Can You Fracture a Tendon?
No, tendons themselves cannot fracture—fractures occur only in bone—but tendons can tear, rupture, or avulse bone fragments where they attach, and these injuries frequently occur alongside or without accompanying fractures. 1
Understanding Tendon vs. Bone Injuries
Tendons are highly organized connective tissues made primarily of collagen (85% of dry weight) that connect muscle to bone and resist high tensile forces. 2 Unlike bone, which is a mineralized rigid structure, tendons are flexible tissues that can bend, stretch, and absorb shock. 2 The term "fracture" applies exclusively to bone disruption, not soft tissue.
How Tendons Actually Fail
Direct Tendon Injuries Without Fracture
- Ligament and tendon injuries commonly occur without any fracture visible on radiography. 1 In one study, 15% of syndesmotic ligament injuries at the ankle showed no fracture on X-ray despite significant soft tissue damage. 1
- Tendons can experience tears (partial or complete), ruptures, or tendinopathy from overuse or acute trauma. 1, 3
- The majority of spontaneous tendon ruptures occur at sites of chronic degenerative changes rather than in healthy tissue. 4
Avulsion Injuries: When Tendon Pulls Bone
- Avulsion fractures occur when a tendon or ligament pulls off a fragment of bone at its attachment site during acute trauma. 1 This represents a bone fracture caused by tendon force, not a tendon fracture itself.
- Stress radiographs or advanced imaging may identify occult avulsion injuries at ligamentous attachments that contribute to joint instability. 1
- Lateral talar process avulsions are commonly misdiagnosed as lateral ankle sprains when only the bone fragment is subtle. 1
Clinical Implications for Diagnosis
When Radiographs Are Negative
- High-resolution MRI can distinguish between tendinopathy, sprain, and partial or complete tears even when no fracture is present. 1
- Bone bruise and adjacent soft-tissue edema on MRI show higher association with acute ligamentous injuries and tendon abnormalities in patients with negative radiographs. 1
- MRI demonstrates 83% sensitivity for diagnosing tendon and ligament traumatic injuries about the foot and ankle in surgically confirmed studies. 1
Concomitant Injuries in Complex Trauma
- Up to 40% of humeral head fractures have complete rotator cuff tendon tears. 1 Tendon injuries frequently accompany skeletal fractures in high-energy trauma. 5, 6
- Patients with complex fractures routinely have concomitant soft tissue injuries including tendon damage or rupture that are often overlooked during initial fracture assessment. 6
- Delayed assessment of soft tissue injuries can lead to chronic pain, dysfunction, and delayed bone healing even after successful fracture repair. 6
Common Pitfalls to Avoid
- Do not assume normal radiographs exclude significant tendon pathology. 1 Soft tissue injuries require dedicated evaluation with MRI or ultrasound when clinical suspicion exists.
- Avoid dismissing persistent pain after "negative" X-rays as a simple sprain. 1 Osteochondral lesions occur in 50% of ankle sprains and 70% of ankle fractures, causing ongoing symptoms. 7
- Do not use corticosteroid injections for suspected tendon injuries, as they may inhibit healing, reduce tensile strength, and potentially predispose to rupture. 8