostic accuracy of ultrasound for complete Achilles tendon rupture. Am J Emerg Med. 2021
▶
Ultrasound sensitivity 94.8%
Ultrasound specificity 98.7%
Schwieterman B et al. diagnostic accuracy of physical examination tests for Achilles tendon rupture. 2013
▶
Thompson test sensitivity 0.96
Thompson test specificity 0.93
AAOS Clinical Practice Guideline acute Achilles tendon rupture. J Am Acad Orthop Surg. 2010
▶
Operative and nonoperative options supported
AOFAS position statement management of acute Achilles ruptures. 2024
▶
Early functional rehabilitation concept within 2 weeks
StatPearls Achilles tendon rupture review. Updated 2023
▶
Misdiagnosis about 20%
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.
← Management Protocols
Home
Management Protocols
Achilles tendon rupture