How should I evaluate and initially manage an adult presenting with posterior ankle pain, swelling, or a sudden pop suggestive of Achilles tendinopathy, insertional tendinopathy, or acute rupture?

Evaluation and Initial Management of Achilles Tendon Pathology

Begin with a focused clinical examination using the Thompson test, palpation for gaps, assessment of plantar flexion strength, and passive dorsiflexion testing—two or more positive findings establish the diagnosis of acute rupture, while chronic posterior heel pain with palpable nodules indicates tendinopathy. 1

Clinical Evaluation

For Suspected Acute Rupture

Perform these specific diagnostic maneuvers (at least two required for diagnosis): 1

• Thompson test (Simonds squeeze test): Squeeze the calf; absence of plantar flexion indicates rupture
• Palpable gap assessment: Feel for a defect or loss of tendon contour
• Plantar flexion strength testing: Compare to contralateral side for weakness
• Passive dorsiflexion: Increased range with gentle manipulation suggests rupture

For Suspected Tendinopathy

Distinguish between two distinct presentations:

Mid-substance Achilles tendinopathy: 1

• Pain located 2-6 cm proximal to calcaneal insertion
• Thickening and tender, palpable nodules on examination
• Most common in adult runners with increasing age

Insertional Achilles tendinopathy: 1

• Insidious onset with chronic posterior heel pain and swelling
• Pain aggravated by activity and shoe pressure, relieved when walking barefoot
• Prominence medial and lateral to tendon insertion with central tenderness
• Radiographs often show spurring or erosion at insertion

Critical Differential Diagnosis

Examine for these alternative causes of posterior ankle pain: 1

• Retrocalcaneal bursitis (Haglund's deformity): Tenderness lateral to Achilles with posterior-lateral prominence, most common in women 20-30 years
• Neurologic heel pain: Consider if symptoms don't fit typical patterns; requires EMG and nerve conduction studies

Imaging Strategy

Plain radiographs are first-line for all presentations to identify fractures, spurs, and Haglund deformity. 2

Advanced imaging is NOT routinely needed for diagnosis: 1

• MRI and ultrasound have insufficient evidence to recommend for or against routine confirmatory use in acute rupture
• Reserve MRI/ultrasound for unclear diagnoses after clinical examination and plain films 2

Initial Management by Diagnosis

Acute Achilles Rupture

Both surgical and nonsurgical treatment are viable options—the choice depends on patient factors and expectations rather than clear superiority of either approach. 1, 3

The guideline evidence is inconclusive regarding optimal treatment, so consider: 1

• Patient age, activity level, and functional demands
• Risk tolerance for re-rupture (higher with conservative treatment)
• Surgical risks and recovery time

Mid-Substance Achilles Tendinopathy

Initiate eccentric strength training immediately as the most effective treatment option. 1, 2

Comprehensive conservative protocol: 1

• Eccentric exercises: Specifically gastrocnemius-soleus complex strengthening
• Deep friction massage: Reduces pain and promotes healing
• Heel lift orthotics: Unload the tendon for pain relief
• Shoe orthotics: Correct overpronation or pes planus if anatomic misalignment present
• NSAIDs: For acute pain relief only
• Activity modification: Relative rest, not complete cessation

Approximately 80% of patients recover fully within 3-6 months with this conservative approach. 2

Insertional Achilles Tendinopathy

Begin with pressure reduction and activity modification; avoid corticosteroid injections near the tendon. 1

Initial 6-8 week trial: 1

• Open-backed shoes: Reduce pressure on insertion area
• Heel lifts or orthoses: Decrease tension on tendon
• NSAIDs: For pain control
• Decreased activity and stretching exercises
• Weight loss if indicated
• Immobilization: Consider in particularly acute or refractory cases
• Critical caveat: Local corticosteroid injections are NOT recommended due to rupture risk

If no improvement after 6-8 weeks, refer to podiatric foot and ankle surgeon for consideration of immobilization cast or fixed-ankle walker device. 1

For persistent symptoms, extracorporeal shock wave therapy (ESWT) is superior to both wait-and-see and eccentric training for insertional tendinopathy, particularly in non-calcified cases. 4

Retrocalcaneal Bursitis with Haglund's Deformity

Initial management mirrors insertional tendinopathy with key differences: 1

• Corticosteroid injections into the bursa (avoiding the Achilles tendon) are acceptable
• Accommodative padding around the prominence
• Physical therapy

If no improvement within 6-8 weeks, refer to podiatric foot and ankle surgeon for consideration of surgical resection of the prominent posterior-superior calcaneus and inflamed bursa; some patients require calcaneal osteotomy. 1

Common Pitfalls to Avoid

Do not inject corticosteroids directly into or near the Achilles tendon insertion—this significantly increases rupture risk. 1

Do not rely solely on imaging to diagnose acute rupture—clinical examination with multiple tests is more reliable and cost-effective. 1

Do not prescribe complete rest for tendinopathy—relative rest with eccentric exercises is superior to immobilization. 1

Do not miss underlying biomechanical abnormalities (forefoot/heel varus, pes planus, overpronation) that perpetuate the condition and require orthotic correction. 1