The Achilles tendon is the strong, cord-like band that joins your calf muscles to your heel bone. It is the largest and strongest tendon in the body and does the hard work every time you walk, run, climb stairs or push off the ground. An Achilles tendon rupture — sometimes called an Achilles tear — is when this tendon tears completely, usually a few centimetres above the heel.

It often happens suddenly during sport or a quick push-off movement. Many people describe feeling as though they have been kicked or struck on the back of the ankle, sometimes with an audible snap, followed by difficulty walking. The good news is that not every rupture needs surgery: many heal very well with a carefully staged rehabilitation programme in a specialist boot, which is what this guide describes.

Achilles ruptures are among the most common sports injuries seen in a foot and ankle practice. They most often affect active adults between about 30 and 50 years of age and are more common in men. A classic pattern is the “weekend warrior” — someone returning to sport such as football, tennis, badminton, squash or padel after a period of relative inactivity.

Factors that can increase the risk include a sudden increase in training, certain antibiotics (fluoroquinolones), steroid injections around the tendon, and previous tendon problems. Because these injuries so often happen on the sports field, they are a frequent reason patients are referred for expert assessment of sports injuries of the foot and ankle.

Typical signs of an Achilles rupture include:

• a sudden, sharp pain or “snap” at the back of the ankle or lower calf;
• the feeling of being kicked or hit from behind — often with no one there;
• difficulty pushing off, standing on tiptoes, or walking normally;
• swelling and bruising around the back of the ankle and heel;
• sometimes a gap that can be felt in the tendon just above the heel.

Diagnosis is usually made in the clinic from your history and a physical examination, including a gentle calf-squeeze test that checks whether the tendon is working. An ultrasound or MRI scan may be used to confirm the diagnosis. Mr Welck tends to use ultrasound to see where in the tendon the rupture is, and how close the edges come together when the foot is pointing down (i.e. what is the ‘gap’).

Modern evidence shows that, for many patients, non-operative treatment with early functional rehabilitation gives results very similar to surgery, while avoiding the risks that come with an operation.

Surgery is still sometimes recommended — for example for some younger, high-demand athletes, when treatment is delayed, or when the tendon ends sit far apart. Mr Welck will talk through the best option for you, because every person and every rupture is different.

Non-operative recovery follows the Achilles Tendon Rupture Protocol. The tendon is held in a plaster and then a specialist boot called a VACOped, with the foot initially pointing downwards, which brings the torn ends together so they can knit. Over the weeks the boot is gradually adjusted towards a flat position. Mr Welck will talk you through his exact programme, which is based on evidence from large trials.

These timings reflect the attached protocol and are a guide only. Mr Welck and your physiotherapist will confirm the exact plan for your recovery.

Some items make recovery safer and more comfortable while you are in the boot. Many essentials — usually the VACOped boot and crutches — are provided or fitted by the clinic, so please check with Mr Welck or your physiotherapist before buying anything, as your exact needs will depend on your circumstances.

• VACOped boot (usually provided) — this specialist boot holds your foot in the correct position and is normally fitted and adjusted by the clinic. You should not buy or alter one yourself.
• Crutches or a knee scooter — often issued by the clinic and needed in the early weeks for safe weight-bearing. A knee scooter (knee walker) is a comfortable hands-free alternative that many patients hire or buy to get around more easily. The knee scooter, such as the ‘StrideOn’, can be rented and can be a real life-saver.
• Waterproof boot / cast cover — this slips over the boot or dressing so you can shower without getting it wet — helpful for keeping the skin healthy over several weeks. VACOped makes its own one that fits over the large boot.
• Leg elevation wedge or pillow — elevating the leg helps reduce swelling in the early weeks, when keeping the foot up is important.
• Shoe balancer / “even-up” — the boot raises one leg higher than the other. A shoe balancer (an “even-up”) fits onto your other shoe to level your hips and ease strain on your back, knee and hip while walking.
• Spare boot liners or socks — as the boot is worn for weeks, spare liners or clean socks help keep it hygienic and protect your skin. The boot comes with one and it is important to change it regularly.
• Shower stool and non-slip mat — a shower stool and a non-slip bath mat make washing safer while your balance is reduced.

Treating a rupture without surgery avoids the risks of an operation, such as wound problems and infection — but no treatment is completely risk-free. The main risks specific to non-operative Achilles management are:

• Re-rupture — the tendon can tear again. This is most likely during the vulnerable move out of the boot (around 10–12 weeks) or on early return to activity. Following the protocol closely and not rushing greatly reduces this risk, which is similar to the risk after surgical repair.
• Tendon lengthening — the tendon can heal slightly longer than before, which can leave the calf a little weaker and reduce push-off power. Careful boot positioning is designed to minimise this.
• Blood clots (DVT/PE) — being in a boot reduces movement and raises the risk of a clot in the leg. Watch for calf pain, swelling or breathlessness, and follow any advice or medication given to lower this risk.
• Skin problems — the cast or boot can irritate the skin. Keeping the boot clean and caring for the skin helps prevent this.
• Residual weakness or stiffness — a minority of people are left with some lasting calf weakness, stiffness or reduced performance at the highest level of sport.

Serious complications are uncommon with well-supervised, protocol-led non-operative care.

Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH) Stanmore and an Honorary Associate Clinical Professor at UCL. He treats patients across London, North London and Hertfordshire and is widely regarded as one of the leading foot and ankle surgeons for sports injuries, Achilles tendon problems, complex reconstruction and total ankle replacement.

He works closely with specialist physiotherapists to deliver evidence-based, protocol-led rehabilitation, so that patients recover safely and get back to the activities they enjoy. Whether your Achilles rupture is treated with or without surgery, you will have a clear plan and expert support at every stage.

If you have injured your Achilles tendon, an early expert assessment gives you the best chance of a smooth recovery.

Email: secretary@matthewwelck.com  ·  Tel: 07547 395 270  ·  Web: www.matthewwelck.com