01Approach to the Critical Patient/attcp21

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

02History/hx30

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

03Physical Exam/exam26

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

04Differential Diagnosis/ddx28

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

05Laboratory Tests/lt14

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

06Diagnostic Tests/dt44

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

07Disposition/dispo27

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

›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

08Treatment/t56

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

09Special Populations/sp27

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

10Background/b25

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

11Patient Discharge Instructions/pdi25

copy discharge instructions

›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

12References/r13

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%

Evidence & Review

Evidence & Review