Management of Achilles Tendon Rupture with Positive Thompson Test
For patients with a positive Thompson test indicating an Achilles tendon rupture, the recommended management includes initial immobilization with the ankle in slight plantar flexion (10-20°), followed by either surgical repair or non-operative treatment with accelerated functional rehabilitation based on patient factors. 1
Initial Management
- Confirm diagnosis with at least one additional test beyond the Thompson test (palpable gap, decreased ankle plantar flexion strength, or increased passive ankle dorsiflexion) 1
- Immediate immobilization with the ankle in 10-20° plantar flexion to reduce tension on the tendon
- Initially non-weight bearing with crutches
- Ice therapy to reduce swelling
- Pain management with NSAIDs as appropriate
Treatment Decision Algorithm
Surgical Treatment Indications:
- Young, active patients and athletes
- Complete ruptures in patients desiring to return to high-level sports
- Patients with no significant comorbidities
- Chronic ruptures unresponsive to conservative treatment
Non-Operative Treatment Indications:
- Older, less active patients
- Patients with significant comorbidities
- Patients preferring to avoid surgical complications
- Partial tears
Surgical Options
- Open repair - Traditional approach with direct visualization
- Limited open repair - Smaller incision
- Percutaneous repair - Minimally invasive approach
Percutaneous repair shows higher physical and mental component scores on quality of life measures and may provide the best balance between preventing rerupture and avoiding complications 1. For chronic ruptures (>4 weeks), minimally invasive techniques like peroneus brevis reconstruction or free hamstring autograft can provide good functional results 2.
Non-Operative Management
- Immobilization in plantar flexion initially
- Early protected weight-bearing to prevent muscle atrophy
- Accelerated functional rehabilitation protocol
- Progressive mobilization and strengthening exercises
Recent evidence suggests that accelerated functional rehabilitation with non-operative treatment provides outcomes clinically similar to operative treatment while avoiding surgical complications 3.
Rehabilitation Protocol (Both Surgical and Non-Operative)
Early Phase (0-2 weeks):
- Immobilization in plantar flexion
- Protected weight-bearing as tolerated with crutches
- Ice and elevation for swelling control
Intermediate Phase (2-6 weeks):
- Progressive weight-bearing
- Gentle range of motion exercises
- Avoidance of dorsiflexion past neutral
Late Phase (6-12 weeks):
- Full weight-bearing
- Eccentric strengthening exercises
- Tensile loading exercises to stimulate collagen production
Return to Activity Phase (12+ weeks):
- Progressive return to activities based on functional improvement
- Sport-specific training for athletes
Common Pitfalls and Complications
- Misdiagnosis (up to 25% of acute injuries are misdiagnosed) 2
- Wound infections and nerve injury with surgical repair
- Rerupture (slightly higher risk with non-operative treatment)
- Prolonged immobilization leading to muscle atrophy
- Corticosteroid injections directly into the tendon (should be avoided)
- Inadequate rehabilitation
Special Considerations
- Bilateral tendon assessment is important as damage can occur bilaterally even with unilateral symptoms 1
- MRI can help determine rupture location, gap distance, and available tissue for repair in chronic cases 4
- Regular clinical assessment of pain and function is crucial for optimal recovery
The treatment choice should be based on patient age, activity level, comorbidities, and rupture characteristics, with both surgical and non-operative approaches showing good outcomes when combined with appropriate rehabilitation protocols.