What is the treatment for a tendon rupture and swelling of the ankle?

Treatment of Tendon Rupture and Ankle Swelling

Immediate Diagnostic Priorities

Before treating ankle swelling and suspected tendon rupture as a simple injury, you must first rule out serious pathology—night pain, inability to bear weight, systemic symptoms, or rapid progression demand urgent evaluation for infection, inflammatory arthritis, or neurologic causes. 1

Critical Red Flags Requiring Urgent Evaluation

• Severe night pain is a red flag for septic arthritis, inflammatory arthropathies (gout, pseudogout, rheumatoid arthritis), or neurologic causes—not a simple tendon injury 1
• Inability to bear weight requires immediate medical evaluation 1
• Systemic symptoms, fever, or rapid progression of swelling suggest infection and need urgent joint aspiration and culture 1
• Erythema may indicate septic arthritis, which can present without fever 1

Physical Examination for Achilles Tendon Rupture

Perform at least two of the following clinical tests to diagnose acute Achilles tendon rupture: 2

• Thompson test (calf squeeze test) - most reliable clinical test 2
• Palpable gap in the tendon 2
• Decreased ankle plantar flexion strength 2
• Increased passive ankle dorsiflexion with gentle manipulation (Matles test) 2

Imaging Considerations

• MRI, ultrasound, and radiography are not routinely required to confirm Achilles tendon rupture if clinical examination is conclusive 2
• Apply Ottawa Ankle Rules if any trauma history exists to determine if radiography is needed to exclude fracture 2, 3
• Reexamine 3-5 days post-injury when swelling has decreased for optimal clinical assessment 2, 3

Treatment Algorithm for Confirmed Tendon Rupture

Both Surgical and Nonsurgical Treatment Are Valid Options

For acute Achilles tendon rupture, both surgical repair and nonsurgical treatment are acceptable options, with the choice depending on patient factors including activity level, age, and rupture characteristics. 2

Nonsurgical Treatment Protocol

• Functional rehabilitation is strongly preferred over immobilization for better outcomes 2
• Begin supervised exercise therapy as soon as possible focusing on proprioception, strength, coordination, and function 1, 3
• Use semirigid ankle support rather than elastic bandages, as it is superior and most cost-effective 2, 3
• Functional treatment allows return to work 7.1 days sooner than immobilization 3
• Functional treatment allows return to sports 4.6 days sooner than immobilization 3

Key Evidence: Nonsurgical treatment shows no significant difference from surgery in functional outcomes, pain levels, or time to return to work, though surgical repair has lower rerupture rates 2

Surgical Treatment Options

If surgery is chosen, open, limited open, and percutaneous techniques are all acceptable options: 2

• Percutaneous repair results in significantly less wound breakdown, fewer scar adhesions, and higher patient satisfaction scores compared to open repair 2
• Limited open repair allows faster return to normal walking, stair climbing, and sports compared to standard open repair 2
• Open repair provides direct visualization but has higher rates of wound complications 2

Post-surgical rehabilitation: Modern approaches emphasize immediate mobilization without cast immobilization, full weight-bearing from days 5-7, and gradual return to athletics from 8 weeks 4

Management of Ankle Swelling

Acute Phase (First 3-5 Days)

Apply PRICE protocol initially, though evidence for RICE alone is limited: 2, 3

• Protection with semirigid brace 2, 3
• Rest for 3-5 days only, then early mobilization 3
• Ice/Cryotherapy combined with exercise therapy reduces swelling more effectively than heat 3
• Compression with functional support 2
• Elevation to reduce swelling 1

Pharmacologic Management

• NSAIDs reduce pain and swelling in the acute phase and may decrease time to return to usual activities 2, 3
• Use NSAIDs cautiously as they may suppress natural healing and should not delay definitive diagnosis 1

Early Mobilization Phase (After 3-5 Days)

Begin supervised exercise therapy immediately after the initial RICE period—this has the strongest evidence (level 1) for effectiveness: 3

• Supervised exercises are superior to non-supervised training 3
• Focus on proprioception, strength, coordination, and functional exercises 1, 3
• Early weight-bearing as tolerated 3
• Manual mobilization should only be used in combination with other treatment modalities 3

Critical Pitfalls to Avoid

• Do not immobilize the ankle beyond the initial 3-5 day period—immobilization shows no benefits and delays recovery 3
• Do not rely on RICE alone without establishing a traumatic mechanism, as this may delay diagnosis of infection, inflammatory arthritis, or venous thrombosis 1
• Do not delay supervised exercise therapy—inadequate treatment leads to chronic problems including decreased range of motion, pain, and joint instability 2, 3
• Do not assume all ankle swelling is traumatic—atraumatic presentations require evaluation for inflammatory or infectious causes 1

Prevention of Recurrent Problems

Continue wearing a semirigid ankle brace for prevention of recurrent injuries, as bracing is superior to taping and has level 1 evidence 3

Implement neuromuscular training programs including proprioceptive exercises to prevent recurrent sprains 3