What is the initial treatment for a patient presenting to the emergency room (ER) with an Achilles tendon injury?

Emergency Room Treatment of Achilles Tendon Injury

For acute Achilles tendon injuries presenting to the ER, immediately initiate protected weight-bearing with a device that limits dorsiflexion, combined with ice application, activity modification, and arrange urgent orthopedic follow-up within 2 weeks to determine if surgical intervention is needed.

Initial ER Assessment and Differentiation

The first critical step is distinguishing between complete rupture versus partial tear or tendinopathy, as this fundamentally changes management:

• Complete rupture typically presents with sudden onset during jumping/running activities, palpable gap in the tendon, positive Thompson test, and inability to plantarflex against resistance 1, 2
• Partial tears or tendinopathy present with pain, swelling, and preserved but painful plantarflexion 3, 4

Immediate ER Management for Complete Rupture

Apply a protective splint or boot that limits dorsiflexion to protect the tendon, allow protected weight-bearing, and arrange urgent orthopedic consultation within 2 weeks 5, 6:

• Place the ankle in equinus position (plantarflexion) using a posterior splint or walking boot to approximate tendon ends 6
• Early protected weight-bearing (within ≤2 weeks) with dorsiflexion limitation is recommended rather than complete non-weight-bearing 5
• Surgical repair should be strongly considered for young, physically active patients, as surgery increases likelihood of returning to preinjury activity levels and minimizes re-rupture risk 1, 2
• Conservative treatment may be acceptable for older, sedentary patients 1

Immediate ER Management for Partial Tears or Tendinopathy

Begin activity modification, ice application, protected weight-bearing with heel lift, and NSAIDs for pain control 6:

• Apply ice through a wet towel for 10-minute periods to reduce inflammation and provide short-term pain relief 6
• Prescribe NSAIDs for pain relief (topical formulations can avoid gastrointestinal side effects) 6
• Provide heel lifts or recommend open-backed shoes to reduce tension on the Achilles tendon 6
• Instruct on activity limitation that avoids aggravating movements, but avoid complete immobilization to prevent muscular atrophy 6
• Arrange follow-up within 1-2 weeks for initiation of eccentric strengthening exercises and stretching protocols 7, 6

Critical Timing Considerations

The 2-week window is crucial for optimal outcomes:

• Early mobilization (by 2-4 weeks) with protective devices allows quicker return to activities during the first 6 months compared to traditional casting 5
• Surgical repair should ideally occur within 2 weeks if indicated, as delayed treatment may worsen outcomes 1
• For conservative management, if no improvement occurs after 6 weeks of initial treatment, referral to a podiatric foot and ankle surgeon is recommended 6

Critical Pitfalls to Avoid in the ER

Never inject corticosteroids into or around the Achilles tendon in the acute setting 7, 6:

• Local corticosteroid injections can inhibit healing, reduce tensile strength, and significantly increase rupture risk 7, 6
• This applies to both insertional tendinopathy and midsubstance injuries 7

Do not discharge patients with complete rupture without orthopedic follow-up arranged 1:

• Delayed diagnosis or treatment of complete rupture requires surgical intervention even in older patients 1
• Missing the diagnosis leads to worse functional outcomes 1

Avoid complete immobilization without weight-bearing for extended periods 5, 6:

• Traditional casting without early mobilization delays return to activities without improving ultimate functional outcomes 5
• Complete immobilization causes muscular atrophy and deconditioning 6

Patient Education at Discharge

Emphasize the importance of compliance with the protective device and activity restrictions 5:

• Patient compliance to protocol is critical to prevent re-rupture, particularly with early weight-bearing programs 5
• Athletes can expect return to sports within 3-6 months after surgical treatment of complete rupture 5
• Approximately 80% of patients with tendinopathy fully recover within 3-6 months with conservative outpatient treatment 7