What are the symptoms and treatment for a suspected Achilles tendon rupture with a 'pop' in the ankle, calf pain, and inability to lift the big toe?

Acute Achilles Tendon Rupture: Diagnosis and Management

Immediate Clinical Assessment

You have an acute Achilles tendon rupture until proven otherwise, and you need urgent orthopedic evaluation within 24-48 hours. The classic triad of an audible "pop," calf pain, and inability to lift the big toe (likely representing inability to plantarflex the ankle) strongly suggests complete Achilles tendon rupture 1, 2.

Confirm the Diagnosis with Physical Examination

Perform at least two of these four diagnostic tests to confirm the rupture 1, 2:

• Thompson/Simmonds squeeze test: Squeeze your calf while lying face down with feet hanging off the table—if the foot doesn't plantarflex (point downward), the test is positive for rupture 1, 2
• Palpable gap: Feel for a defect in the tendon approximately 2-6 cm above the heel 1, 3
• Decreased or absent ankle plantarflexion strength: Inability to stand on tiptoes on the affected side 1, 2
• Increased passive ankle dorsiflexion: The foot can be pulled upward more than the uninjured side 1, 2

Imaging Is Usually Unnecessary

Advanced imaging with ultrasound or MRI is not routinely required when clinical diagnosis is clear based on history and physical examination 2. Reserve imaging for uncertain cases or when surgical planning requires detailed anatomic information 1.

Treatment Decision: Surgery vs. Non-Operative Management

Both surgical and non-surgical treatment are viable options, with the choice depending on your activity level, age, and risk tolerance for complications. 4, 2

Key Trade-offs Between Treatment Options

Non-surgical treatment carries a higher risk of re-rupture but significantly fewer wound complications, infections, and surgical risks 4, 2, 5:

• Re-rupture rates are higher with conservative management 4, 5
• No surgical wound complications, infections, or scar adhesions 4
• Preferred for lower-demand patients, elderly individuals, or those with significant medical comorbidities 2

Surgical treatment reduces re-rupture risk but increases complication rates 4, 5:

• Lower re-rupture rates compared to non-operative treatment 4, 5
• Higher risk of wound breakdown, infections, scar adhesions, and nerve injuries 4
• Minimally invasive techniques (percutaneous or limited open repair) offer better outcomes than traditional open surgery, with fewer wound complications while maintaining low re-rupture rates 4, 5

Surgical Technique Selection (If Surgery Chosen)

If you proceed with surgery, choose minimally invasive repair (percutaneous or limited open) over traditional open repair 4, 5:

• Percutaneous repair results in significantly less wound breakdown, fewer scar adhesions, and higher quality-of-life scores compared to open repair 4
• Limited open repair allows faster return to walking, stair climbing, and sports compared to traditional open surgery 4
• Both minimally invasive techniques have comparable re-rupture rates to open repair 4
• Watch for wound puckering with percutaneous techniques and potential sural nerve injury with both approaches 4

Rehabilitation Protocol (Critical for Both Treatment Approaches)

Regardless of surgical vs. non-surgical treatment, early functional rehabilitation with protected weight-bearing is essential 2, 5:

• Begin protected weight-bearing within 2 weeks if possible 2
• Use a protective device (boot or brace) that limits dorsiflexion initially 2
• Start mobilization by 2-4 weeks using the protective device 2
• The combination of minimally invasive repair with accelerated functional rehabilitation provides the best overall outcomes 5

Critical Rehabilitation Considerations

• Patient compliance is crucial to prevent re-rupture—non-compliance significantly increases failure risk 2
• Monitor for deep vein thrombosis (DVT), which can occur with both surgical and non-surgical management 2
• Expect residual strength deficits even with good functional recovery—technical force measurements show persistent deficiencies despite patients reporting no limitations in daily activities 6

Common Pitfalls to Avoid

Up to 25% of acute Achilles ruptures are initially misdiagnosed, leading to chronic ruptures that are far more difficult to treat 7. Don't mistake this for:

• Achilles tendinitis (insidious onset, no acute "pop," gradual pain) 4, 1
• Calf muscle strain (pain in muscle belly, not tendon, preserved plantarflexion) 3
• Retrocalcaneal bursitis (tenderness lateral to tendon, not in tendon itself) 4

Avoid corticosteroid injections near the Achilles tendon—these are contraindicated and can precipitate rupture 4.